30924 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BU I LDING-ELECTRICAL PERMITNO. IN 0/N/N /I
BUILDING DIVISION APPLICATION/PERICAL
J( UVJ L 4MI7• PLUMBING
.�, BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - I SANITARY NO, AP1'PILI1�CATION SUBMITTAL DATE
OWNER'S NAME: ` ONIi, CON'TRACTOR'S NAME: LICNO..'k'I G
1$ 'C-✓^ l rl f [{ryyl/ N/C CONTROL#
�A CHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDO . ELECT PLUMB MECH
P4*I CIr4w S-S `— ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FE13
I harebyammo Pm I met licensedam
nder provrsmnscf Chapter 9(eomeneing JOB DESCRIPTION
WOO with Section 7000)uflusision 3dfthe Busineasand Professinns Cnla,and my license is
l- in in full force ass end eIT G
id PERMITISSUANCE RESIDENTIAL:
IY Licen �'0 ❑SFDWL ❑KITCHEN REMODEL
QF VZ U se CTL .#
N6 Dam Conuua •Je j ry •uvx APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPIT
h,Dy ARCHITECTS DECLARATION _ - ❑MULTIUNIT ❑STRUCTURAL
,Z o n Z I understand my plans shall be used as public records PANELS
0z J p UP TO 200 AMPS MODIFICATION
a to 1-21 Licensed Rofessinnel ❑INTERIOR ❑CHIMNEY REPAIR
201-10(IOAMPS IMPROVEMENT
yesy S...4I OWNER-BUILDERDECLARATION ❑BATH REMODELREPAIR ❑DEMOLITION
d' 6 1 hereby off rte thatOW I am exempt R the Contractors Limns Law for the OVER IOIN)AMRS
)d 36 following reason.(Section 7031.5,Business vad Professions Cole:Any any or county SIGNS ELECTRICAL ❑OTHER
y1 which requires a Period to construct,alter,improve,demolish,or repair any structure
prior to it,lssuanea,nanrequlres the applicant lar such Permit m fleasignedemtmoem SPECIAL CIRCUIT/MISC.
ytat he is licensed prrsuant lomhepo isions ofthc Conuacmr's License Low(Chnpter9
WC) (commencing with Sectimnl)UO)ofDivision 3 ofthe Businessand Pmfessese;CodaTor TEMP.METER OR POLE INST. COMMERCIAL
a q M C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
yXl Try Section 7031.5 by any applicant fora pemmi,mbjects the applicant to.civil pereahy of POWER DEVICES
t more mad rive hundred dollars
❑TENANT ❑FOODSERVICE.
p' < I,as owner of the norm loees wit woes as their sole cont tion, SWIMMING POOL ELECTRIC IMPROVEMENT
G ❑ property,Y YetnP Y B compensation,
q will do the so unit.and the stmcmrc is net intended m offered for sole(Sec.7044,Business OTH HR
L5 and Professions Cale:The Contractor's License Law does not apply to an owner or OUTLETS-SWITCHES-FIXTV RES
.. property who builds or improves thereon,and who does such work himself or through ,
his we employees,Provided that such impmvemems are nut intended or offered for NEW RESIDENTIAL ELECfR SQ ET
sole.IChowever,thebuiiding0rimprovementnuild within0ne ycorcifmeopiction.the SQ.Fp.FLOOR AREA VSQ.Oct
0wneumilder will have me burden of proving that he did not build connotative for pur-
,avo[salcJ.
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
netmet the project(Sea 7044,Business and Professions Cal The Cirmuccmr's Li. II11
n;e Law does not apply m on owner of property who builds or improves thereon,are Q'FY, PLUMBING PERMIT FEE A I D
who contracts for such forests with a contra drains)licensed pursuant In the Contractor's 4p'?License law. CO
❑Iamexemptuulersec. ,B&PCm
forthisason PERMIT ISSUAN
ALTER—DRAIN&VENT—WATER(EA) Y N
Owner Dale
WOR KER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE y�rL 1
• I hereby affirm under penalty of perjury one of the following declarations:
urrMl�N
Z"L'Ilhnve and wi 11 maintain Or Certificate of Consent o self-insure for Worker's Cooper- DRAINS—FLOOR,ROOF,AREA,COND. STORIES 'fYl'B CONSTkUCI'I(lN
order,es provided lin by Section 3700 of the lobar Code;for the perfomm rce of the
work for which this Permit is issued. FIXTURES—PER'MAP
ED 1 have and will maintain Worker's Compensation Insurance,as required by Section
POO of Pe Ll.0Cole,for no perforat of he were for whiOh,hia petmit is isssued, GAS—EA.SYSTHM-I INC.4 OUTLETS OCC.GROUP APN
My Work Ss�tltfns�INsu nr#re cam erod Policy
,mbar 2 L— I / GAS—EA.SYS]'HNUOVER 4(EA)
r T} !� 4(. 3 1/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRI,WASTE INTERCEPTOR
(Thissaruam need nm be completed if the Permit is future hundred donec($I Om - B GILDING OIVI.S ION FEES
or less) GREASE TRAP PLANCHECK FEE
Toy any Pat in in Permy manner oist becomek for subjech tho Perthe W rker,'ed,lshall
n- SEWER—SANITARY—STORM G.21Ml FT.
on employ any person in any manner so as m become subject ro the WmkeK Compen- ENERGY FF.E
Z sation Laws of California.Data
� O A licam WATER HF.ATIiR WNENT/ELECPIi
PP GRADING FEE
NOTICE TOAPPLICANT.If,after making this Genius o of LLabor iodyoushould WATER SYSTI?MRREATING
a
become subject m it Worker's Coons or(his
provisions of the Labor Code,you must SOILS PET?
W forthwith comply with such provisions or permit shall he deemul revoked. Wp'fER SERVICI?
Q
� z CONSTRUCTIONLFNDINGAGENCY NEW RESIDENT']AL PLFIB. SQ.FT PAID
V Q work
which
Pe mere isot sued( ec.0n lending agency for performance of Um Receipt#
to work for which tis permit is issued(Sec.3107,Civ.C.)
0Lender's Name TOTAL:
LUQ Lender's Addsoss TOTAL:
L4 I certify that I have read Pis upphetaker and.slate that the.thove information is BUILDING
t, r7et correct.I agree td comply with all city and county ordinances and sone laws relating te QTY. MFCHANICAL PERMIT FEE
V F7 building construction,and hereby authorize representatives of this city to enter upon the SEISMIAli
above-mentionpe
ed prorty for inspection purrytses. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupenino against ELECTRIC IT
liabilities,judgments,costs and expenses which may in any way aceme against said City ALTERORADDTOMECH.
in asequence of the scanning of this permit. PLUMBING F.F.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,003 CFM)
SOURC EGUI S. MECHANIC LTEE
u /- 1 ? AIR I{gNDLINO UNIT(OVER IO,OIM)CFM) CONSTRU.TIONTAX
signnaattureo onvactor / L Date EXHAUST HOOD(W/DUCT) HOUSING ATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant start or handle humorous materiel HEATING UNIT(TO 100,000 BTU)
as defined by the Cupenino Municipal Cale.Chapter 9.12,and the Health and Safety
Cole.Section 25532(m)'1 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No PAID
VENTILATION PAN(SINGLE RESID) Date Recei #
Will the applicant or future definedding nonfby the
use equipment or devices which BOILER—COMP(3HP OR 100,000 BTU)
emit hamrdous air contaminants as defined by the Bey Area Air Quality Alwhgement
District? 'fOTAI.:
❑Yes ON. BOILER—COM P(OVER 100,000 BTU)
1 have real the hazardous materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER
9 ISSUANCE DATE
fnmia Health&Safety Cede.c aI nos 255115,23533 and 25534.I wukrsmnd ma it td NEW RESIDI?N'1'IAI.MUCH. SQ.ff.
bulldingdrcsnnt yh:rvo ntenun1,that it ie my responslM1llity le maily the occupant
rho uireme suwnicymust lamu pddnoiaxnnnca ora Cenmc ,e`upanry. ,. ./
Owner or suntanned aagge/niter' Data TOTAL: ISSUED BY:
1.
OFFICE