31412APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUIIAING - ELECTRICAL
PERMIT NO. z�q
BUILDING DIVISION APPLICATIONMERMIT .PLUMBING MECHANICAL
3a�
314 I1 L
2
BUILDING PRf3JPC1' IDENTIFICATION
BUILDINGADDRPSS: -
SANITARY NO.
APPLICATION SUBMITTAL DATE
dd
OWNER'S NAME: PJ1ONE:
t19r1_1%r le E 0 Z /L &NIC
CONTRACTOR'S NAME: LIC NO:
❑
CONTROL
ARCHITECT/ENGINEER: LIC NO,
ADDRESS:
CONTACT PHONE:
BUILDING PERMIT INFO
'
❑ Consultant Fees Paid by Applicant(Initial)
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 hereby affran that 1 um licensed under provisions of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTrON
with Senion](KKBof Division3o(the Business enJ Pndeasiam Code, and my license is
LiceneCifull e and effect.
License Class Lica
1 Doc Commctor
RESIDENTIAL '
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RE -PIPE
❑MULTI -UNIT 0STRUCURAL
MODIFICATION
FENMI'1'ISSUANCE
APPLIANCES—RESIDENTIAL
j ARCHITECTS DECLARATION
I arson. any plans shall be used ss public retorts
PANELS
UPT0200AMPS
El INTERIOR (:1 CHIMNEY REPAIR
IMPROVEMENT
❑ RATH REMODEUREPAIR [I DEMOLITION
❑OTHER
Licensed Profasionul
OWNER -BUILDER DECLARATION
License Low for the
I hereby affirm onnt I em exempt from the Contractor Code:
following reason. (Section 7031.5, BusinessitPmfdemols h, is, Any city or county
which requ[rex permit to a eller, improve, Demolish, or repair any swaure
20140100AMPS
OVER 1000AMPS
SIGNS ELECI'RICAI.
rs the
it n the applicant for such a
Law(ned mmment
SPECIAL CIRCUIT'/MISC
hfanwdloororeyviree
Chior t be pursuant Coandorntinoicareut
the Cndwcmr's License Law(Chupmr9
, m
TEMP. METER ON I'n1,Ii INST. -
COMMERCIAL: '
71. 0M) of Divionxof
(commanding with
(nsmmcncingwith Section ]000)uf Uivision3af the Hminesx anJ Profesxinnx Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects she applicant n a civil Penalty of
oon mart live hundred dollars ($500Y
i��❑FOODSERVICE
er of the property, or an, employees with wagnaa their sole caapensatim,
will do the work, unit the structure is not immddedarolffiaed for sale (Sec. 7044, Business
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
and Professions Cale; The Contractor's License Law dons not apply n) an owner of
OUTLETS—SWITCHM—FIXTURES
prapeny who builds or improves amnion, and who does such work himself or through
his awn employees, provided that such improvements arc out intended or upland for
NEW RESIDENTIAL ELECfR SQ FT.
saki If. however, the building or improvement is sold within one year ofcompletion,she
Q. FT. FLOOR AREA
ASQ. FT.
owner -builder will have the burden of proving that he did not build or improve for pun -
Pa. of sale.),
TOTAL:
❑ h as owner of the property, am exclusively contracting with licensed contractors to
n.tontine project (see. 7044, Business odd Pmfexsiam Coda:) The Comactm"s L-
reade Law doca not apply In an owner of propeny who builds or improves herem, and
QTY, PLUMBING PERMIT FEE
t
who contracts for such projects with a contmcer(s) licensed purauant to the Carnation's
ISSUANCE SQ
License Law.PERMIT
El nco oxcntpt n •r Stu. , B & P C Tonhis raison
ACfER —DRAIN&VENT —WATHR (EA)
nn )ate
VALUATION
BACK FLOW PROTECT. DEVICE
WORKER'SCOMP.NSATIONDF.CLARATION
D
I hereby air. under penalty of perjury ane of rhe fallowing decli ationc
,�
DRAINS— FLOOR, ROOF. AREA, COND.
❑ I have and will maintain a Certificate ofComaens to self insum for Worker's Compcn.
satin, as provided for by Section 37M of the Labor Cake. for the perforounce of she
work far which this permit is issued.
STORIES
NOV 06
TYPIiCONSTRUCOON
996
FIXTURES — PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
37M of rhe lahar Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance summer and Policy number arc:
GAS—EA.SYSTEM- IINC.40METS
(]C
/�.. VUYi
f1IIIVU AIN
Cartier: Policy No.:
GAS —FA. SYSTEM-OVIR 4 (EA)
V
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('this section need not he completed it she permit is for one hundred doll an LUTM)
in less)
GREASP/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
-
GREASRTRAP
PLANCHECK FEE
SEWER - SANITARY — STORM EA. 200 FT.
I certify that in the performanceofthe work for which this permit is issued, l and
not employ any parent in any manner so as to beconasuhjed to the Workcr.,' Carman.
ENERGY I'EE
IWATEN /VENUELECTR p
nation Ltwaof Collfnrnia.DxteER
Applicant
GRADING FEE
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject nt the Worker's Compensation provisions of the Luna Code, you muss
WATER SYS' FEMORPAT[ NO
SOILS FEF.
forthwith comply with such provisions or this permit shut[ he deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
PAID
NEW RESIDENTIAL PLMB. SQ, FT,
I hereby affirm that hem is a construction lending agency for performance of
Dom ReceiptX
the work for which this Permit is issued (Sec. 3097, Civ, C.)
Landcls Name
DOTAL:
Leader's Address
TOTAL:
I cenify that I have read this application and state that she above information is
BUILDING FEE
QTY. MEET IANICAL PERMIT FEE
courrect. l agree to comply with all city and county ordinances and state laws rclatingto
SEISMIC
building constmmion, and hereby authonze representatives of tldi city to enter upon Ne
anme-mentioned property for inattention purposes.
(We) agree m save, indemnify and keep harmless the City of Cupcnlnn against
P13NMI'I' ISSUANCE
ELECTRIC
liabilinias,judgmems, costs and expenses which may in any way actin, against said City
in consequence of the granting of this permit,
ALTER OR ADD I'O MECH.
PLUMBING FEE
AIR HAND NO UNIT (TO 11,000 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10k000 CFM)
CONSTRUCIONTAX
Signature of ApplicnVConsmcmr Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUSTHOOD(W/DUCD
HOUSING MITIGATION FEE
HEATING UNIT LTO ITTLOOI BTU)
Militia applicant or future building occupatnnoreor handle hazardous material
es defined by the Cupertino Municipal Code, Chapter 9.12, and the HwOh end Safety
Code, Sasion 25532(a)]
HEATING UNIT (OVER 100.000 BTU)
❑Yes 0 N
Wlltheses ail Ondionant rfuts re building by the nt Bay Are.
emit hazardous Dir contaminants az defined by the Bay Arco Air Quality Menagcmem
Air eholity Management
Dianna?
PAID
Date Receipt#
VENTILATION PAN (SINGLE RESID)
BOILER— COMP(3HP OR 100,000 BTU)
TOTAL:
BOILER — COMP (OVER Wo" BTU)
❑Yea F1 No
AIR CONDITIONER
1 have rend the he ... nos materials requirements toner Chapter 6,95,df the Cid-
IS ANCE DATE
NEW RESIDENTIAL. MECIi. SQ. FE.
forms Haulth & Safety Code, Socamsv 25505,25533 add 25534. 1 understand that If the
an,
have. conal.Nato ismyresponsibilityrotdodifythepant,m
in. rat ttofy throancy.
irdnotnwhichmically
of eofaibill
of Ne regma,nsamu which musthemen poor nt is
LSSUEDBY:
Owner nr nthorrzeA aliens Date
- TOTAL:
nF np -