23186APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Proeet Identification
Building Address:
111875-
PERMIT NO.
2318 6
Flume:
9 uE449
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BMDINGE.ECTRICAI MLYMBING-MECHANICAL
1 .2^�
L--j—
Contractoe. Nam: Lie. No,
JIM/'V 60 I
CATEGORY
C Q
Architect/Engineer. Lie No:
Q1-vELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
IUL ❑ ❑
Y
LICENSED CONTRACTOR'S DECLARATION
(hereby III= that l am licensed under provisions of Chapter9(convnem,
Ingwith5e [ion7000)of Divlsion 3 ofthe Buslnessand Profession.Code, and my
license is In full t dcifeti / Z y`(`
Lkensc- C �L�C,Lno sD J �(JJ /J
Date T �j Comncmr
ARCHITECI•S DECLARATION
I understand my plans shall be used "public records.
Licensed Professional
OWNER -BUILDER DECLARATION
that l am exempt from the Contractors License Law for the
I wing reason.
following re"on.(Section 7031.5, Business and Professions Code: Any city or
county whkh requiroa penult tommtmn, altep improve, de=llsh,or repair
anystructurepriortolbWuance,also requires theappliant lorsuch permit to
Ole a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(comunencing with Section MOB) of Divi-
1.0olthe Businessand Professb"Code) orthat he 13 exemptthercfromand
the bosh for the alleged exemption. Any violation of Stolon 70115 by any
applicant fora permit subjects the applicant too civil penalty of not m mthan
live hundreddcllam($500).
❑ 1, as owner of the property, or my employees with wages as their sok
compensation,will dothe work, and thestructure le not Intended or offered for
Bale (Sec 7094, Buslnsss and Professions Code: TM Contractola Wce"e law
dom.w.pplyto an owner of property who builds or Improv"thereon, and
whodeassuchworkhm selforthrough hlsownemployees, provided thatsuch
Improvereenls are not intended oroflered for sale. If, however, thebuilding or
m
Improveent b sold within oncycarofcompimion, the owner-bu0derwlli have
tryR3inrdenof provingthat he did not build or improve forpurpose ofszls.).
U L asowner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Prolealom Code:
The Contractor's Llcense Law dean not apply to an owner of property who
Wilds or improvesreo
then, and who contracts for such pMojecta with a
cgR¢ador(s)licensed pursuant to the Contractors License Law.
I am exempt under Sec. B & P C for this reasonOUTSIDE
APPUANCESRE E
]OB DESCIUI7ION
• W 1J
AMPS
-101))AMPS I III
OVER10Dl AMPS -
SQ. Irf. FLOOR AREA $/SQ. FT.
g L E D l
� � � -
n p
�d.� / I
E �
/
SIGNS ELECTRICA
SPECIALC /MISC
'
�P, E'IQt OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLEISESE
SWTTCHXT1lRES
NEW RESIDE SQI,7,
S'IpIZ1ES
TYPE CONSTRUCTION
TOT
QTY, PLUMBING PERMIT FEE
OCC. GROUP
RES. UNITS
PERMIT ISSUANCE
ALTER -DRAIN &VENT -WATER (FA)
FLOOD ZONE
APN
FEE SUMMARY
BACK FLOW PROTECT DEVICE
TITS
FLOOR ROOF, AREA, CONTI.
FIXTURES PER TRAP
SANITARY Y N_
RECEIPT R
OwnerDRAINS
Date
WORKMAN COMPENSATION DECLARATION
ora
hereby affirm that I have o Insu me of consent to copy thereof
3800,cqviffLab CfWorkeri Compensatloni"urana mracertified ropy themo((Sec.
Poli lab CJ
Policy p
SCHOOL TAX Y N
RECEIPT M
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FFE Y_ N
RECEIPT p
GAS EA. SYSTEM( OVER d (EA)
Cam any
BUILpING DIV ON FEES
�CAlfied copy is herebyth the cid.
Certified ropy V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cot beco
Rhin section need rad bra completed 0th. penult V (Drone hundred dollars
($100)orlea3
I cent that o the performance any on weak so as to b this permit j Is Issued,
I shall not employ any person f any manner so "to become subject to the
Workca Compensation laws of California, Date
Applicant
NOTICEco APPLICANT: If, after makingthis Certificate roo(ExempteLyou
of the Labor
shouldbecome forth tot he Workers' Compensation or this
Code you must forthwith comply with such provlaons orchis perult.hall be deemed revoked.CONSTRUCTIONLENDINGAGENCY
IherebyalBrm that there is a co"ttuction lending agency for the perfomfTOTAL:
of the work for which this permit is Issued (Sec. 3097, Civ. C.)landcr'sN.me
Lcreler'.Addres.
cerHfylhat I have read thisapplication and statethattheabove informationbconect. I agree to comply with all my and county ordlnanms and nate laws
relating to building construction, and hereby authorize representatives olthls
city to enter upon theabove-mentioned property for inspection purposes.
(We) agree to ave, indemnify an d keep harmless the City of Cu pemoo Ilabliltiea,judgmentscotls and expenses which may In any way accrue
'
nat Cit n enc. the gr mingofthle pe t.AIR
GREASE/WDUSTRL WASTE INTERCEPTOR
PLANCHECIC FEE '
PAID
Date -Recei 1#
1
L
GREASE TRAP
SEVER-SANITARYSIORM EA. 200FT,
WATER ITER W/VENT/ELECTR
ENERGY FEE Y N
P
at
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB.SQ.ST.
IC FEE
ELECTRIC FEEante
QTY, MECHANICAL PERMIT 'FEEP
I
I (CAL ITI
PERMITISSUANCE
•S PAID:
tR�
ALTER OR ADD TO MECH.
Date
AIR HANDLING UNIT RTO 10,000 CFM)
SUgo
HANDLING UNIT(OVER I0,000CFM)
CONSTRUCTIONTSignatureofA
11 t/Contmotor tr
MATE ALSDISCLOSUREWlllthea plicas, or future buiI'inpant.mmmh.ndlehaaardou.
nutcrlalcue .finedbythe CupertinonklpalCode, Chapter9.12, and the
Ilralthan toy Cade Senlon 2553 (a)7
❑ Yea No
Wi111 z ppllcentorfutumbui ingoavpantusecquipmetordevices
which cult haa.rdou sI, is antes. defined by the Bay Area Air
Quality Management District?
4 Yes N No
hy%ad the hazy o..material. req.1mmu!nN under Chapter 6.95 of
the Califemia Health & Safety Coda Sections 25505, 25533 and 25531. I
understand that if the building does not currently have a tenant, that it is my
responsibility mmet
to notify the occupant of the requirements which must be
prior to Issuance of a Certificate of Omvpanry,
IXHAUST HOOD (W/DIKT)
CONSTRUCTIONHAZARpOUS
HFATINGUNIT(TO100,0URTU)Date
HEATING UNIT(OVER 100,000 BTU)
VENTILATION FAN (SINGLE RIESID)
ISSUAN(tDATE
PAI D
QQ
JAN 22
- r
ISSUED BY:
BOILER -COMP OHP OR 100,000 BTU)
BOILER-COMP(OVER 100,'X10 BTU)
NEW RESIDENTIAL MECH. SQJ7.
Owner or autholtr agent Date
TOTAL:
OFFICE COPY