S 0763 j APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
I S 0763
BUILDING PROJECT IDENTIFICATION
SANITARY NO, AI'i'I.I CATION SUB M I 1'IAL DA TE
BUILDING ADDRESS:'
I I Sa s 2
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO: NIC CONTROL#
Z 5s wt oln
RCHITECT/ENGINEER: LIC or, ADDRESS:
PCONTA�: PHONE: BUILD( PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) I .DG ELE( PLUMB MINCH
❑ ❑
LICENSED CONTRACTORS DCCLARA'I ION QTY. ELECTRIC PERMIT FEE
afro mat 1 alts Emnsed under pnwisioat of chapter 9(cmmencing JOB DESCRIPTION
O0 C, 0)of Division 3 of the Business and Professios Cole.and my licen.wis RESIDENTIAL:O PERMIT ISSUANCL eDect. ❑SFDWI. ❑KITCHEN REMODEL.
aVU License Class Lic.a gpPLIANCfS—RFSIDENTIAI. ❑ADDITION [I PLUMBING RI>PIPE
F. 4411 Dao Commar r
y
OR
ARCHITECI"S DECLARATIONElMULTI-UNIT ❑STRUCTURAL.
PANELS MODIFICATION
Z FO Py Z I tmdvaland my plane,ball persist as public records
7, UP T02(NIAMI'S ❑INI'Ii1210R ❑CHIMNIiY RIiPAIR
Oz=1
i-q Licensed Pmfic,,mnal 281-10DOAMPS IMPROVEMENT SWIMMING POOLS
�Y 2-1 OWNIiR-BUILDER DECIARATION OVER]Bud AMPS El BATH RIiMOUF.UREI'AIR ❑DEMDLITIQN
C W Q I hereby affirm that 1 am exempt from the Commerce,License Law for the
O 6 U following acus...(Section 7031.5,Business and Professions Code:Any city(it county SIGNS ELECT TICAL Ll OTHERN1x13 W which mgaimc u Permit to const uct,alter,improve,demolish,or repair any stmeore
F„�O prior tO its...rouce,.N.nequires theappla nl tinauchpermina filea,iguedsaaenteat SPCCIAI.CIRCUIT/MISC.
,Ny (hat M1e is licensed punuantmme pmvieinns of me COntmctor's l.ian,c law lCM1apter9
=00 (commnming with Sectlon]q#q ofDivision3nl the Btuiness and Pr..fccsions Code)or TEMP.METERORPOLCINST. COMMERCIAL'
Q.y e T� mat he is exempt therefrom v^d the basis(.,,he alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4X! LL
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES ❑TENANT' ❑FOOD S17RVICE
w mol mom than live hundred doll.n(S5W).
Q IMPROVEMENT
El ownerol he przTerty,rr my employees with wages as meirwde compenshin I. SWIMMING POOL ELECT RIC
will do the work,and me adoclure is not Intended oroforwi forxale(Sw.7ID4,6u,hw,, ❑OI BER
and Professions Code:The Cannot License law does not Itpply to an Owner of OUI'LIHS—SWITCHES—FIXTURES
�' r property conn builds or improves thereon,vnd win does such sunk himself nr mrough
his own employees,provided that such impmvcmcno arc not intended or offered for NEW RESIDGNAL F.LT:CTR SQ IT.
sale.If,however.the buildings improvement is sold within one year ofcomplenion,the TISQ.FI.FLOOR qµ[A SISQ.IT.
owner-builder will have the burden or proving that he dM
id not build or Improve for pan, P A I D
pose 01 sale.).
❑ 1,as ownerof the property,ant exclusively contracting with licensed contractors to IDEAL:
ombah the project(Ser.7044,Business and Professions CW e:)The Contractor's Li- D`v
cense law docs not apply in an owner of property who builds Or improves thereon,and QTY. PLUMBING P171ZMIT FEE R[Apw
who contracts for such projects with a conuachms)lice^sed pursuant the Contractor's /� LIGlu
License Lew. ,H&PCLor tris reason PERMIT ISSUANCE CITY VI"
❑ I am exempt under Sec. V
ALTER—DRAIN&VENT—WATER(EA) VALVATI
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK(:LOW PNOTECT.DEVICE
1 hereby affirm under penalty of
to perjury one of the following for derroars Camper-
❑(have vnd wevifo by ection 37W of the Lahr self-insur the Wrforma ce or thDRAINS—FLOOR.ROOF,AREA,COND. STORIES TYPE CON51µUCTION
stairs,is provided for by Section 3]W of the Labor Ctsle,for the performance or the
work for which this permit Is issued. FIXTl1R17S—I'ER TRAP
I have and will maintain Workers Compeasmirn Insurance,as required by Seenno
3700Oftlte Labor Code,forlhe performance Oldie work forwhich this permit is issued. GAS—EA.SYSTEM-(INC.4 OUTLETS OCC.GROUP MIN
My Workers Compensation Insurance carrier and Policy number urs:
Cameo Policy N., GAS—IA.SYSTEMOVER4(EAI ..
CERTIFICATE OF EXEMPTION FROM WORKERS' GkF.ASIIINDUSTRL WAS'1'F.INTENCF.ITOH
COMP17NSATION INSURANCE BUI DI )(VISION PGIi.'
U his section need not be completed it(III i,Wane It r1mdd.11aOSI(NB GRP.ASEI'RAP
or less.) PLANCHHC 9:-
IoyanytpetinthepednamanmOOhewodhtrwhichnhispenninisiss.ed,lshall SEWER—SANITARY—STORM EA.200 BE
not employ any person m n y manners as to becnate subject m the Workers Compen- ENERGY EGG
z sation laws of Califo WATER HEADER W/VEN'1'IELECTR
Applicant , GRADING IEE
NMIC17 TO APPLICANT I;uhe ing thAcailicme of Exemption,you should WATER SYSTEM/I'RP.ATING
y SOILS 1717li
l"t bee me subject to the Worker' pensaninn proic.st,.f the LnMt Code,you nmst
forl comply with such provisions or this permit shall be deemed revoked WATER SERVICE
a �
CONSONLENDINGAGENCY NEW HILSID[NTIALI'LMIi. SQ,17. PAID
= Z IM1ereby atfirmmauhem them is isaconstruction lending agency for the performance of Ike Receipt
W2 the work for which this#omit is i...ed(Six.3897.Co.Cd
p U TOTAL:
Lender,Name
131 Lender's Address 'IY)TAL:
y 1 canify that I have rtad this application and sone tent the above information is BUILDING FEE
Z) Congo.l a greed comply with all city and county ordinances and slate laws relating or QTY. MECHANICAL PERMIT FEE
C„) z building concoction,and hereby authorize representatives ofthis city to enter upon the SEISMIC PER
above-mentioned property for inspection purposes. PERMIT'ISSUANCE
(We)agree m save,Indemnify and keep harmless the City'If Cupenino agvinsn ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City' ALTER OR ADD TO MSCI I. PLUMBING FEE
in consequence Orme granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010.000 CFM) MECHANICAL PGE
SOURCE REGULA11 'S.
AIR HANDLING UNIT(OVER 10,1100 CFM) CONSTRUCTIONTAX 14
Signkt of Appl it interim Date EXHAUST HOOD(W/DUCII HOUSING MITIGATION FEE
HAZAN DOUS�D it All Dl CLOSURIi
Will't or do,Occupant spot car handle hazardous material HEATING UNIT(Tit I(N),fNN)B'1'U7
as defined by the Cupenino ff..l�r i al Cole.Chapter 9.12,and the I leulnh and Safety
Cade,Section 25532m)? HEATING UNIT(OVER Pat,"BTU)
C3 Yea Fl No VENTILATION FANS I NGLE RESID) PAID
Date Nereipn#
Will the upplama or(hurt build,.,o eupatu use egnipmant in devicas which BOII.FR—COMP UHP Olt 100,080 BTU)
mit hazardous air c.nmminanns as defined by the(lay Area Air Quality Management TOTAL:
District? BOILER—COMP(OVER 100.00OBTU)
❑Yes ❑No
I have mad the hazardous materials attainments under Chupor6.95 Or the Culi- AIR CONDITIONER ISSUANCE DATE
formic Hetdm&Safety Code,Seeli.ns 255(15,25513 and 255311 to deNood that if the NEW RESIDENTIAL MECII. SQ.IT.
building does not currently have a mount,that in u my reslmnsibiliny w notify meoccupanl
of me requirements which nw,n hr met prior m issuance ol'a CeriOente m Occupancy.
Owner nr aunhnrized agent Date ,
TOTAL: ISSUED II Y:
OFFICE