22031APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'— USE BALLPOINT PEN.ONLY
Bulldin vm'en IdemiHcalon
Building Add...: -
PERMITNO.
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22031
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION /PERMIT
Contractors LIc...No:-
V S 6D L OI E Y
BUILDING-EI-EC'IRICAL-PLUMBINGMECHAMCAL
CATEGORY
CONTROL M
AmMtect/Engineer.: Lk. Na
" =`- It t 5' '' "P'
•QTY,) -`I ;ELECTAICPERl1'tIT y -, 4''i,l`(?EE 1
4 t'b BUILDINCTERMIT INFO 'r
4"-..
Add.. 1077 Ocll.(�a•4tP .leu -
PERMITISSUANCE
LICENSEDCONTRACTOR'SDF.CLA ATION
I hereby affirmthat l am licensed under provisions of Chapter 9(mmmene-
Ingwith Section 7000)of Dlvislon3ofthe Buslnessand PrefnsionsCode, and my
license is In lull time and effect rL
License Class- �Nt C.m ZSh10a
Dale Contractor %F -
APP]-LANCE-RF-SIDENTIAL
JOB DCSCRIPTION
�.. .
'. ' ^? �
PANELS
S
AMPS
ARCHITECI•SDECLAhcmmrd
]understand my platy shaBW used azpub0crcrorda
V
OVER00
OVER 1000 AMPS
SQ.IT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Profeeslooal
SPECIALCIRCUIT/MISC
• OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License law fui the
,
TWp•MEEQtORPOLE ]NST.
following resson.(Section 70315, Business and Professions Code: Any city or
muntywhlchrequiresapermlttomretruct, alter, Improve,dernolbh,orrepair
-
anystructmepriortoitsbsuance, also requirestheappllcontfor such permit to
file a signed statement that he is licensed pursuant to the provisions of the
- POWER DEVICES
V ,•
'
0'
SWIMMINGPOOLELECTRIC
Contractors License Lav, (Chapter 9(commencing with Section 7000) of Divi-
elon 3 ofthe Budneae and Pro(esiom Code)orthat he k eumpt themfmmand
VALUATION
the basis for the alleged exemption. Any violation of Section 7m LS by any
applicant for a permit subjectsthe applicant to a civil penalty of not more than
OUTLETSSWITCHESFIXTIJRES
lJ[.�� -
QWa 0 j
h'EW RESIDENTIAL ELECTR SQ FrWFEE
(Ive hundred dollars ($500).
as owner of the property, or my employees with wages as their wlecompensation,
PECONSTRUCTIO1,
wi ldo the work and the structure is not intended or offered for
sale (Sec 70K Business and Profesionss Code: The Contractors License Law
-
doesnotapplyto'an owner of property who Wilds or improves thereon, and
who doessuch work himself orthrough his own employees, provided that suchimprovements
2
. UNITS1k
are not intended oroffered !orils. l( however, theWilding orImprovement bwld widunonsyearofcompletmn, theownebuilderwiil have
t rden of proving that he did rot Wild or Improve for purpose of sale.).
L as owner of the property, am exclusively contracting with licensed
contractor to roretauct the project (See. 7D4k Business and Professions Code:
QTY, �•���•PLUMBING PERNU
PERMIT ISSUANCE -
The Contractor's License Law dcee not apply to an owner of property who
Wilds or Improves thereon, and who contracts for suck ptojects with a
,.,Extor(s) licensed pursuant to the Contrachh'a License Law.
L I am exempt under Sec. B k P C for thin reasonOUTSIDE
QATF
ALTER -DRAIN k VEhT-WATER
AY•
BACK FLOW PROTECT. DEVICE'
FEES
DRAINS FLOOR ROOF, AREA, COND.
FO(TlJRES PER TRA]'
SANITARY Y N_
OwnerDale —RECEIPT
WORKMAN COMPENSATION DECLARATION
21 hereby affirm that I have a certificate of consent to self -Insure, ora
certificele o(Workers'Comperuation Insurance or a certified ropythereof(Sec.
3800, lab C.)
Policy M
Sp{OOL TAX Y__ N_
RT M
CAS FA. SYSTEM -1 WC.40UTLETS
PARK FEE Y N —
RECERT X
GAS EA. SYSTEM-OVER4(EA)
Coma
B UILDINC DI VISION FE IS
ad
ratified copy b heed with the city " -
Certified copy k filed with the city Inspection division.
', CREASE/WDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE .
CREASE TRAP
CERTIHCATEOFD(EMPTION FROM WORKERS'
COMPENSATION INSURANCE
need ors Mcompleted lithe permit Is for one hundred dollars
(0),arl
PAID `�TI•k
Date Rewi t#
P
SEWER-SANITARY-STORMFA.200FT.
WATER HEATER W/VENT/E.FCTR
ENERGYFEE - Y N
es.)
($]II mmlyth
1rert1(y that In the performance of thework forwNch this permit biswed,
WATER SYSTEM/TREATING
I shall not employ any person in any manner w as to become subject to the
Workeri Compensation laws of California. Date
PAID
Applicant -NEW
NOTICE TO APPLICANT: If, after naking this Certificate of Eecmptlen, you
RESIDENTIAL PLMB. 9Q.l•T.
Date Revel tN
'.
TOTAL:
Amid become subject to the Workers'Compereat ion pmetalt oltM1e Labor
Cale, you must forthwith comply with such provisions or this permit shall be
deemed reGELE
voked.
ILD N
SEISMIC FEE -
CONSTRUCTION LENDING AGENCY' -
(hereby affirm that them is a mmtmction lending agency for the perfarm
ance, of the work for which this permit Is towed (Sec. 3097, Civ. C.)
Iandar. Name-
Lender'.'Addre.n -
Icertlfythat l have readtMsapplicattonand smtethat theabove Information
Is correct.I agree to comply withal] city and county ordinances and pain laws
relating to building ronstmNon, and hereby authorir<rcprcsntativn of this
TOTAL
_
ELECTRIC FEE
-
QTY.'"'. .MECHANICAL'PERMIT ,',l', FEE'„)_
PLUMBING FEE
MECHANICAL FEE
POWITLSSUANCE
FEE AID: T
6 L 7-2,
city to enter u Pon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
agnlhat lW ]]ties,judgments, costsand expenses which may lnanywayaccme
against gild Clty In ohne nceo the granting of th pe
ALTERORADDTOMECH.
Date ,Receipt#
-
AIR HANDLING UNIT (TO 10,000 CFM)'
SUBTOTAL:
AIRHANDUNG UNIT(OVER 10,0D0Cr•M)
CONSTRUCTION TAX
gnalure of Ap li-nt/Contractor Data I
HAZARDOUS MATERIALS DISCLOSURE
WIAUSTHOOD(W/DUCT) ..
CONSTRUCTION TAX -PAID:
1 ry�
HEATING UNIT(TO 100,000 BTU)
Willtheappilcant orfiWmbu0ding« panistomorhandlchaeardous
material as ciefirud by the Cupertino Municipal Cods, Chapter 9AZ and the
Health and Safety Cede Sect re, 25532(a)7
❑ yrs rlc�-1 No,
Willthe applicantorfdturebuildiagoccupantuu equipment or devices
`which emit hara dour air contaminants., defined by the Bay Area Air
2u lity Management District]
`n❑'Yes v„ ®No
]haveread tealth&Safet materials mons 2555, under 2553aChapter.1 of
the California Code, 25hatit
the
Date Receipt �l I ''
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VFNfILATION PAN (SINGLE RESIDE
”
ISSUANCE DATE
fJ A
111IJ
BOILER -COMP PID' OR 101LOW BTU)
BOILER-COMP(OVER100,000 BTU)
NEW RESIDENTIAL MECH. 'SQ.FT
at If building
understand that if the building don not arrently havealenanl. that ltbmy
not have a t nan
Ng111
responsibility, to notify the occupant of the requirements which must be met
phorto Lsuance of6Certiflcateof Occupancy.
C9yy Mi•]N a�@�QO
Mi
k
ISSUED 6Y: �e �•+
Owner or d agent
authorlac.Date
-
'
TOTAL:
' 'M1.
OFFICE COPY