S 1182\ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINIKEN ONLY
t CITY OF CUPERTINO BaILDING- ELECfRICAL
I BUILDING DIVISION 1LLI;_p � MKC,Hn Nicol.
APPLICATIONIFERMIT -
IIl11LDIN( I R D'IDT IIIENTI NICATIUN
BUILDING ADDRESS:
Iq4-% 0 �j�VENS G GK
OWNER'S NAME: PHONE: CON1'RACTOR:S NAME: LIC NO
GVt3� ah�coe S� c� • 332Io¢o
4 ANC 1'fCCI'/ENGINEER: LIC ori ADDWiSS.
11 d N,oAVV
CONTACT: `_ q PHONE: �
GO 1 &Go QSB ^ �•-' ❑ Consultant Fees Paid by Applicant (Initial)
I hereby affem ihm 1 i m Named under provisions of Chapmr 9 (rammencing
with Section 7000) of Division 3 of3he Business and Profession, Code, mod my license is
in full (oree vnd c( L4
Date sc A>;axs Liaa
Dom 1 Contract
ARCHITECT'S DELL R ON
1 understand my plans shall be used as pub - ¢suss
LiccmW Professional
OWNER -BUILDER DECLARATION
I hereby affirm That I am exempt from the Contractors License Law for the
following it (Section ]031.5, 13uninexs not 1'rafe..ions GNe. Any city or ',,-my
which requires a permit Its construct, thou, improve, demolish or repair any struclum
prior to its issuance, also requires the applicant for such penniftn file a signed stalamem
that he is licensed pursuant o the pmvisinns of the Contractors License Law (Chapter 9
(commencing with Seolinn 918() of Oilmen 3 of the Bm'int,w and Profewiam Cadc) or
that be is exempt therefrom and the basis for the alleged exemption. Any vidinu n of
Section 7831.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not more thus film hundred dollars ($50T.
[:] 1, as owner of the property, or my nnployeeN with wager m their side compmtxution,
will do the work, and the structure Is not intended om0ered for sale (Sec. ]W4, Business
and Professions Cook: '[be Cotnmctors License law docs not apply to an owner of
propeny, who builds or improves human, and who diva such work himself or through
his own employees, provided that yellilumnAl mcmN arc not intcalpl ar offomn for
sale. If, however the building or improvement N sold within one year of compleAon, the
paper -builder will have the burden of proving that he did not build or improve for pe,
pose of sale.),
1, as owner of the pmleny, an exelus'wely mrmncting with liccnmd continuum to
conwruct the project (Sec. 70tL Business and Professions Code:)'Poe Contractors Li-
can.m Law daes not apply to an owner of pmpeny who builds or improves thereon, and
who contracts for such projects with a concomitants) licensed pursuant o the Comment,
Lievorm Lew.
,C] I am exempt under See. B & 1' C for this reason
nor Dale
WORKER'S COMPENSNI ]ON DECLARATION
1 herby affirm under, penalty of Perjury one of the following decNot ions:
I have and will mainmin a Cce ificm of Consent o self -insure for Workers Compen-
as provided for by Section 3100 of the labor Code, for the petforniance of the
kfor which this permit is isaucd.
I have and win maintain Workers Compensation Insurance, as required by Section
0 Ise Labor Cale, for the performance of the work for which this permit is issued.
CERTIFICATE Ole EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section ne01 not he nrntpleted if Lha permit ix for one hundred dallarx 151 W)
"less
d 1 '
I
Iecnify t6s mbc pednmt eanft 'mor
bleb tI isperyi'. J.Ishall
.at employ
any Pers n �n m1 ncr s r( For
so �i to mpcn-
outinn Luws of Cldifm11d
Ap",can,
NOTICE: TO AP ' CA , one, making this Certifies, of Enemptiun, you should
become an
ct m the Wo i s Co.Pensaion foul ...in, of the labor Code, you pmt
limhwith comply whh sok provisions onM1ia permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the Performance of
,he weak lin which lots permit Is issued (Sce.309], Civ. C.)
ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANFI S
UP TO 200 AMPS
201-1000AMPS
OVER 1100AMRS
SIGNS ELECTRICAL
SPECIAL CIRCI113'/MISC.
*1 EMP METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECIIUC
OUTI.F.TS— SWITCHES — jSC44IIS
NEW RESIDENT Al, ELE SQ Ff.
PLUMBIN t \
PHRMI'f ISSUANCE
ALTER - DRAIN & VENT -WA'rE (li
BACK PLOW PROTECT. DEVICE
DRAINS— FLOOR. ROOF, AREA, C011
FIX'I UIt ES — III 7K TRAP
GAS — HA. SYS'1'I:M-I INC.4 OUTLETS
GAS —FA. SYS 'PEM-OVI'.It 4 (1l)
GRHASFANDUS'IRL WAS ]'I. INTERCEPTOR
GREASE TRAP
SEWER—SANITARY—STORM EA. 200 FT.
pool HR HEA'1 11R WIN END
WATER SYSTHIAGRF.A'1'ING
Wood ER SERVICE
NEW RESIDENTIAL PI -MB. SQ. FI
Leaders Address
1 cer ify that I have read this application and state that the nhteve infonnaion is
ruserau. to comply with all city and county unbalances and state laws relining In QTY.
building construction, and hereby alltliarizz mprcunladves of Nis city to enter upon the
above-memiened pmpcny for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of CaP Irt ,, vgaiaw
liabilities. judgments, costs and expenses which may in pry will ncencagalnst sold Chy-
in consequence of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signamre of ApplicanUContmcmr [)am
HAZARDOUS MATERIALS DISCLOSURE
Will the applicvnl an film. hadding tewpunt wore er handle h vardous mumnal
as di fncd by be Cincotta Municipal Cale, Chapter 9.12, and tue Health and Safely
Crile. Section 25953(.0]
❑Y., C]No
Will the applicant or future building tccnpa s use equipment or devices which
emir haaardoes air contaminants m def sed by the Bay Area Air Quality Management
Distrin't
Dyes 0 N
1 have mal the harardoer materials requirements tinder Chapter fruit of the Cali-
fomia llaullh & Safe Code, m 2550. 5533 and 5534.1 understand that if the
huildin Jces�tcJ'�J^/'ny.1 l t lir to of
of the rcai�/(wR.v vAtt4tt rsr nY o en I fpgy�n
MECHANICAL PERMIT
PERMIT ISSUANCE
ALI ER OR ADD TO MEGA.
AIR HANDLING UNIT (1'0 10,000 CFM)
AIR I[AN OILING UNIT (OVER 10,000CPM)
EXHAUST 11001) (W/DOCO
I113AONG UNI "P ('f0 100,000 BTU)
HEATING UNIT (OVER 11)) OW BTU)
V17N'FILA3'ION FAN (SINGLE RESIDE
BOILILR -COMP QHP OR I W,(Ig) BTU)
BOILER -COMPEOVER 100,M) BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. Fr..
0
.182
r�p
e..
INFO
❑ ❑
JOB DESCRIPTION
RFF IDS
GSFDWI.
❑KITCHENRF.MODEI.
❑ADDITION
❑PI.UMBING RE -PIPE:
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
El INTERIOR
E) CHIMNEY REPAIR
IMPROVEMENT
E]SWIMMING POOLS
❑ BATH REMOD11LIREPAIR 0DEMOI.1'r1ON
❑ OTHER
COMMERCIAL;
❑NEW BLDG/ADDITION El DEMOLITION
[I TENANT ❑FOOD SERVICH
IMPROVEMENT _
SQ. I -L FAIR AREA
J 4
oz—
PEE
CUF��r t!
VAI. TION
STORIES TYPI
OCC. GROUT'
But I N D VIS10 P
I'LANCHEC
ENERGY F
OR I ' EE
SOIIS FEE
PAID
Date Recein a
EEE q SMIC FEE
--IIIE IC IFE
PAID
Date
Zt F$Vi 9
DATE
$/SQ. lel'.