28720APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL PERMITNO. A w'2 0
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL L
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CONTACT: PHONE:
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❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
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LICENSED CONTRACTOR
under S DECLARATION
I hereby affirm Thin 1 Pm iib B r under provisions of Chapter 9 (commencing
with Sution](Xp)ofDivision 3nfthe Business ane Prnlesaiots Code.md license is
m full force Pnd arc« . O
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License las,. _ Lia. /
Dr Contrunm ' `
ARCHITECTS DECLARA'I'10
I understaml my plans shall be used as Public meant
QTY. ELECTRIC PERMIT FTE
JOF3 DESCRIPTION
RESIDENTIAL,
❑SFDWL C1 KITCHEN REMODEL
❑ADDITION [I PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
E) INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
C1 BATH RP,ryirpp1C`UREPAIR ❑DEMw
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JJJIII 111
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL -
PANELS
UPTD 201 AMPS
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Professional
DECLARATION
Dat I am exempt firm
1 hereby affirm that 1 am exempt fmm the Contractors License Law for the
whichfolloingmmi, mason.
parnalt ]o3 (irm. after, Pict Professions Co de: Any city or musty
whim requircan permit retmreWc6Nmr,improve.h permit t firepair any tuement
that hes its blernenm.aBorcmdre the proatilica,nthe sucContractors Licensle ae ned aw(Cltemem
thsheisliia, with pofDisi,nso od he Bman,i, nd Pmmxdmw Tuptcr9
Calc)or
Division 3 oftbhaped eenAt,,
(car he is sem ith Seaton] add the cal pploar1exemption. Any it Pa tine of
therefrom and for .Per fns tire bj subject.
ths phis 31.5 by
Scednn]o11.56y any epplicam fore permit subjects the epplicam macivil penPRy of
not mare than five hundred dollar ($500).
(] I, as owner orthe pmpeny, or my employees with wages as their sole compensation,
will do the work, and thentionate is not imenacdmoffcrcd for sale(See70,14, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds in, improves thereon, enol who does such work himself mr through
bis own employees, provided that .such improvements are not intended or offered for
sale. If, however, the building or improvement is sole within one year ofcomplctimn.the
owner -builder will have the burden of proving that he did not build or improve for pur-
ryraofale),
❑ 1, as owner of the property, am exclusively contracting with licart amann ems to
'comuuct the pro04
project (See. ]4, Badness and Pmfessin a, Code:) 9'he Contractor's Li-
se Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a conoactoKU licensed pursuant o the Communities
License Law.
El I am exempt under Sec. , B & PC for this rcaimn
201-1000AMPS
OVtik 1000AMPS
SIGNS ELECTRICAL
SPECIAL CINCUITIMISC.
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
[]TENANT ❑ FOOD SERVICI?
IMPROVEMF,yT
❑OTHER
POWIiN DEVICES
SWIMMING POOL ELECTRIC
DUT1.13TS- SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ Er
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SQ. FT FLOOR AREA
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'I $�
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NOV 1995•
,
CITY ur uurtrs I INU
$/SQ. FP.
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QTY. PLUMBING PERMIT I7BE
PERMI'I'ISSUANCE -
ALTER - DRAIN & VENT- WATER (HA)
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Owner Dme
VALUATION
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WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Ceniocse of Conserv to self -insure for Worker's Cumpen-
anion, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will mei rdir Workers Canape nsaIran Insurance, us reruirrtl by Section
37W ofthe labor Care, for the performance ofthe work for which this permit is rowed.
My Worker's Compensation Insurance carrier and Policy number are:
Currier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ihissmtion need not be completed ifame t is boom, hundred dollars 100)
lass.) pcmn
Icmify that in the performance of the work for which this permit is issueJ,lshall
nme ny any person in any normae so as nbecgsu}9ec Workers Camper-
sur laws ofj'alifomt etc A /� 1) / <'� }9 yipd,e
pliant—L`rrta r��i 1ti /r�I hY���S(
BACK FLOW PROTECT.
DRAINS- FLOOR, ROOF AREA,
STORIES
TYPE CONSTROC ION
FIXTURES - PER TRAP
GAS - EA. SYS 'FF -1 INC. 40UT S
OCC GROUP
APN
GAS - P.A. SYSTEM -OVER 4 HA)
GREASPIINDUSTRL WASTE INTERCEPTO 40
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEE
SEWER - SANITARY - STORM EA. 201 FT
ENERGY FEE
WATER HEATER WNF.NT/ELECIR
GRADING FEE
NOTICE TO APPLICAAAA�Ber mramlml this Contriver, of Exemption, you should
become subject to the Workers Compensation provisions of the Fads Code, you must
mnhwid, comply with such provisions or this permit shall be deemed revoked.
GDNST is.axs Now;ionINGAGENCY
Ihercbyamrm that there isaconstmnion lending agency for the of
the work for which this pent is issued (Sec. 3197, Co, C.)
Lander'a Name
WATER SYSTEM/TREATING
SOILS FE
WATER SERVICE
PAID
Date Rttcipte '
NEW RESIDENTIAL PLMIi. SQ. EF
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TOTAL:
BUILDING FEE
rill
Lender's Address
I cenif at I has d this application and st�yt� th a above information is
comet. I actocnmp with all city and county ttPdo as and state laws relating to
orm, Iran, rep con, 'vas nfthi,�city mententrymthe
tion n instruction, ,form,,
uhn-mentioned r ve findemnedionp
(We)ugree save.indemnify keep Ks Tess the City of Cupeniw agaimt
iabilities,juden ts,astsandexpe swhict, inn accmc against said City
in autocrat a nortin, of rs par
APPL T ENSTANDS AND LI. COMPLY ITH ALL NON -POINT
SO CER. ' TIONS.
,]
TOTAL:
QTg MECHANICAL PERMIT' FEE
SEISMICV11.
PENMITISSUANCE
ELECTRIC
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT pro 10,000 CPM)
MECHANICALFE
AIR HANDLING UNIT (OVER 10,1101 CFM) '
CONSTRULTIO A%
.ignatu Applice C nano Date
ZAR SMATE LS DISCLO
WhIfficapplicant,ffumrc.uildi aeupant sone or handle haeardous mmerial
us defined by the CUPeninn Municipal ode, Chapter 1.12, and the Ilealah tint Safety
Coble Section 25532(0)'1 /
[I Yes (g•N
use equipmentArQin or devices which
Will the air accountants,
tafmurc building by he
emit hazardous air cuntnminants a Jefincd by the Bay Area Air Quality MPnegemenn
District?
F7 Yes Na
I have rend the batardmus materials repriremenu under Chapter 6.95 offle Cali-
morma Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that Hthe
hnilding Jar notur
crct0y have a amount, that it is my respossihility to notify the occupant
of the rerulmments which must be met promo issuance of u C nifi am of Occupancy.
EXHAUST HOOD(W/DUCT)
HOUSING MIT ATION FE
HEATING UNIT ORD 100,010 BTU)
HEATING UNIT (OVER 10B.000 BTIJ)
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PAID
Dat Receipt
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VENI'ILATIONPAN (SINGLE RES ITU
- -
BOILER - COMP (3HP OR 100,000 BTU)
AI
BOILER -COMP (OVER 10 ,000 BTU)
AIR CONDITIONER
ISSU CE DATE.
'
ISSUED BY "V'✓ - /
NEW RESIDENTIAL MECH. SQ. EE
Owner or authorizW agent Date
TOTAL:
OFFICE