00010116APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 11.1T V
CITY OF CUPRRTIN0 BUILDING - ELECTRICAL PNO.
BUII,nwG nR'AL I
ISION APPLICATIONA'ERMIT Vr ^''V�nni—lNG e Mtfa��rvL1-o—rN
CdJ
c SIT cr HON ,1
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LICENSED CONTRACTOR S DECLARATION
I hereby affirm doll L xo h, reed nolo prnvii inns of Chapter 9 at Inmem'Ing
OZZ with Section ]OMpof Division 3 ofthe Business and Professions Caleand my licence is
F�� in full fnrceondelfect.
aUU Liceme Cleo, Lieut
Zw NGL Date Contr'Ictm
ARCHITECTS DECLARATION
~ m Z I understand my plans shall he used us public awards
OZ
P: 4!: W Licensed Professional
OWNER -BUILDER DECLARATION
C C Q I hereby affirm fault I om exempt trout the Contractor's License Law for the
�a i U following marar. (Section 7031.5. Business and Professions Codw Any city or county
613 0.y which mcmics a permit to construct, alter, improve, demolish, or repair any structure
F��G prior n: its issuance, also rcyu area the applicant lar such Front to life asignal smtenrm
that he is licensed pursuant o the provisions at he Contractor's License Law (Chaper9
(commencing with Section 7(00) of Division 3 of the Business and Professions Cade)or
a q o C 1h h he is exempt thardrom and the basis for the alleged exemption. Any violation of
W M m Section 7031 5 by any appllcam ran peon.mh aro the applicant ret a civil Isennhy of
n more than five hundred dollars ($500).
~ y Q ❑ 1, m owner of the progeny, m my employees with wages as their sole compensation.
f.0 tui 11 Jr the work.and memucmreunh ine,aaa nolTemtl fmsafc(Set. 70W4, Business
63 m and 1'ralevoirm Cale: no Contractors License Law Joos ret apply to an owner of
pmpeny who Wilde or improves thereon, and who dotes such work himself or through
his own employees, provided that all improvemonts are not intended or offered for
sale. It, however, the building or improvement is sold within one year of completion, the
erhuilder will have the burden of proving that he did not build or imgfo m for pur-
pose of sale.).
1. as owner of the pr ped , am exclusively contracting will' Ilcrnsed conuanors In
construct the project (Sec. 7141. Business and Professions C(rde:) The Contractor's Li -
se Law does not apply m an owner of property who builds or improves themon, and
who contracts for such Projects w ith u contractions) licensed pursuhnuo the Comru lor's
License Law.
❑ 1 am exempt under Sec. . B & P C for this reason
ole
f/,UUs 70 /O 146
—_'❑ Cll%5onsulltttaaa'nt Fees Paid by Applicant (Initial)
ITY. ELECTRIC PERMIT FEF:
PERMIT ISSUANCE
PPLI ANCIiS — R1i$ IIl1.NTIAI.
PANELS
UP'10200 AMPS
Date
wncr WORKER'S COMPENSATION DECLARATION
I hereby affirm muter penalty of perjury one of the following declarations:
❑ 1 have and will maintain u Ceniticme of Cnnscm m xclf-i'ssurcfor Worker's Compcn41
-
wrion, as provided for by Section 37M of the Labor Code, for the performance of me
work far which this permit is issued.
E] I have and will maintain Worker's Compensation Insurancu, as reyuiral by Section
3700 of the LaMn Cale, for the performance of the work fan which this gem'It is issued.
My Worker's Compensation Insurance camber and Policy number are:
Caron: Policy Nos
CBRTIFICATE 01: EXEMPT [ON FROM WORKERS'
COMPENSATION INSURANCE
(Ibis w Mian need our he ctnnplewd ifthe permit is froure hundred Jolles ($IIID)
or less.)
1 certify that in the performance of the work for which this Permit is issued.) shall
not employ nay person in any manner so as to become subject o the Workers'Compen-
OZ smion Lows of California. Dam
Z 2 Applicant
NOTICE TO APPLICANT: If, after making this Cenifrcam of Exemption, you should
bonne suhjao m the IS kcis Cnmperu,lioa provisions of flue Labor Code, you mull
forthwith comply with such provisions or this permit shall lx deemed revoked.
IlE CONSTRUCTION LENDING AGENCY
U O Ihenhy off roe promote is compact job lending agency lnnhe performance 'If
the work for which this Permit is leaurd (Sec. 3097. Civ. C.)
Q U Lender's Name
Y Lender's AJJre.o
G 1 rectify that 1 have read this application and state that the above information is
Fr N coram. 1 agree nt comply with all city and county ordinances and state laws relating to QTY.
U z holding construction, and hertby tmmorne representatives of this cut, to) enter apm the
above-mentioned pm,L for tnslwction Par,owl.
(We) agree to save indemnify and keep hmrtitees Ne City of Catania. against
Iiabi lifics, judgnrens, costs and espcloes which may in any way school against said City
one/Ido I,c9ucnre of the granting flit Ili
tf/sf/�1(11111i1APPLICANT Q QII lam.
SQ37E REG U I ER�IT U'1 1 A W y L COMPLY WITHALL
AV I� ION -MINT
11 A
HAZARDOUS MAL VRIALS DISCLOSURE
Will the applicant or future Wilding becapanf share or handle lumardum material
as Jefined by the Cupertino Municipal Code. Chapter 9.12, and the Health mall Safety
Cn Ir. Section 25532(n)'!
❑Yes ❑No
Will the applicant or future building occupant use epaipmem or devices which
writ luaardous air contaminants P. defined by the Boy Arca Air Quality Management
Diadce
❑Yes ED No
1 have mad Ile Lar. tutedals «yuimmenn under Chapter 6.95 of rhe Cali-
`y� ° th & Safety Cr c t ans 255 S, 2553) and ]S5.U. 11ndenduar 1 that Little
/nllllutlfocs not cuirentl hn aIll�iaiiern9rzospnnriM1ijitl(\r yrti[y �reyrpyrabt
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP. METER OR POLE INST.
POW17R DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES — To
NEW RESIDF.NI'IAL ELF.CIR
PERMIT ISSUANCE t
ALI IIR— GRAIN & YEN 'T—WA9.It( )
BACK RT. OW PROTECT DEVICE
DRAINS—FLOOR. ROOF, AREA, COND.
FIXTURES — PER TRAP
GAS —ILA. SYSTEM -I INC. G OU RETS
GA —6A. SYSTEM -OVER 4 DIA)
GREASE(INDUSTRI. WASTE INTERCEPTOR
GREASE TR AI'
SEWER — SANITARY — STORM EA, 20() FT
WNI17R HEAT ILR WIVENTELECTR
WATER SYSTEMOTHATING
WATER SERVICE
NEW RESIDENTIAL PLMIL SQ. 14.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING ON1'T (OVER III (im CPM)
EXHAUST HOOD lW9UUC )
HEATING UNIT (TO 100.000 BTU)
HEATING UNIT (OVER 100,00 BTU)
VEN ULATION TAN (SINGLE Rnsin)
BOILER—COMP LdIP OR 10),001(1 B'NJ)
BOILER — COMP OVER 100.000 BTU)
AIR CONDITIONER
NEW RESIDENTIAL. MECH. SQ, FT.
OFFICE
FEE
- 2 S- 2-0 0D
JOB DESCRIPTION
RESIDENTIAL❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
❑MULTLUNIT
❑STRUCTURAL
MODIFICATION
[I INTERIOR
C3 CHIMNEY REPAIR
IMPROVEMENT
C] SWIMMING MOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ a] HER
80,000
S'I')RIES TYJ'1_CONSTWI II(Oo
OCC. GROUP 5�1&/Pjq.2yj2lyyyj ((JT/TF.
P3 O)q
BUILDING DIVISION FEELS
PLANCI IECK IEE
ENERGY FEE
GRADING FILE
SOILS IEE
PAID
Duro Riscryl of
BUILDING FIZE
FEE SEISMIC FEE
ELECI'RU ME
PLUMBING FILE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Ilam Rmi #
TOTAL:
ISSUANCE DATE
�-9'C>0
COMMERCIAL:
❑ NEW BLDGIADDITION
[ji B ANT
IMPROVEMENT
[]OTHER
C3 DEMOLITION
❑ 1'OOD SF.RVICB
SQ. FF. FLOOR AREA
ti x000
$ISQ. IT.
OV
4o —
80,000
S'I')RIES TYJ'1_CONSTWI II(Oo
OCC. GROUP 5�1&/Pjq.2yj2lyyyj ((JT/TF.
P3 O)q
BUILDING DIVISION FEELS
PLANCI IECK IEE
ENERGY FEE
GRADING FILE
SOILS IEE
PAID
Duro Riscryl of
BUILDING FIZE
FEE SEISMIC FEE
ELECI'RU ME
PLUMBING FILE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Ilam Rmi #
TOTAL:
ISSUANCE DATE
�-9'C>0