30467APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
PERMITNO. � O 467
BUILDING PRO3k:C1' IDENTIFICATION
BUILDINGADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
10t-70
Q� -'LA Atte
WNI?I'S DMF.: PHONE:
CONTRACTOR'S NAME: LIC NO:
N/C
CON 'TROLa
1
Q^ O�
iO
.tCHITE I GINEER: {.1(' O:
ADDRESS:
CONTACT.
4P -71 1P
N Consultant Fees Paid By Applicant(Initial) _ _
EPER
BUILDING PERMIT
BLDG ELECT MECH
PL
tI1-'tso49 4e
TV
LICENSED CONTRACTOR'S DECLARATION
I hereby air,,. that I am licensed tinder provisions of Chapter 9 (commencing
wishll Lown 9000) of Dlvisinn 3 of the Busivess and Pndcxxiom Crcle, unA my licwsa ie
Licene Cls and effect.
License Class LLCM 3
Dote Contractor
QT'Y. ELECTRIC PERMIT FEE
]OBDESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
DITION ❑ PLUMBING RE -PIPE
TLUNIT ❑STRUCTURAL
MODIFICATION
PERMITISSUANCE
APPLIANCES—RESIDENTIAL
j ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
PANELS❑M
7
UPTO200AMPS
[]INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
❑ BATH RPMODEUREPAIR [I DEMOLITION .
0 HfiRR ,
p�
Licensed Professional
OatIam BUILDER DECLARATION Contr ON
1 hereby affirm that 1 nm exempt from the Cnntructnh License Law for the
fild"Mag reason. (Section 11111 S, Business and Professions Cad
Cade: Any city or county
which reyuires a permit m cna'huct, ultes. improve, Jemolixb, or repair tiny ewuwroKL'N
201-HIN AMPS
OVER!NMAMPS
ELF.CT
SIGNS RICAI.
Jct prinrmits issuance, also reyuircxthmtpplicanl for such pemtinn tileuxigned stmemcnt
that he is licensed pursuant o the provisions of the Commedors license law (Chapter 9
(cmnmencing with Section 701 of Division 3 of Ne Business and Professions Called or
C that he is exempt therefrom and the huffs far the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the alicbut to. civil penalty of
pp
and more than fixe hundred dollars (8500).
�Ql. as owner of the propcny, nr my empinyces wiNwuges as dheiraolecnmpensatie..
will Jo the work, and the structure is and intended or offered for sole (Sec. 7144, Business
SPECIAL CIRCUIT/MISC.
TEMP. METER OR P(11.E INST.
❑ NE 1 �DITIONi(,('j1DEMOLITION
❑TENANT 'Lei FOOD SERVICE
OVEME st�%
Bg 4
❑ OTNI:TAXs?
POWER DEVICES
SWIMMING POOL ELECTRIC
3 and Professions Code: Use Contractors License Lme taco not apply to an owner of
OUTLETS - SWITCHES — FIXTURES
Q�
property who builds or improves thereon, and who docs such work himself or dhrougb
his awn employees, provided that such improvements arc nut intended or offered for
NIIW RF:SIUEN'1'IAL ELIiCTR SQ per
SQ. FT. FLOOR AREA
S/SQ. FT.
aide.If, however the buildingor improvement is said within tine year of clandrlogdhc
rwnerbudder will have the burden of proving that he did nm build or improve for par.
pose of sale.).
I, u owner of the propcny, um exclusively contracting with licensed contractors do
Q , E ^ '
_ 1.�
w
b IJ%
1't
1.
compact the Pmjat (Sec. 9000, Business end profession, Code:) The Contr4cmrx Li-
QTY, PLUMBING PERMIT FEE
cense Law does not apply to on owner of property who bulls rr improves demon. and
who contends for such projects with u anntmcmr(q licensed person us the Contractors
PERMIT ISSUANCE
License Law,
I ammpt exeunder Scc. ,B& P C far this rensmt
ALTER — DRAIN & VENT— WATER (EA)
ter Uom
VALUATION
1 W3,' (�
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
PACK FLOW PROTECT. DEVICE
DRAINS— FLOOR, ROOF, AREA, GOND.
Jlheve andwillmaimainaCenilicam o(Comem do sdGinxurc far Warkcr's Compete
ention. ses presided foe by Section 3]1X1 of performable labor Cade, far the perfounof the
STORIES
TYPE CONSTRUCTION
FIXTURES —PER THAI'
work for which this permit is issued.
I have and will maintain Workers Compensation Insurance, as required by Section
370(1 of Ne Labor Code. for the perfenamnce of the work for which this permit is issued.
My Weaker', Compensation lommice earnerind Policynumhcr ore:
GAS — EA. SYSTEM -I INC.4 OUTLETS
OCC. GROUP
APN
Currier: Policy No,;
GAS—EA. SYSTF.M.OVER 4 (EA)
CERTIFICATE Olt EXEMPTION FROM WORKERS'
COMPINSATION INSURANCE
aectionn alma be completed ifdhe permit is for one hundreddollars(9100)
or pas.)
Ioyanythat in in perfomimer. tow,becthe walk far m inifl hNis tine W.,ke.ued,leha.
not employ any person in any manner xa a d(1 become subject do rite WorketV Compcm
sation Laws of California. Dam
t Applicedn
GREASE/INDUSTRL WASTE INTERCEPTOR
RUILDIN DIVISION FEES
GREASETRAP
P"NCHECK FEE
SEWER — SANITARY — STORM F.A. 200 PT.
ENERGY FEE �..
WATER HEATER W/VENT/RLECTR
GR
NOTICE TO APPLICANT: 1L til ler making Nis CcnifcaN of Exemption. you should
became subject to the Worker's Compact action provainnx of the Lubar Cale, you must
WATER SYSTEM/I'HEA'I'ING
6OILS FR1?
Forthwith comply withsuch previsimtsoe this pennitshull be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that hem iso construction pending agency for the performance of
Wgy'I3R SERVICE
PAID Z
Doteeipd
NEW RESIDENTIAL PLMH. SQ. pl.
the work for which this permit is issued (Sec. 3097, Qi, C.)
TOTAL:
Lenders Name
Lenders Address
T
p cmify Nm p have rtaJ this application and sate Nat Ne above infarmadion is
BUILDING FC (B"16.1
QTY, MECHANICAI, PERMIT FEE
mandrel. l agree to comply with all city and county ordinances and state paws relating to
bu ilding construction. and hereby amortize repicamirlive, of this city In ender upon the
SEISMIC FEE
` 1h
alm, wotentloned property dill inspeedina purposes.
(We) agree to save, indemnify and keep hamiless the City of Cupeninn against
PERM IT ISSUANCI?
P.LP.CTRIC"P.
ALTER OR ADD TO MECH.
PLUMBING FEE
liahilidies,judgments, costs and expenses which may in any way accme against said City
in consequenre cattle granting of this permit.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FdE
APPLICANT UNDERSTANDS AND WILL COMPLY WI'T'H ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER p0,0IXp CFM)
Jkl /Qti� y/I �Iq.�
CONSTRUCTION TAX
Signa cofApplicam/Condmctar Date
HAZARDOUS MATERIALS DISCLOSUREEXHAUST
HOOD (W/DUCT)
HOUSING MITIGATION FEE
II EATING UNIT (T0 1 00,00d BTU)
Will the a micabl ur boom building oceopant dollar handle hnzordous material
,
as defined h, Ne Cupen inn Municipal Cade, Chapter 9.12, and tine Health and Safety
GMs, Section 25532m)1
1 HEAT ING UNIT (OVER I00,0k) BTLF
[3 yes ❑Na
,, `` Will the applicant or future building occupant use equipment or devices which
hamrdom air contaminants as defined by the Bay Arca Air Quality Management
RRRRRR»sss> coffee?
Raba?
❑yes ❑No
PAID
Ude Receip,
VENTILATION PAN (SINGLE RESID)
BOILER—COMP GHP OR 100,000 BTU)
TOTAL:
BOILER—COMP(OVER 100,000 BTU)
AIR CONDITIONER
I lmvereudthe hazmdaustnaterialsreuiornats undo Chapter of the Cali-
4 p
ISSUANCE, DATE
NEW RESIDENTIAL. MIiCI1, SQ. IT.
that if the
Ibmiu I esimdoes & Safety GMs, Sections t, that 25505, 25533 esp 25534.1 u amity the
building does not currently have a tenant, that it is my responsibility to notify the cecupam
1.1
f the rtyuire ds which must he ten prior a issuance of n Cenilic� til (kc pancy.
EDDY.
Owner ar+mhorized agent Date
OFFICE