29709APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL. PERMITNO. O
APPLICATION/PERMIT PLUMB NG - MECHANICAL.
BUILDINGDIVISION "In. r,u, an" not , rrnxr,rer. a 1-10
OFFICE
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�ARIT[CT NGI E :/1 R O,
i
CONTRA R' NA LICNO:
ADDRESS:
NIC
ONTR�N�T.RsOL M
CONTAT: PHONE:
e 415- �
❑ consult nt Fees Paid by Applicant (Inl[IRp -
BUILDING PERMIT INFO
BLDG ECl' PLUMP MIiC11
� � ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (am earming
with Section 7") of Dtvisinm3oohs Busin nd I•rnlessim Icode, and beau is
nifull forcIe snd effect.
Lia
L<UV rucm
sCom
QTY. ELECTRIC PERMIT PEE
naZ
W 0 0
JOB DESCRIPTION
RESIDENTIAL,
❑ SFDWI❑ KITCHEN REMODEL
ADDITION PLUMBING RiE
-PIPEP.Q4Dt
PERMIT ISSUANCE
APPLIANCES - RESIDNIAL
NO
Z�a Z
524
r4 tF., 4�
�6 ...4I
L W 6
x d U
41 O
Ythatheislimmed
CTS DECLARATION
1 understand my plans shall he used as public records
PANELS
UP TO 2(X1 AMP$
❑MULT-UNIT ❑STRUCTURA.
MODIFICATION
TERIOE ❑CHIMNEY REPAIR
I ROVEMENT .
❑BATH REMODEI/REPAIR El DEMOLITION
OTHER
License, Professional
OWNER-
exempt. RDE Ce ContrON
I hereby affirm thin I am exempt from the Convnmor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a Permit to constmc6 alter, imPmve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such priori, to life a signed statement
pursuanuo the pmvisioms of Ne Contmnor, Llcerrse Lew (Chapmr9
201-IfNNIAMI'S �
OVER 1000AMPS
SIGNS ELECTRICAL❑
SPECIALCIRCUIT/MISC.
TEMP. METER OR POLE INSI'.
COMMERCIAL:
(commencing with Section 7") of Division 3 ofthe Business and Professions Codeine
0. n rG
4th•
nXahas
G
mm he is exempt IhereEom and the basis fur the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permi, subjects the applicdia to a civil Penalty of
of more than five hundred doll... ISSW).
owner of the norm In eu with wa as as their sale roan
❑ Prolx Y Yx'mnP Y 6 pen.xmion,
will do the work, and the structure is not intended oroffemd for sale (Sec. 7M4. Business
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOODSERVICE
ROVF.MCN'I'
OTHER
POWER DEVICES
SWIMMING POOL E1.13CfRIG
mand
Professions Code. llm Coommuse.s License Law does not apply to an owner of
OUTLETS - SWITCHES - FIXTURES
prmeny who builds or improves thereon, and who docs such work humidifier through
his own employees, provided that such improvements arc not intended or offered far
NEW RESIDENTIAL ELF.CTR SQ
,.I,. If, however the holdinymlmprnvement is sold within on,,rou of enmpleoon, the
_
SQ, FT, FLOOR AREA $/;Q. FT.
owner -builder will have the burden of proving that he did not build or improve for pur-
pose mould.).
0'1, as owner of the property, am exclusively contracting with licensed contactors to
L
construct the project (Sm. 7014, Business and Professions Code:) The Contractors Li-
c seLaw dost nm upplyman owner of progeny who milds art improves thereon,and
who contracts for such projects with a monsoons) accused personal m the Contractors�+.�
q ry
-�
Q9'Y. PLUMBINGPERMIT FEE
PERMIT ISSUANCE
License Law.
❑ Iamexemp,under Sec. ,II&PCfnr,hisra... a
` L�
fsl'r. U
ALTER -DRAIN&VENT-WATERIG)
BACK FLOW PROTECT. DEVICE
• VY VALUATlo
ULs'J`
4Yy /lllrV
Owner Dare
WORKER'S COMPENSATION. DECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations:
DRAINS- FLOOR, ROOF, AREA, COND.
❑ I have and will maintain a Certificate of Comenuo self -insure for Worker's Compen-
sadom as provided for by Section 37W of the Leon, Code, for the performance of the
STORIES
TYPE CONS'I'NUCI'ION
FIXTURES- PER TRAP
work fee which this peon, is issued.
❑ 1leve and will maintain Workcf, Conpenswion Insurance, as required by Section
37004the LaborCWe, for the performanceman, work for whichthispel i. tisjysycit
My Waftyfy�r�na�fntm ce carderonlynli yyygr)�(-L'gyr'^��Q4}Jg
GAS- P.A. SYS'rEM-I INC. 4 OUTLETS
OCG GROUP
APN
GAS - EA. SYSTEM -OVER 4(1iA)
Carrier Folic No a��1"rr
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
Q z
z Q
COMPENSATION INSURANCE
(This section need nm beanopleted if the permit is far one hundred dollmr ($I W)
or Icss.)
Loy any that lnthein performaanyintance eo theass work for which this Ceroidsesu Compaa)l
not employ any Canon in any manner so as to become subject to the Workers Compen-
p licant Laws of California. Date
Applicant
App -
ORGSMNDUSTRL WASTE INTERCEPTOR
❑ill OIVISIO FRES
PLANCHF.CK FF:I'
GREASE TRAY
SEWER-SANI'PARY- STORM P.A. 21X1 FI'.
ENE NGY ISE
WATER HEATER WNENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: IL oiler making this Certificate of Exemption, you should
subject to the Worker's Compensation provisions of the Labor Code, you most
WATER SYSTEM/IREATING
V)
abecome
SOILS FEF
RI
%r
L)Q
[Ty E -n
Q
forthwith comply withsuch provisions or this permit shall he deentedrevoked
CONSTRUCTION LENDING AGI7NCY
l hereby affirm that there is a corewnion lending agency for the performance of
me work for which this Permit is issued (Sec. 3097, Civ. C.)
Leader, Name
WATER SERVICE
PAID
oddeNitj
Receipt#
NEW RESIDENTIAL PI.MB. SQ. FT.
.TOTAL:
Lenders Address
'TOTAL:
U
W
'rn Ln
U Z
s
I mmy, that I have read this application and state that the above information is
cnrzccrl agrmmcomply with all city melmontyoNlnamea and otos lawardudngto
building construction, and hereby authorize representatives ofthis city to enter upon the
shove -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cuperino against
BUILDING FEE
`
QTY. MECHANICALPERMIT PCE
SEISMIC PEE to
FERMI I ISSUANCE. •
ELEN
_
liabilities,judgments, costs and expenses which may in any way eccrue�gainst said City
in couse,ucnm of the Edison, m thia permit.
ALTER OR ADD TO MIiCH. \
PLU
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
(RC: ?GULAT 'S.
AIR HANDLING UNII'(TO 10,0110 CPM)
MEC
NRHANDLINGUNN(OVER 10,00)CPM)
CON
EXHAUST HOLD(W/DUCT)
SigntmcrfA,,dwnC7..mcmr (late
HAZARDOUS MATERIALS DISCLOSURE?
HOU
BEATING UNIT (TO 100.00) BTU)
Will the applicant or future building occupant store or handle harallous material
as defined by the Cooperator, Municipal Code, Chapter 9.12, and the Health and Safety
Cole, Section 25532(.)7
HEM ING UNIT (OVER I03,IMX) RTU)
�emll
[]Yes MNn
Nidi Ne air commorfmurc defined occupant use cyvipmemtor lity devices,which
hazardous air contaminants as defined by the Bay Arta Air Quality Management
Dntrid'!
❑Yes ON.
PAID
(late Receipt#
TOTAL:
VENTILATION PAN (SINCLB RES ED)
BOILER- COMP CHIP OR IQB,000 HTO)
IIOILER- COMP(OVER IW,(NIfI BTU)
AIR CONDITIONER
I have read the harmdous... ,edals require meats under Chapter 6.95 of Ne Cali-
Bonds Health A Safety Code, Sections 25505, 25533 and 25534. 1 understand thd if the
huilding docs no ctoremly htrveu tenon,, that i, is any responsihility tonotify the occupant
u
cors rdnrmi,. a sofa Ce , efoy�ayyy.'�(�
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT
owner or autbotlzW agent Dam
ISSUED BY:y 1 1
- .
OFFICE