26078APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
ILDIN-ELECTRICAL
OF CUPERTINO APPLICATION/PERMIPLUMBING-MECHANICAL
BUILDING a N IIUILDING PROJECT IDEN'I'IFICA'I'ION
PI?RMI'TNO.CITY
26078 0 J oQ
G r
BUILDING ADURIBSt
U' ' Z UNITW LOT#
SANITARY NO.
APPLICATION SUB/MI ITAI. DATIi
7 /q
OW
BRS NAME: PHONE:
NO:—NIC
CONTRACTOR'S NAME:le
❑
CONTROL#
, S.LIC
e
ARCHHE UE1GINEER: _ — LICNO:
ADDRESS,"
CONTACT: alio E:
QTY. ELECTRIC PERMIT PEE.
BUILDING PERMIT'INFO
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE
ryc0C-
; _
❑ '0 ❑
IO
LICENSED CONTRACTOR'S DECLARATION
I herehy off irm that Lon licensed under provisimnsofChvpter9(eommencing with
APPLIANCES - RESIDENTIAL
PANELS
DP TO 200 AMPS
Section 9lNIU)sl Dlvixion3 of to Business and Rofaeslons Code, and my license isln
full torrtall effect.
License Cla,v Lic.# t fLwile
—Contractor
✓ {�-
_C
Dam
- 1 sm
er I ARCIIITECTSomblic ATION
OVER
OVEk ItNq AMPS
1000 AMPS
SQ. FT. FLOOR AREA
S7SQ. FI'.
1 underemnA my plans nhnll he used es public recnrtls.
SIGNS ELECTRICAL
Licensed Rofessionul
OWNER-BUILDERptrom DECLARATION ON
SPECIAL CIRCUIT/MISC.
1 herby License Low for the
that I am exempt from the Gonion
TEMP. METER OR POLE [NST.
ns Code: Any city or
(Se Co
following reason. (Sem, to
L5, Businesser. andunloose,
co3
which se, Clear moony
permit orrepairud muaurc
its naso
its Ci exconstmn,alter,improve,demomilo
theaisions tfore pemtors filLicense
POWER DEVICES
that he La(Chaser
that he is ncensnl pursuant to the provisions of the Contractors License Luw (Cheater
to the Co
Y commencin Division 3ofthe Professions Cod e)
(
SWIMMING POOL ELECTRIC
VALIJ/QQM
exempt therefrom and ed exemption.
Sor ection
he is 1.5 by any applim and the berms for the alleged excmant to Any violation of
v subjects The applicant to,civil perky of
ii
1 ^� t ��
OUTLETS - SWITCHES- FIXTURES
.at noreduan3by
andledicmttforepermit
ployestorofwagcsasthei(sole
C1 morethan roffive hundreddollars yemp.
❑ I, mnwrk,andcpmperry,e
(J�
NEW RESIDENTIALELECTR _SQ. FT.
STORIES
IYPIiCUNS'IRUCTION
is not mil (Sec. Business
0aTL Business
will duthewons
he Contisnots License Law to an
and Professions Crdc: The Contactors License Law does not apply m an owner of
Colic:
property who builds or improves thereon, and who does such work himxlfnr through his
own employees, provided thmsuchimprvemesnare not intendedoroffered foreale.If,
OCC, GROUP
BES'UNITS
TOTAL:
however, the building or improvement is sold within one year ofcompletion, the owner.
hail der w 11 l have the burden of ruin that he did not build or int far f
P 6 prove purpnseo
Q1Y. PLUMBING PERMIT - J'I?R
❑ I. its owner of the property, am exclusively cunWning with licensed emm�remrx nm
FLOOD ZONE
AI'N
construct the pntject (Sec. 91004, Business and Professions Code:) The Contractors
License Law docs nmapply to an ownerofprpery who builds or improves Thereon. and
PERMITISSUANCE
who contracts forsucn projects with acontrucmr(s) licensed pmsusnt to the Contractors
License Law.
ALTER - GRAIN & VENT - WATER (EA)
PEE SUMMARY
❑ 1 am exempt under Sea , B & P C for this reason
sIs
BACK FLOW PROTECT. -W CE r
SANITA YN
—" RECGII'fp
Owner DoleRAT
DRAINS - FLOOR, ROOF, TyA, CONI. —
., 1
WORKMAN COMPENSATION DECLARATION
GRO AX Y N
❑ [herehy affirm the lhaveecenificate of cmnsenno self-irnure.on ccnificme of
Workers C ...... join Ins urencem acetified Copy thereof(SaJ800. Lab C.) which
FIXTURES - PER TRAP
RECBIET4
PARK FEE Y N
GAS - PA.SYSTEM- IN040��y-�
YA k�.
n vllcmployee's undenhis permit
Policy #
RECEI.7
ILDING DIVISION FEES
Companyert
GAS - EA. SYSTEM- BA)
PLANCHECK FEE
❑ Certified copy is hereby furnished.
GREASEANDUSTRL WASTE INTERCEPTOR
GRADING HE
Certified copy is filed wit the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GRFASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 200 FT.
ENERGY FEE
(This section need not he completed ifthe permit is forms, hundred dollars ($100d
or les,.)
WATER HEATER W/VENT/ELECTR
I certily that in the periosmunce of the work for which this permit is issued, Ishall
not employ any person in any manner so as in become subject to the Workers
PAID
WATER SYSTEM/TREATING
Compmnsmlon Lnws nfCulifnmia. Date
Date Receipt#
Applicant
NO'IICH 'TQ APPLICANI':If,afler making this Certificate of Exemption, youshouW
NEW RESIDENTIAL PLMB. SQ. FII
TO'1'AI.:
hecsme subject in the Worker's Compensation provisions of the Labor Code, you muss
forthwith comply wiih,,uch provisions or this permit shall be deemed revoked.
OUILDING FEB /"
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby uffirm that tem is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Nome
TOTAL:
ELECTRIC FEE
Lenders Address
QTY, MECFIANICALPERMIT PEE
PLUMBING FEE
1 certify that I have read this application and version the above information is
Correct. I .,.,a Comply with all city and county oNnc
inaes and stem laws relatiligto
PERMIT ISSUANCE
MECHANICAL FEE
buildingeautruction, and hereby uuthonu representanves of this city to enter upon the
abovementioned poll for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(WC) agree to save, indemnify and keep harmless the City of Capetian against
liabilide.,judgmcn¢, rose and asperses which may in any way accrue against said City
AIR HANDLING UNIT (TO 10,000) CFM)
conseyuen�t fthe grg of tisatinpermit.
T \
AIR HANDLING UNIT(OVF.R 00,0010 CFM)
6Aii)
Signature or ApppllicanUContructor Date
EXHAUST HOOD(W/DUCry
PAID
1[EATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt #
aceorhandl as material
Will the applicant or furore hiding occupant erre m handle hazardous Health
as defined by the Cupeninm Municipal Code, Chapter 9.12, and the Health anA Safety
HEATING UNITOVER 100,001) BTU)
T
Code, Scai 25 5 3 200'!
❑
13 Y5 ❑ No
VENTILATION FAN (SINGLE REBID)
Will the applicant or Onurc buildingoccupamose equipment ordeviceswhichemit
BOILER - COMP DIP OR 100,00(1 BTU)
ISSUANCE DATE
BOILER - COME(OVER BTU)
berardous air Contaminants as defined by the Bay Area Air Quality Management
District?
.h q
❑ 11100,000
Yee No
4
1 D
NEW RESIDENTIAL MECH. SQ. PI'.
I have lead the bmudous materials requirements under Chance 6.95 of the
California I lulth & Safety Code, Sections 25505, 25533 and 23534. 1 understand that
if the building does not currently have a tenant, that it is my responsibility m notify the
qR _
C//�
cupant of the rtyui7�$�^\ a which run be t/p^,or to iumnce of a CCnifioare of
«cuaurcY.
Vh `
✓ J_on ,'/? /9y
y
ISSUED BY:
Owner or authonacd agent Data
TOTAL:
OFFICL