B 0432 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ BUILDING-ELECTRICAL p PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �pnp
- BUILDING PROJECT lI1ENTIFICATION. 1+��
BUILDING ADDRESS: - - SANITARY NO. APPLICATION SUBMITTAL DATE,
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OWNESNA�p: PHONE: CON ACTOR'S NA LIC NO:
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H TF,CT/ENGI LIC NO AWkF.S$: ❑ ��� /�
CONTACT: PHONE: , BUILDING PERMIT INFO '
❑ Consultant Pees Paid by Applicant(Initial) BLDG LEC'T PLUMB MN,CH
LICENSED CONTRACTORS DECLARATION
QTY. ELECTRIC PERMIT FEE
1 hereby uffiun d a l l e 'a d provisions f Chapter 9(conn ng JOB DESCRIPTION
W04 zOC villa Section 7000)if D' Isiooacidic Busin s and Professions Coda,md myl'anm is RESIDENTIAL,
WO PERMIT ISSUANCE
H W 0a.full force and eR«t ❑SFDWL El KITCHEN REMOUEI.
4,UU License Class' Lic.% APPLIANCES—RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
F W Dam Cdclocon
ARCHITECTS DECLARATION El MULTI-UNIT El STRUCTURAL
ZOm'� I understand my plans shall be osetax public records PANELS MODIFICATION
UP TO 200 AMPS
OZ G Ed INTERIOR ❑SWIMMINGREPAIR
OCU
P4tM,.44 Liansul lknfcasioovl 201-1000 AMPS IMPROVEMENT SWIMMING POOLS
C 6 OWNF.RRUILDER DECLARATION OVER IOW AMPS ❑BATH REMOUHIJIMPA1R ❑DEMOLITION
�0 1 herehy affirm that 1 am exempt trait the Contractors License Law lot be
iWSiyy O U following moon.(Section 7031.5,Business and Pmfia,,hirs Code:Any city or eamnY SIGNS ELECTRICAL OTHER
which requiras a permit to wnswc6 Year,improve,demolish,or repair any avucmre
prior 1n its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
G� Oma he is licensed purman,0 the provisions of the Cintraamrs License Law(Chapter 9
COMMERCIAL:
4,.00 (ambermiingwith Sachou TOW)oi'Division3efihe Businessand Professions C.de)or 'TEMP.METER OR POLP.INST
0.q a a' that he is exempt therefmm and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W"m
Station 7031.5 by any applicant for a permit subjects the applicant o a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
yZ
not more than Eve hundred dollars($5W).Y IMPROVEMENT
�p60 ❑ Lo he work,the pmp,ny,nrmyemntendex wiNwages as their sole compensation, SWIMMING POOL ELECTRIC
will Pr Newark.and athe The structure,notLicenseed Law
do for
no(apply to an owner
❑OPHI?R
� m and Professions Code:Tlno Contmchars License Law does nil apply to an iwnit of OUThP.TS,_SWITCHES—PI U '
a property who builds Or improves match,and who does such work himself or hrough
his own employees,pervaded that such improvements are not Intended or iRered for NEW RESIDENTIAL ELEZZ
sale.If,however,the building.,improvement is sold within one year ofcompletion,the Q FQ. 01 S/SQ.FT.
wartheilder,will have the banderol person,that he did not build or improve for par,
f sola).
l
an o
E]1,n.,her of the pmpeny,nm exclusively contracting with licensed conductors t, �j 0 1999
instruct the project(Sec.9044,Business and Profession,Cadl The Conwrir',Li-
me Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT
who contracts for such projects with a cortraaor(,a)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
❑Iam ova pt un ,B&IsCfir La revO
ALTER—DRAIN&VBM—WATER(EA) 8 VALUATION
Dale
WOkKF.R. ' S ION DECLARATION BACK FLOW PROTECT.DEVICE, I O
I erehy vfrtm under penalty if perjury one of the following eclvtations
I have and will maintain a Cenifiale of Consent to self-insure for Workera Comped- DRAINS—FLOOR,ROOF,AREA,GOND. STORI S 11 TYPECONSTRUCTION
Orion,us provided for by Section 3700 of the Labor Code,for the performance of the
work for wldch Nis permit is issued. FIXTURES—PER TRAP V N
E]I have and will maintain Wirkeu's Coen
mpsalirn announce.as required by Section
37M oflhe Labor Code,for the performance ifthe work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP _
My Workers Compensation Insurance carrier and Policy number aro: 2 ',7 1
Certain Policy N..: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FF_P.S.
(Thio section need urn ha cemplemJ if the pemdt le Nr one hundmd dollars($100) GREASETRAP
or loss.) PLANCHECK FEE
I codify that in the performance ofthe work firwhich this permit is issued,Ishall SEWER—SANITARY—STORM EA.2W FT. - -
a.t employ any person in troy meaner so as 4n,became subject m the Workers'Curacao- ENERGY FEE
,•7. cation Laws of California.Data _ WA'PER HEATER WIVENT/ELECTR
C Applicant ) GRADING FEE
`t NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTRAICRF.ATING
f•'t hcome suhjeot m the Worker's Compensation prawkinns of the Labor Coda, an most SOILS FEE
Wty forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW kESIDENTIAI.PLMB. SQ,FT. PAID
V Q I hereby affirm that is.construction lending agency for the perfoutance.1' Dom ip
i—t the work for wlorlF this permit is uhard(Sa.347,Cie CJ
w H Lender',Name TOTAL.
W Lender',Address TOTAL:
1 certify that 1 have read this application and Male Net aha alcove information is BUILDING FEE
Z) correct.l agerem comply with all city and county ordinaries and state laws relating to QTY MECHANICAL PERMIT ' FEE
building construction,and hereby authorize representatives of this city to enter open the SEISMIC FEE
,dam e-memexual property for inspection purpose,. PERMIT ISSUANCE
(We)egreeto save,indemnify and keep harmless the City Of Cupenine u,aint ELECTRIC PGE -
liabilitFccoftheinne,tstpis"init.
and exenses which may in any way accrve again,said City ALTER OR ADD TO MECH.
inconcrew, haPLUMBING FEE
APPLSTANDS A WILL COMPLY WITH ALL NON- DINT AIR HANDLING UNIT(TO 10,000 CPM) MLCHANICAL 1'EE
SOURNS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX -
Sign fApplianl/ tacmt Date/ EXHAUST HOOD(V/DUCT) HOUSING MITIGATION PEC
HAZA MATER I.S DISCLOSURE
Will the applicant or farm building occupant store it handle hazardous material HEATING USTI'r GO 100,000 BTU)
it,darned by lino Cuprnini Municipal Coda,Chapter 9.12,and the Health and Safely
Code,Sectio 25532(a)'I HEATING UNI'1'(OVER I OII,1N)0 BTU)
❑Yes EJ No VENTILATION FAN(SINGLE RESITY PAID
Dam Receipt#
Will the hirlioam art firm,,staining eeenpant use equipment.,devices which
mit hw.rdnus air orientation as defimed by the Bay Area At,Quality Management' BOILER—COMP(311P OR 100,000 BTU) T(TAL:
District, BOILER—COMP(OVER 100,WOBTU)
❑Yes E]No
AIR CONDITIONER
64,A
M,e,S mrm15a 05.25533.n under Chapmr6.95.Rhe Culi- ISSUAN�
hermitCele,, a..W25505,25533 and 255]4.I understand Nm if the NEW RESIDENTIAL MECH. SQ.FT.
buildlyhave a.1 Nhin home�harlo i,s nceifaf7mbicadefOccupancy. C���/]�5]{p/���
Ow r am61
anzed age Dale TOTAL: ISSUED BY: +�
OFFICE