99110190APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL PE SH N
APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING DIVISION mat 1111.. PRntECn HIEN-rIFICAnoN S0001 WPM
s, R'SNAME1e I� iV/S /r'� PH � /S � OR:S AMKMVN�"/� -1fo9/97
❑ Consultant Fees Paid by Applicant (Initial)
FEE
FEE
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BLDG ELECT PL{A.�B R MUCH
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JOB DESCRIVI ION
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT
1 hereby affirm that 1 nor licensed ..it,, previsions of Chrpmr 9 (comvancing
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with Section 7000B.f Divm..3 ofthe Businessund Professions Code. ondmy license is
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PERMIT ISSUANCE
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mfhn rnr«arae y
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IJcenm Class Lie
API'LIANCI!S- RESIDENTIAL
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ANCHITECTS DGCIA A ON PANELS
EPAIR ❑ DI3M01.1'FI0N
I undcmgoa my plans hall he used as publis mcords
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UP TO 2fXIAMPS
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Licensed Pmfic... en:d IDI-10011AMPS
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OWNHR-BUILDER DECLARATION OVER HXX]AMPS
Coances License Law for the
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that 1 aro exemom the is
1 hereby affirm pt fr
rollnwing season. (Section 7031.5. Business and I'ndesslans Cade: Any city or county SIGNS ELECTRICAL
which requires a permit m construct. alcor. improve, demolish, or repair my structure
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issuance. elm myuimsthe applicant for such permit m file a signal statement SPECIAL CIRCUIT/M ISC.
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uagthe pros inions of the Contraand License law (CM1npmr9
that he is licensed punno
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anpepec.cing wish Section7n)(Mof Division 3 of the Brimless and profession, Cede) or 'PEAL'. M FTER OR ML12 INS F.
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that he is esc Nin thenfir nn and the M1mis for the allugN exanptioa Any vialainn of
Section 70315 by any applicant for a Permit nu neck the applicant m a civil penalty III POWER DEVICES
not room than rive hundred dollars ($.NIO).
❑Lax owner of the pmpcny.mmyempinyeeswithwagesmtheirwle rompennatioq SWIMMING POOL ELECTRIC
P.
willdothc viod.andthestma.re snot lmcndedcroBcred fmsale(See 7044. Boarms
unit ITdessions Calc: The Contractor's License law does not apply toan aider of OUTLETS -SWITCHES -FIXTURES
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pmpeny who builds or improves therao, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for NEN' RESIDENTIAL ELECTR SQ FT.
sale. If, however the building or improvement is sold within one yearof completion, the
crbuilder will have the bnticn of proving that he did not build or improve for pur-
pu c of talc ). 'L'OTAI:
❑ I, torturer of the propan, um e.el.xivcly contracting with licensed amiranors to
construct the project (Sec. 70,14. Business and Professions Cale:) The Contrvemr's Li-
censeLaw days not apply inanawnet of properly who hands or improves thereon.and QTY. PLUMBING PERM IT
who emm cts for such projects with It con ecolons) licensed pursmnt to the Cun meta"s
rnu law. PERM IT ISSUANCE
I am exempt under Sec. . B & P C for this M axon
ALI ER - DRAIN & VENT- WAMR (EA)
Owner Date
WOR K IftS COMPENSATION DECI.A RATION BACK FLOW PROTECT. DEVICE
I hereby iflimn madcr lwnnity of perjury ane ol'the folkesing declarations:
Hiaveoadwill maintainaCeniticateel ConsenOoself-insure for Worker's Compca- DRAINS- FLOOR. ROOF. AREA. COND.
along, as provided for by Section 3700 of the IaMt Cale, for But performance ill the
tk for which this pcla lis issued. PI%'NRES - PER TRAP
I halt and will maintain Workees Compensation Insurance, as required by Section
GAS EA. SYSTEM -I INC. 4 OU1FLL7S
3700 of the lava Code. for the performance of the work fill which this permit is issued. -
My Work Compen.xaJJWI�a lnxuranee carver and Policy nu9� 9�
GAS -I!A SYSTL'MOVERAH!A)
Curzier,7191f hw.?7 Policy Na:
CI3R'r119CA1'Ii OF L%EMPI'ION FROM WORKERS' GREASEINDUSTRL WAS' 11; IN'ItiRC1717OR
COMPENSATION INSURANCE
(This secrinarced nmbecompleted ifthe pemtit ixforenchundmddollno($I00) GREASE *1'RAP
ar lesal
theinthe ofthe wnrA( which trhis it SEWIiR- SANITARY - STORM EA. NXI FT
Loy
r o the WAms'd.lshall
not employ any person in any mn-�s�r hmlmtc subjauo the Woders' Cnmpem
any any manor
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sail Laws of California7 WAIT ER IIEA'fER WNIiM'/E11CI'R
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NUMieant
NUI t, Exemption. You should WATER SYSTEM?RIiAn'ING
perking this Cisions
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e subject (lie Co nn, of [be Loan Coda you Inuit
to tic Workers Comlmnsmo,
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conic be de
forthwith comply with cnch pmvisinry nnhixpennit ,Mitt be JccmcA rcvukN. WA D!R 913RVICE
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CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM 13. SQ. FT.
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I hereby affirm that is a coratrvction lending agency for the perfomence of
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the work for which his permit is issued (Sec. 3197. Civ. C.)
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lenders Name TOTAL:
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lender's Address
certify the 1 have read this application and state that the aNice information is
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eorza't. I agree m enroply with all city and county ordinances and state laws relating In QTY. MECHANICAL PERMIT
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bnildingeonxuuetion, and hembyauthorise reprcunmtives ofthucity to enter also the
akoe mentioned prn,sam lar .,pennon Purprws. PERMIT ISSUANCE
(we) agree m save, indiamify and keep hmnness the City of Cupcnino against
BaliBides,judgmenu. costs and expenses which may in any way acerve against said City ALTER OR ADD TO MECI I.
nmquenccoftbegranting fhas permit.
APPLICANT U ' ST S AND WILL COMPLY WITH ALL NON -POI T AIR HANDLING UNIT (TO 10,000 CFM)
t
SOURCF.R' IU
A AIR HANDLING UNIT(OVIiH I11,gXI CFM)
Si mof ApPlaant/Cononcun Date EXHAIIS'T HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
_
Will the applicant or future building occupant once or handle hosanna., material IIHA ING UNIT (TO 100.001 It I U)
defined by the C.penino Municipal Cade. Chapter 9.12, and the Huahh and Safety HEATING UNIT (OVER 100,0 X) BIG)
.S. 25512(0)"
El Yes �No VENTILATION FAN (SINGLf:RLSID)
! Will the applicant or future building occupant use equipment or devices which ROIL ER -COMP (3HP OR DXI,(XXI BTU)
emit hasnNcus air oontar arm as defined by the Bay Area Air Quality Management
Finnic'! ,/ BOILER- COMP(OVER I W.000 ItI U)
E] Yes yyNo
( AIR CONDI'I TONER
I base read the haemduus materials me airenants under Chapter 6.'15 of the Cali
fn rda Health & Safety C e. Sections 25505. 25533 and 23533. I ualerstmd that if the NEW RESIDENTIAL MECH. SQ. FT.
building Ileo note sen mnmt. the it is my nsponsibi!ity to tour Mass.pant
oldie "or Must W met gho to issuance of a Ceni�� Ve. ycy
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TOTAL:
Own�ied.,cut %Am %
OFFICE
FEE
FEE
C
BLDG ELECT PL{A.�B R MUCH
F-1LJ-
JOB DESCRIVI ION
RESIDENTIAL
0SFDWI,
❑KITCHEN REMODEL.
❑ADDITION
CI PLUMBING RE -PIPE
❑MULTI -UNIT
[I STRUCTURAL
MODIFICATION
❑IN'IPRIOR
❑ Cl I NINEY REPAIR
INIVR(IVEMENT
[]SWIMMING POOLS
❑ BATH REMODE
EPAIR ❑ DI3M01.1'FI0N
C1 OTHER
1 1'
❑NfiW BLDG/ADDITION
❑DEMOLITION
❑TGNAN.11
❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. IT. FLOOR AREA I 5/SQ, PT.
BUILDING DIVISION FEES
PLANCHECK ITE
ENERGY ITE
GRADING illi
BUILDING Phil
SEISMICITE
PLUMBING FEE
MECHANICALFEE
CONSTRUCTION TAX
HOUSING SH I'[GA'I'ION Fiii!
PAID
Dam Rcreipt X
ISSUANCE DNI I.