99080069APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY LL_ CA n5u)ntl7a
CITY OF CUPERTINO BUILDING - ELECTRICAL
PE
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- MECHANICAL.
'BUILDING PROJECI' IDENTIFICATION!..'
BUILDINGADDRESS:
19'6-71 < road f
SANITARY NO.
APPLICATION SUBMITTAL DATE
g_ Q
O ER'S NAME : PHONE:
I-P I G t ! �
A HITS iNGIN E C- LIC N(I:
CONI'RACI'012'S NAME: LIC NO'.
1 L/ z/ 7/
ADDRESS: N V
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SIC
❑
CONTROGO
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CONTACT. PHONE:
1/ BUILDING PERMIT INFO
Cultnt Fs Paid by Appliant (initial)
BLDG ELECT PLUMB MECH/
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby ammo mat I am Eeensed under pmvisiom of Chapter 9 (commencing
want Section 700(nofOivlsion 3ofthe Business and Professor, Code,and an, license is
in all numeral attecn
License Class LiaN
Da¢ Contractor
QTY ELECTRIC PERMIT FEE
,
O�z
00 a
LLF
aF.UU
JOB DESCRIPTION
RESIDENTIAL,
❑SFDWL O KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE-PIPE
PERMIT ISSUANCE
APPLIANCES—RESIDENIAL
NQL
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ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
PANELSm
UP TO 200AMPS
❑MULTI-UNIT ❑STRUCTURAL
MODIFICATION
0INTERIOR E:1 CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
O BATH REMODF.IIEPAIR❑ DEMOLITION
❑OTHER
Licensed Professional
OWNIam exempt from
Ce Contractors
1 hereby a"act that 1 I exempt from the le,,do , Co License Law for the
following reason(Sermon 7113L9. Boalmi, and o Code. Any city nr rounrY
201-10X0AMPS
OVER I"AMPS
SIGNS ELECTRICAL
LL y
I"'
¢smut
00
improve,
whit" requires n permit m construct. aper, improve, demolish or repair any amount
demolish.
de
its eturance.also requires meapplimnt for such Contrarminoicese Law(Chapter9
he, heisring ih Sextant m(amel the alma 3the Contract.', License Law (, C de)9
Pmfesxionv CoJc)or
(ce,
SPECIAL CIRCUIT/MISC.
L
TEMP. METER DR POLE INfi'I'.
COMMERCIAL:
a a n
Mea
>y
W
W ao
hats exempthomfon9tNadm basison3ofobernosinessand
that he is exempt tbercfrmn nnJ me "osis for the allege) eaemilion. Any violation of
Sermon 7031.5 by any applicant far It .I, subjecrsthe applicannoa civil penalty of
rot mom mon Eve hundred dollars (8501).
❑ I, m owner of the propert, or my eiployces with wages as their sole compensation,
will dothewnd.andihestrucmreisnot intended or offered for sale (See, 7044, Business
and Professions Code: ITe Contractor's License Law does not apply In na r—net of
propcny who builds or improves memon, and who does such work himself Cr through
❑ NEW BLDG/ADDITION O DEMOLITION
OTENANT ❑FOOD SERVICE
IMPROVEMENT
EI OTHER
POWER DEVICES
SWIMMING P(IOI. ELECTRIC
OUTLETS— SWITCHES — FIXTURES
_
his own employees, provided that such Impmveramis are not intended or otfercd for
NEW RESIDENTIAL ELECTR S
SQ. FII FI,OORAREA
$/SQ. FT.
.sale. If, however, the building or improvement is said within oneyearofcomploion,the
b Ider will have the human of proving that he did not build m improve far pur-
Ie.l.
T
05—
owner of the propcny, am exclusively contracting with licensed contractors to
consumer me project (Sec, 7044. Business and Profexxions Code:) The Commmm's Li-
Cause Law illicit not apply to air owner of perfectly whit builds Or oppresses itheyetan, and
QTY: PLUM BING PERMIT FEC
who contracts fnrsuch Pro, act, tt Vernal(,) licenssd pmenanuo me Cannanore,
t
PERMIT ISSUANCE
Li s
❑ 'mexet tund"Sec ,B&PCbridal' t s
ALTIiR —DRAIN & VENT — WAFER (EA)
owner Dam
W KIiRS COMPENSATION DECLARATIO
VALUATION
BACK FLOW P11"I'ECT DEVICE
1 er yaf0rm onJcr pCnalty of perjury one of the following dechrrntinas;
U
DRAINS—FLOOR, ROOF. AREA, COND'S'TORI
❑ Ihxv anJ will maimoina CertiOcum of Consenunsell-insure lin Worker's CCmpen-
.tion, as presided for by Section 3700 of the labor Code, for tha permarrance of me
hS TYPE CONSTRUCTION
walk for which this permit is issued.
FU TURES — PER TRAP
❑ I have and will maintain Workers Compensation Inxorrace, microbial! by Station
9700 ofthe Labor Code. for meperformmtwofthe work for wbull his permp is issued.
MyW'orkers Compensution Insurance career and Policy number arc:
Cardec Policy Na:
GAS— PA.SYSTEM-I INC.40UfLh
GROUP APN
7 VZ
GAS—EA.SYSTEM-OVER4(EA)
CERTIFICATF.OFEXIiMPT10N ItROM WORKERS'lti
COMPENSATION INSURANCE
(This seniors need not IN eompincJ if be patron is fomite hundred 0111In, 04100)
or less.)
'. I1IJILDING DIVISIONFEES a
GREASFANDUS'fRL WASTE IN`TR#Vd0RH
GREASETRAP
K
IAN FEE
/ � � '
SEWER —SANITARY —STORMS
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r1)
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I terrify mut in the pedomnnce ofthe work for which this permit is issue, Ishall
not employ any person in any manner so us m become subject vt the Workerx' Cnmpen-
cation Laws al'Coliforniu. Data
App leant
ENERGY tE
WATER HEAT ME WNENI'/ELECTR
FEE
NOTICE TO APPLICANT. IL aper making this Cenipcnm of Exemption, you should
become subject to the Workers Compcn.sanon previsions of the Labor Code, you must
forthwith comply with such provisions or,this permit shall be deemed meow".
CONSTRUCTION LENDING AGENCY
I hor wh am. the marc acorn See, 30 )ending agency lar the performance of
work for which oboe pemtit is issuul fSw. 3097, Co. G)
WAITER SYSTEMnREATING
WA'IHE SERVICE
SOILS FEE
PAID
Date ReceiptN
NEW RESIDENTIAL FILMS. .FI
TOTAL:
0
Lenders Name
Le
Leaders Address
} f31
Val
C.),�
TOTAL:
BUILDING FEF.
I
I certify ohm I have real this application anA state that the above information is
correct. [agree meomply wire all e"yand countyerdinance.sand.stmemws relanagm
hnllding coaamnioa and hereby nwhnria.t repruenmtivas aF this city ro emer upon the
QTY, MECHANICAL PERMIT 'FEE'.
t I
SHISMICFEE?
almme-mentioned property for inspection purposes.
(We)agree m save. indemnify and keep harmless the City of Cupertino against
PERMIT ISSUANCE
ELECTRIC FEE
Iialeities,judgments,ams and expenses which may in any way acame against said City
asequence Cf rhegmata th'npermit.
tPPL
AI:I BR OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (TO 1(1.1100 CFM)
MECHANICAL FEE
ANT' .RS S AND WILL COMPLY WITH ALL NON-POINT
URC GO I
AIR [LANDLINE UNIT (OVER I0,010 CEM)
CONST'HUCTION TAX
'
EXHAUST HOOD(W/DUCTI
gnu col' p Commnor a
HAZARDOUS MATERIA/ DISCLOSURE
HOUSING MITIGA'T'ION PEE
HEATING UNIT (TO I OfLINO BTU)
Will the applicant or future buildi ng Occupant store or handle hazardous material
its defined by the Capetian Municipal Code, Chumer 9.12, and the Health and Surety
Coda Section 25532001
HEATING UNIT (OVER IBB,IIW BTU)
❑Yes Fl No
Will the applicantorfuture building mea equipmentordevicaswhich
emit hazndous air nnmwninuna as dtline by by Thethe BBay Area Air Quality Management
Uistdn?
❑Yrs ON.
1 hove real me haznmous tial. arena uecr Cha tar 695 ofine Coli-
snspare p
PAID
Date ReteiptM
VENTILATION PAN SINGLE RESID)
BOILER—COMP 100,000BTU)
TOTAL:
BOILER—COMP (OVER 100.900 BTU)
L
AIR CONDITIONER
ISSUANCE DATE
NEW RF.SIDF.NI'IAL MECH. SQ. PT
ealth &Safety Code. S ti s 25505. 255V and 25514. 1 undcrsmnJ ohm if me
ilding not to ❑yh rnnt.,hat it is my msponsiolity m notify l ecce t
ort nw 'h .era met no issuance ofa Cenificm f
ISSUED BY:
or A thori eJ rot 1 1 nd
TOTAL:
OFFICE