S 1740APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO IH H.DING - ELECTRICAL _
Bra LDING DIVISION APPLICATIONA'ERMIT PLOMHINC•-MECHANICAL
HUMMING PROAL?C,'1' IDENTIEICA'1'ION
PEB IT NO, 1740
BUILDING ADDRESS ��� ��"�,A (\aY,1��1( v�•
MAO OD rSWPW H PAULA
SANI'IAI<Y NO,
AI'I'LICAI'I�SUIIMI' AL DATE
OWNERS NAME V1 PHONE:
CONTRACTOR'S NAME: LIC NO:
SEt
NIC
❑
CON '1'ROLp
RCHfIIiCI'/IiNOINEER: LIC NO:
5 �t F
ADDRESS:
OrvrTACT:. p e p(,�. /` PHOMi:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MIiCH
`q6 -ZSO I `�
❑ Consultant Fees Paid by Applicant(Initial)
`460)
s o —Ian 7 w
❑ 7F❑ ❑
�aZ
] O OPERMIT
L -F"
C-yU
W
LICENSFD CONTRACTOR'S DIiCLARATION
I botchy affirm that I all licensed under provialon. of Chapter B (commencing
with Seaiunn00).f Diviub Intl the Rc.loess nnJ Professions Code, and mylicemcis
eBect. M
infulle Class
License lvsx Lic.
Dam Contractor
QTY. ELECTRIC I'1912MIT FCC
-
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL [I KITCHEN REMODEL
❑ADDITION [I PLUMBING RE -PIPE
'Id1NIT ❑STRUCTURA
❑MUI:1L.
MODIFICA'T'ION
[I INTERIOR El CHIMNEY REPAIR
IMPROVImiNT E]SWIMMINGPOOLS
F1 BATH RENIODELIR17PAIR El DEMOLITION
17fFIER
ISSUANCE
APPLIANCES —RESIDENI'[At.
O Q
�m
ARCH1TEC7'S DECLARN'(ON
I walmsam my phuo Out be.,d o. puhlic ne,unis
PANELS
UP TO 200 AMPS
L W Q
. U
O^
Licensed Professional
OWNIiR-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Convectors License Law for the
following obiu n. (Sllion 7031.5, Business and Flofcsinns Cale: Any city nr county
which M,mo,s a permit to construct, alter,iIMPnne, duna9ish, or repair any structure
priorolLv inenxncq also raptircn the.pFlicma fnmcll....nino filcasignalstmctneth
201-1100AMPS
OVER 1000AMPS o
SIGNS ELECTRICAL
SPLCIALCIRCUI'I'/MISC.
Jct
!Iy
COQ
a
S c IY
�Z
m
thahei.liccnscdpursuantiothcprnvisionsoflhc Contwtor's]-iccn,c[,aw(Chapmr9
(wmmnming with Seainn]IX)()prf Divumn3 of the llusinery and PrnlcssiunsCdepa
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to u civil Penalty of
Int more than rive hundred dollars( S500).
1, as owner of thepropeny,nnny employ... with want as thcltsnl, mmpemation.
wdl do lou uvrzk, and do onucaue is not immakad or nRned farad, (See. 7144, Burine.,
and Profession, Cale: The Common 's License Law does not apply an owner of
ma
who builds or improves thereon, and who does such work himself or through
TEMP. MIiTI1R OR POLE INS'K
COMMERCIAL:
❑ NEW BLDG/ADDI'OON ❑ DEMOLITION
,D TENANT (D FOOD SERVICE
IMPROVEMENT
171 OTT [];-ITV
POWER DEVICES
'WIMMIN. POOL ELECT RIC
OITTLIi1'S-SWI ICHES-IBX'TUH&S
property
his own employees, provided that such improvements am not intended or offered for
sale. If, however the building or improvement is sold within one yevrnf completion, the
NEW RP_SIDENT1AL ELLCIR SQ FT.
SQ. FI'. FLO(jpylRf�A'
VSQ. IT.
e did not build or prove for our-
ownerbuilder will have the harden of proving that him
C �' D
pose nl'slde.).
I, vs owner ofthe pmprny, um exclusively ernioning with licensed contractors m
nnrnjea (Sec. 71,44, Baines, and Profession. Cale:) I he Contractor', Li-
aa the ro
JUN 1
'I OPAL:
nselawdt knot pply to an owner of.ropeny who builds orimprnscs thereon, and
QTY. PL PERMIT FEE
�
wholontace also mj es with a contramor(0 licensed pursuant to the Commit
CITY
PERMIT' ISSUANCE
License Law.
❑ 1 am exon . H & P C for this action
Ur
Wren 1 uV
Date
ALTER - DRAIN & VENT- WA'
VN.IJA PION
BACK PLOW PROTECT. DEVICE
OR -R'S COMPENSATION DECLARATION
I herthy alarm under Dcnalty nfperjury one of the following dedamdons:
I I have and will maintain it Certificate of Conaenuoself-insure for Worker's Compere
inion, as provided for Section 37of the Luton Calc, for 0. perlitntvnce of thu
DRAINS -FLOOR, ROUP,44CONUf
S'roRILS
TYPE CONS'fRUCf10N
work for which this perininil is ixnual,
FIX'I'UItE$ -1'IR TRAP
❑ I have:md will maintain W .. orr, Cion,c alio i Insurance, as on,mard by Section
3700 ofthe Labor Code, forlhe Performance ()(the work lorwhich this permit is issued.
GAS -EA.SYSTEM-I INC.40UTLE'1'S
OCC GROUP
APN
My Workers CompeMinum Insurance extraction] Policy number arc:
Cartier. Policy Na,
GAS- HA. SYSTEM -OVER 4ICN di
GREASH/INDUSTRI, WASTE I NTF.RCEPI OR Cy
CERTIFICN'E OF EXEMFHON FROM WOR KERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
Cflllx ticdion ted nal bcamtpletd if0opm;nit is l'nr one hnndl'aldollm, S10))
...less.)
GRLASIi'fRAP
PLANCIIECK PEE
I cenifyihaf inthe.erfammaceofthexork for which thisporon is issued, limit
not employ any peon in any maner so nas,, bemmc subject subjeco the Workers Cion,.-
rs
SEWER - SANITARY -S'FORM EA. 200 FT
ENERGY IIBi
WATER HER WELECfR
WA'I'17R SYS 'I'17MUREAI ING
GRADING PCE
',�
� O
rjA
a
6 Q
7Z
L)
I't' 17"
e
saioicant o(Califnmia. DaHEATERNNI'/Ii
Applicant
NOTIC1710 APPLICANT: IL cher making chis Certificate of P,xmnpfion, you should
hereon,"to",tothe W..iCompcnsalonpnwlsions nfthe labor Code, ynulnnal
fonhwiobcnntply with such Forte imi this pennnnholl be deemedmvoked.
CONSTRUCTION is o rIONL;ion lending
i.a ed(Sri.10 len ding agency for the.erformancanf
IM1erebyvftirtn l annual
the work for which this permit i, issued (Sec. 3(N), Civ. CJ
Lender's Nunn
SOILS FEE
WATER SERVICE
PAID
Dam '
TO 1'A L:
NEW RI!SIUENTIALPLMB. SQ.
U
� U
WBUILDIN
OZA
V z
Lenders AAdrexs
this applicationaemono.rare that the starve information,g is
1 certify that 1 have with
comply and withvllumnad counryotatives eland say to entr upongu'
building construction. and hereby authnnze representatives of this city to enter upon the
'I'(yl'AL:
ITEF
Q'fY. MECHANICAL PERMIT FEE
SEISMIC
Is
PERMITISSUANCE
ELECTRIC THE
vhnve-ntemianed.,.No, far inspection pamp ... el
re Indenmily.nd keep harmless the Clly of Cupertino againel
(WfA
ALTEROIt ADD'IOM1701.
PLUMIIINGP
iabilma axlwnscs whicbmnyinnny way aecnm nguinxt said CllY
it e.nseling of iti Pennh.
AIR HANDLING UNIT (IT) IQ(XO CFM)
MF.CHAN] ALIBiE
APPLICNOS AND WILL COMPLY WITH ALI. NON -POINT
SOURC 1[�
.(" Q Y
AIR HANDLING UNIT (OVER 10.000 CIM)
CONS MUCTI TAX
SignatunlNpplw unllrrodur Dane
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant orfunummilding m'enPam xlorcormarfic intimations material
EXHAUST' I IOOD(W/O(JC'1)
HOUSING MI'TIQAT FI?li
HEATING UNIT ('1'0100OX) Ii'I U)
as defined by the Cupenlnm Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
HEATING UNIT (OVER Ilq,(XIO BTU)
❑Yes 0 N
Will the u licanl nr haute huildia, orcn a I Ise et ai next or devices which
PP 6 PTI' PI
emir hazmdnus air ummminau, as deiced by the [lay Area Air Quality Management
PAID
Datc Receipt p
VENTILATION FAN (SINGLE RISID)
ROILL'R-COMP(JHI'OI211XklNX1 BTU)
TO'T'AL:
BOILER - COMP(OVER 11)(1,0X0 BTU)
iarictP
❑Yes ❑hm
AIR CONDITIONER
I have mad the hazmJous..aerialsrees under Chatter 6.95 of the Calm
requirements men
ISSUANCE DATE
NEW RESIDIiNT1AL MliCll. SQ. Irl'.
fomia HrnhM1 is Safety Cde, Section, 255]3 34, 1 undclxwnd that Hill,
ding dna nut currently have er2Shat,, e,sma cl ramify thenwcelvnt
nom, that It is my actiofa
be Celity
of IM1e rcyvircmens which mull beano issnmme of a Cenillcute of (XntDancp
of t
ISSUED BY: V Y
TOTAL:
Owner or amhonzd meat Date