99090169 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PER
BU ILDINGIIIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDINGPROJECTIDENTIF'ICATION
BUILDING ADDRESS: U(/-� SANITARY NO. APPLICATION SUBMITTAL DATE
7 ` z L RS U `1- 24
O NBR'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
44 I _ ILIA
�Q NIC CONTROL.
C'flENG1NEER: LIC NO: ADDRESS: ❑
L .nsEn G-O(PHONE Z
C NLACT PxorvE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG - ELECT PLUMB MUCH
a Of23j GO . J� � �_ 211-
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby am.nt that 1 am licensed under......into of chapter 9(commencing _ _ JOB DESCRIPTION
with th Seen..700shm Division retire Busim,wiad Prnfesorm,Code,and an,license is RESIDENTIAL:
F O
�Uin III force and effect. �7 '7 ,/ PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
ZV License Ch�yyss�eeryLick /�1��7 Complain, APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
,,,=� Ume 7� - r ARCHITECTS DECLARATION L1 MULTI-UNIT ❑STRUCTURAL
PANELS
ypy7J. l unde.stond my pip shall�•�ed rs public recuNs MODIFICATION
O�Z4O in "a UP TO 200 AMPS El INTERIOR E)CHIMNEY REPAIR
LicensedLicensed Professiva.] 201-IODOAMPS IMPROVEMENT E]SWIMMING POOLS
C C JOWNER-BUILDER DECLARATION OVER 1"AMPS ElBATH REMODEL/REPAIR ElDEMOLITION
heQ 1 hereby
storm that 1 am exempt from the Contractor's License Low for the
L OC V following reason.(Section"131.5,Rosiness anal Emissions Code:Any city or county SIGNS ELECTRICAL C OTHER
which requires a pohnot to consumer.alter,improve,demolish,m repair any stmcture
�0 pri ra,a,cuar...1oo requires theapplicam I...chpourch to file a signedidamencon SPECIAL CIRCUIT/MISC.
that he is licensed Pursuant to the provisions of the Contractors License Law(Chapter 9
W 00 (commencing with Section 7")(if Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. DMM R IA
thin he is exempt therefrom and the basis came alleged exemption.Any violation of ❑,...,,NEW BLDG/ADDITION ❑DEMOLITION
W ti
m Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES 4?IbNANT ❑FOOD SERVICE
I
SQ n more than five hundred dollies($500). IMPROVEMENT' ❑ I,asowner of the propeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
C will do the work,and the stmcture is..,intersholornffered mrsole(Sec 7044,Business ❑OTHER
ad Professions Code:The Contractor's Licens.Law does no,apply to an owner of OUTLETS-SWITCHES-FIXTURES
4i 3 r property who builds or improves thereon,and who does such work himself or through 33
his own employees,provided that such improvements are no,intended.r offered for NEW RESIDENTIAL ELECTR S
seta lL howeveq the building orlotproveomris sold within one yoor o(complui.n,the SQ.Fp ORARHA E/SQ.FI'.
comer-milder will have the burden.f proving that he did not build or improve Por pur-
,anit e.IeJ,
❑T.as owner of the property,am exclusively contracting with licensed contractors to TOTAL: O
instruct the pmjeal(Sea.4x94,Business tad PrnPoselons Cale.,The C.mmetors Li-
cameLawdoesnotapplymunownerofpropenywhobuildsorimproves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such pmjeets with a conmaerons)licensed pursuant to the Contractor s
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this arson
ALTER-DRAIN&VENT-WATER(GA) VALUATION
Owner Date
WOR KER'S COMPENSATION DECLARATION BACK FLOW affirmPROTECT.DEVICE O O
1 hereby arm under penalty of perjury one of the fallowing declarations: 0 o
I have and will mai main r Certificate of Consent o self-insure lar Worker's Common- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
salon,as provided liu by Section 3700 of the Labor Code,for the performance of the
work for which this permit is iesucd. FIXTURES-PER TRAP
❑I line and will maintain Worker's Compensation Insurance,as required by Section
37M.f the Labor Code, performance of the work for which this permit is issued GAS-P.A.SYSTEM-I INC,4 OUTLETS OCC.GROUP /� ZIP
My Wnr tionlnsurance canter and Policy numbe ire _ o
Cvrier;/11".4RIS//la Policy hedf ll GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WO I RS' Q 3
COMPENSATION INSURANCE. GREASEANDUSTRL WAST- R
BUILDING DIVISION FEES
(This secdonomd not fortioriifthepermit is[Drone hundred donors($100) GREASEIRAP
or less.) PLANCHECK HE
1 really that in the performance of the work for which this permit is issued,I shall
not employan SEWER-SANITARY-STORM EA.2W Fri
y person in any mmmer o hjed to the Workers'C.mpoa- ENERGY NEE
'� .salon Laws of Califnmi.. ate IyJ. ��Ne su
Q 0 ApPlicant ��� '/__-- WATER HEATF,R WNENT/F.I,UCTR (GRADING FEE^„ �,_
NOTICE TO APPLICANT rOef tr this Cenificam of Exem ..nn, . maid i
.mss 6 , nus WATER SYSTEM/TREATINO
a became comp to the Workers Compensation emulsions of the Lrbor Cade,yam must }O LS FPB U ^`f
W Q fnahwilh comply wltM1 such provisions nr this pennh shop be deemed revoked. WATER SERVICE I I
jz CONSTRUCTION LENDING AGENCY NEW R[$IDENTIALPLMB, SQ.FT. AID �I f
V n I hereby storm thdamere is reinsurance lending agency for the performance of �Dnte�✓ RweipiA �'
F
the work for which this permit is issued(Soca 3097,Ci,CJ
0 Lender's Name TOTAL t
Leader's Address TOTAL:
y 1 certify that I have rend this application and stale that the uM1nve inform.......is I ILDING FEE 1
0.�. h correct.l agree to comply with all city and county ordinances and sate laws relating to QTY. MECHANICAL PERMIT FEE '' '---
V ,z building contraction,and hereby authorize representatives of this city to enter upon the SEISMIC
.bion-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cimarron against PERhBT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way.ceme against said City ALTER OR ADD TO MF,CIL
in consequence of the graving of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,100 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
9/zy AIR HANDLING UNIT(OVER u1,000CFM) CONSTRUCTION TAX
17,21A, gChad--_
HAZARDOUS MATERIALS DISCLOSURE EXHAUST 110011(W/DUCT) HOUSING MITIGATION FEB
Will the applicant or future building ottvprmwore or handle hazardous material HEATING UNIT(TO 100,000 BTU)
.s de0ted by the Definition Municipal Gtde,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)'1 HEATING UNI'P(OVER 100,000 RTU)
El Yes ❑N. VENTILATION PAN(SINGLE RESID) PAID --
Dare Ree t M
Will the applicant nrfuture building occupant use ea Air uratdeviceswhich BOILER-COME QHP OR I fig"BTU)
h hazardous vis comaminams as defined by the Boy Area Air Quality Management TO
�svir7
❑Vas 0N BOILER-COM P(OVER 100,000 BTU)
I have read the inamorata mareriap,requirements under Chapter 6.95 of the C.l i- AIR CONDITIONER ISSUANCE DATE
ftmia Health&Safety Chile,Sections 25505,25533 and 25534.1 undersand that tithe NEW RESIDENTIAL MECH. SQ.FT. /"I ' �k
building does not currently have a mount,that it is my responsibility to notify the compmincompete /e,�
.fere r9{'IreancnswMas�..�.�re..net prior :...neofa CeAf[r/amn./ky�ypancy.
rX0 �9F1PE� E� / I Car TOTAL: 1
ISSUED BY: �
OFFICE