S 0260 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMJCIT NO. 0260
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PRf1JEC1IDENTIFICATION
BUILDING ADDRESS: SANI'LARY NO, APPLICATION SUBMI'1"FAL IIA❑
033
$a 6 iSV'
air
OWN 'S ME:k rd P ONE. CON I RACfOR'SN C: IDC NO: �/�r/��/1��-31
NIC 2 C✓—v M
.ARCHITE I'll: GINECR: AIC NO ADDRESS:
27
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicanl(Initial) HI DO ELECT VIAMB SfCCH
LICENSED CONTRACTOR S DECLARATION . .
I hereby affirm that 1 am licensed under proQTYELECTRIC PERMIT FEE
visions of Chapter 9(commencing JOB DESCRIPTION
�0Z with gection]IXXgel, vision 3ofthe Buamessand Professions Code, dmy Iicunae it ,T
F O "n fall 6meand eRect. ��/ PERMITISSUANCE
�V1"' L [I KITCHEN RCMODIih
Z License Class Lich APPLIANCES-RESIDENTIAL
yQ Date _ Cunvamor ❑ADDI'TION ❑PLUMBING RE-PIPE
It.7m ARCHITECTS DECLARATION PANELS MULTI-UNIT ❑STNUCTUNAI.
Z p m� I undentend my tans Nall Me sews as public records MODIFICATION
024O I1P'I'O ZIIO AMPS
F F'41 LuenwJ Profesnonal [IINTERIOR ❑CHIMNEY REPAIR
201-1000AMPS IMPNOVEMI!NT
OWNER-BUILDER DECLARKI'[ON ❑SWIMMING FOOLS
Q 1 hereby affirm tbut I am exempt from the Connector's License Law lot the OVER 1110E AMPS El BATA REM(]DF.IIREPAIR ElDEMOhI"P[ON
6OaV following mawn.(Stettin]031.5,Businessand Profit,inns Cela Any city or county3SIGNS ELECTRICAL
❑OTHER 1L F" which requires a penuil w amsucel,alter,improve,demolish,nr repair any amemre
�I�0 prinrtoitsisaue,
anculsorequirestheapplicam for such pemainn Neasigned s0aemem SPECIALCIRCUIT/MISC.
.EMp. Nat he is licensed pumman to the provisions of the Conamewri License law(Chapterf)
�E58c (commencing with Section]Ik00)ofDivision3eftheBusiness anti PrmoAion,Calc)m IHMPME1tRORPOLHINST. COMMERC&
0. n that he is exempt therefrom and Ne basis fur the alleged exemption.Any violation of
'MN Section 7031.56 an applicant for El NEW 1,pG/ADDITION ❑DEMOLITION
Y Y PP permit subjects the applicant to acivil penalty of POWER DEVICES �a,w4
*111
5 y not Loreohne fivehundreddol oursyemp. ❑TEN VYf/K/tt�' OU SERVICE
i,=0 ❑ Las owner n(Ne properly,or my employees with wages as their sole cmnpenselion, SWIMMING PDOI.ELECTRIC IMPR
a;1-t will do the work,and the structure is not intended uraaReud forsale(See 7] ,Business ❑tM1h�Bg
�13 and PmfiN,,mm Coda GO ConmanL's License Law does not apply to an owner of OU'TLEI'S-SWITCHES-FIXTORES _ ! G 4
his own
mplhails,provided
that
such improvements
amn intended
or (fend or
hisownemployeese provided thatsuchimproveoldwam not intended..pleli for NEW RESIDENTIAL ELCCI'R SQ PB
ownsaleeIf,howevcatheve mingorimprovement issoldiid non build improve far
SQ.IT.1q,0012AREA $JSQ.FT.
sof ealder will have Nt burden of proving that he did not build or improve fir par- O�
pose o smolal
❑ 1,as owner of the property,um exdmively contracting with licensed cnntrre nn w
constructthe project(Sec.IND.Business and Profession,Ctdc:)The Comracwr's L41.i-
censeLawdoesnotapplytounOwnerofpropenywhobuildsorimprovesthemon,and QTY, PLUMBING PERMIT FEE
who anomie for such projects with a mntracmr(..)licensed pursuant to the Contractors - C /)
License law. PERMD ISSUANCE
❑ I am exempt under Sne. ,B&P C for this mason
DETER-DRAIN&VENT-WATER WA)Owner Date VALUATION
WORKER'S COM PIiNrjury on DECLARATION OACK FLOW PROTECT.DEVICE �w
I hereby unarm under penalty nl'perjury one d see ful lmn-ing declamtimn: "i V
❑I have and will mainuina CenlNcxteofConwnunulf-insum fir Workers Comte- pNA1Nti-FLOOR,R(R)P.ARIiA,CON0. S'TORIF.S V TYPIi CONSTRUCfIl1N
smiun,as provided[Or by Senion 37W of oho Labor Code,for the performance of the
work for which this pemail is issued. FIXTURBS-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
37M ofthe Lalmr Core.for the performance of the work for which this permit is issued. GAS-EA,SYSTIiM-I INC.40UTLETS
M W k,, imalma J POlic DEC.GROUP AI'N
Ner a
Comer:, coca MON RO;-`�� GAS-IA.SYS'1'EM-OVER J(IiA)
CERTIFICATE Be EX ENSA PTIONFRAN (IRK.R
COMPENSATION INSURANCE GRFASIJINDUS'I'RL WASTE INTERCIiP10R
QTis,xtion need not be completed Has permit is Burne hundred dollan(E10i BUIL G IV 'IONIEnS
or less.) GREASE TRAP PLANCI HICK ITT
Loy any that persnthe inp rformance ymannero as
wmkmesufar bjhthis parmil the Workers
Ca 11 Nall SOWER-SANITARY-STORM EA.2W IT.
not employ any perste in any manner so as m hecome,ubjen m the Workers Campeau ENERGY HE
sti zO Applicant sof Cul1fomiv.Date WATT:RIIIiNI'ERWNEN']IF_LEC IR
GRADING FEf
h NOTICE TO APPLICANT.If,aper making this Certificate of Exemption,you should WATER SYSTCM/FREATING
1--1 become nobject to the Workers Compenmtion smu,kiom of the Labor Code,yon must SI XLS I'IiL
i� forthwith comply with such provisions or this Nnaitshull be dcemedrevoked. WATER SERVICE.
a Q
CONSTRUCTION LENDING AGENCY NIiW NESIDEMI'IAL PCMB. SQ.PI', 1'AIU
V 0 l heeehyemrm that isaed Sco.iNElending agency for Ne performance of Ua Rtteiptq
W � the work(or which this permit is issueA(Sec.31W],Civ.CJ
ULender's Name
W Lender,Address 'I OTA L:
;It1 certify that 1 have read this Implication and them that the ahnve information is BUILDING I .E
0 terrane)ague wcnmpoy wish all city md'county ordinances an(]state laws refining it) QTY. MECHANICAL PERMIT NEB
V Zbuilding contraction,and hereby authorizercpmumatives of this city meter upon the SEISMIC F,E
above-mentioned ErepenY for iruNindon purposcs. PERMIT ISSUANCE
(We).gree towel,indemnify send keep harmlca the City of Capcninn against ELECTR 1 FCB
Iiabilitics.judgmems,costs and expenses which may in any way accrue against laid City ALTER OR ADD TO MUCH.
in ncequence of the granting ofthis permit. PLUMB GFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WI'T'H ALL NON-POINT AIR BANDUNG UNITOO 10.000CPM)
SOURCE REGULATIONS. / N112CH ICAL IIiC
77t AIR HANDLINGUNIT(OVER 10.(IIX)CPM) CONSTRUCT ION TA
Sag o[AI t/n�wi Dete ]7/ EXHAUST HOOU(W/DUCT) HOUSING MITIGATION PF,E
c AZARIR)US MATERIALS DISCLOSURE Will the applicant or furore building occupant varc or handle M1armJuus nwanal BEATING,UNIT(10101.01011UJ)
as defined by the Capetian Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 251320p1 IHATING UND(OVER I(0LB(11)BTU)
C3 Yes F1 No
VENGLATION FAN(SINGLE RESiD) PAID
Will thea licant or future huilAin Use Rcceip p
pp gytheBamea Air uordeviceswhich BOILER COMP OR 100,001)BTU)
:mit hazardous air contaminants as Defined by the Bay Area Air Quality Management TOTAL:
Ld�snm
(]No HOLLER-COMI'(OVER 100,OIX19TU)
mad the hazardous materials requirements under Chapter 6.95 of the Cali- IRCONDITIONERISSUANCE DATE
&Safety Code,Sections 25505,25533 and 25534.1 unaeomndtht if NO NEWRESIDCN'1'IALMIiCH. SQ.FI'.nm cumen0y have a tenant Nat it ix my respmsibility m rmtify the cecupuntr w which must be met por to issuance ofa Ceniricnte of DecoNncy.orized agent Date T1—T ,
T
_ ISSUED BY:
OFFICE