29537APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDIbELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUME NG -MECHANICAL 29537
BUILDING PRl1d F.C1' IDENTIFICATION
BUILDING ADORES SANITARY _ SANITARY NO. APPLICATION SUBMITTAL DATE
wet. �pii1'1) QXi W01r� 7101 tS�I�IIF �j Qs C5.PI ";j
OW 10istig MI As2P NI?: CONTRACTOR'S NAME: LIC NO:
�+/fg3, •FII AfAd•'�F1 NIC CONTROLp
RARCHITEC"/ENGINEER: LIC NO: - ADDRESS: ❑
li►�A4M�Ar11�►�e,: �{i5-3265711
CONTACT.
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7100) m Division 3 of the lbeiness and Profccsimne Gde, and my license is
I. full force and eRo't.
License Class Lic. #
Done Contractor
ARCHTTECFS DECLARATION
I undep rad my plans shall be used as public records
❑ Consultant Fees Pair) by Applicant (Initial)
QTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT02WAMPS
OWNER -BUILDER DECLARATION 201-1(XX)AMPS
I hereby affirm that I em exempt from the Cnnlmcmr's License Law barite
following reason. (Section 7031.5, Business and Professions Cede: Any city or county
which requi cs a permit to nmstrun, tthcr, improve, demolish, or repair tiny structure
pd., to its issuance, abo requites the applicant for such pnmiun file a signedstatement
that he is licensed pursuant to the previsions of the Compactors License Law (Chapter 9'
(cmmnteneing with Section 70(10) of Fa,Aion 3 of the Business and Pmfe,,mus Code) or
Nat he is exempt Nerefmm and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not more than five hundred dmllm's ($51111).
Los owner ofthe property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended proffered for sale (Sec. 704,1, Business
and Prof slop. Code: The Convenor's License Law does not apply to an owner of
popery who bytes, or improves t such improvements
and vem dors such wnrk him elf or through
his employees, provided that such nnecal emilw are intended or deli r. for
sale. I -builder will
Ne buildingur i n of movint is soh within encyclical or completion, the
pmeeobuiher will hove the burden of proving that he did not build m improve for Pur-
❑Las owner of the properly, oat excessively contracting with :) The
contractors i-
onse La the project (Seeapply
7044. Business and Profccsions ds or The Conwcton, and
ss Lew dues not apply je an owner of property who builds rn improves Contra, and QTY.
whonse Low. such projects wi01a communists) licensed pursuammthe Comrucmi's
ElIamLaw.
Ism exempt under Sec. ,B&PCfor this reason
Owner am
D
emaintain
COMPENSATION UIiC1.ARAate
I I hereby affront under penalty of perjury one of the following dreti
eclannc
❑ Ihave and willa Certificate of Consent to self-insua for Workers Compi
cation, ax provided fur by Section 3700 of the Labor Code, far the perfomtanee of the
work for which this permit is issued.
❑ 1 have and will maintain W'orker's Compensation Insurance, as required by Section
371X1 nfthe Labor Codc, fur the perfornumce mf the work fur which this permit is issuol,
My Workers Compensation Insurance carrier and Policy number are:
Carrie,. Policy No.:
CER'1'I FICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE
(This section need not be completed Hine Permit is formic hundred dollars ($100)
or less.)
1 certify that in the performance of the work for which this permit is issued. I shall
not employ any person in any manner tit as to become subject to the Workers Compete
% s.It Laws of Cul l rorniu. Date
O O Applicant
G NOTICE TO APPLICANT: IL after making this Ceni ficate of Exemption, you should
CFri become subject m the Workers Compensation previsions of the Labor Cute, you must
forthwith comply with such Provisions or this permit shall be deemed revoked.
a
J - CONS
emisac RUCTION LEN DING AGENCY
U O I far by which
this pim it i is a construction lending agency for the performance of
C)Fthe Lewnrkforwhich]his preteritis issued (Sec. 3091, Civ. CJ
O U Lender's Name
W Lenders Address -
1 certify that 1 have read Misty and soca and ¢tete that the above infor hating e,
CA rortutlugrcemcotnply with all city and eomny ordinances and state lows hatinge, QTy.
U z abovengcvtioned ro end hereby auNon a purposes. fives of this citymcmer upon Ne
above mentioned property for inspection pugwus.
(We) pgreets, cove, indemnify and kith hay in an the City of Cnpenst s against
inconsequence ftheroc¢and expenseswhich may in any way vccme against said City
consequence NDS this permit.
WILL
APPLICANT UI Di] STANDS AND WILT. COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature o'ApplipmViComrucmr Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haxurdmoe nnuenal
as defined by the Cupenim Municipal Cole. Chapter 9.12, and the Health and Safety
Codc, Sieben 25532007
C3 Yes Fl No
Will the applicant or furore building occupant use equipment or devices which
emit hanrdous air contaminants as deposit by the Boy Area Air Quality Management
Dotnctp
❑Yes nNo
I have tensile: hazallous materials requirements under Chapter 6.95 right Cali-
fornia Heahh & Safety Gds, Sections 25505, 2.5533 unit 25534. 1 understand that if the
building does not currently have a tenant, that it is my responsibility to notify the occupant
of the requirements which must be met prior to issuance of a Cenilicane of Occupnacy.
Owner or authorized agent Data
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
'I' EMP. METER OR POLE INST.
POWER DEVICES. -
SWIMMING POOL ELECTRIC
(IUTLE'I'S - SWI I CHES - FIXTURES
NEW RESIDENTIAL ELEC lk SQ IT.
PLIJMB INO PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & \
BACK PLOW PROTECT DEVICE
(BRAINS- FLOOR, ROOR AREA, C( _
PINTO RIS -PER TRAP
GAS -EA. SYSTEM -1 INC.4OUTLEI'S
GAS- EA. SYSTEM OVER 4(EA)
GREASIYINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER -SANITARY -STORM EA, 200 FT.
WATER HEATER W/VENT/ELL'CTR
WATER SYSTEMMEATING
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ. IT.
MIECHANICALPERMIT
PF,RMI'1' ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10. 000 CFM)
AIR HANDLING UNIT (OVER 10,000 CPM)
EXHAUST HOOD (W/DUC ,
IfRATING UNIT (TO 100,010 BTU)
I]EATING UNIT (OVER 100,003 BTU)
VENTILATION CAN (SINGLE RESID)
(BOILER - COMP (3 HP OR 100,000 BTU)
BOILER - COMP (OVER 100.000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. IT.
FICE
FEE
❑ -❑ ❑ ❑
JOB UESCRIVIJON
RESIDENTIAL
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑ PLUMBING REPIPE
❑MULTI -UNIT
El STRUCTURAL
MODIFICATION
❑INTERIOR
El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR
El DEMOLITION
❑OTHER
J�
COMMERCIAL
❑NEWBLDG/ADDITION
❑DEMOLITION
❑TENANT
FOOD SERVICE
IMPROVEMENT
❑OTHER
SQ. Ff.
iA / / IF r %
(BUILDING DIVISION PEPS
PLA
NCHECK PEE R8 YIW
ENERGY FEE
GRADING PEE
SOILS FEE�Wjr*,
PAID
BUILDING FEE
PEI? SEISMICFEE
ELECTRIC FEE
PLUMBING FEE _
MECHANICAL PER
CONSTRUCTION TAX -
HOUSING h1ITIGATION FEE
PAID --
to Receipt#
TOTAL: