S 2827PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELEC'TRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO,
C O
J G o 27
BUILDING ADDRESS: �l
SANITARY NQ
APPLICATION SUBMI'TT'AL DATE
r
OWNER'SNAME; PHONE:
CO ACID 'S NAME: LIC NO:
HOS-
_
NIC
❑
CON ROL#
f
�L _f 6
ENGINEER: LUNO:
R4 IT /C-d�
U C Gao6n.r,
ADDIR>S
s m. ' s
CONTACT: PHONE:
-
BUILDING PERMIT INFO
BLDG ELECT PLUMB - MECH
® ® ❑ L9
Aw- W
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
I nemby affirm that 1 am pleased made. pmvisbns of Chapter 9 (eomtnenrnng
with Section 7100) of Division 3 ofthe Business and Pmfossions C ... wandmylicamaic
in full forcemad edea. ��jj " #Db
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RBSIDENTIAI:
❑SPDWI. El KITCHEN REMODEL
PERMIT ISSUANCE
APPLIANCES -REMDGN'UAL
License CieN
Duro ContractorARCHITECT'S OECLARATIUN
I understand my Florissant be used as public retards
El ADDITION El PLUMBING RE -PIPE
❑MULTI-UNI'T ❑ MODIFICATION
CHIMNEY
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
PANELS -
UP To 200 AMPS
Licensed Pmfnuslonal
2111-1000AMPS
OWNER -BUILDER DECLARATION
1 heachy rural that I am exempt four the Contractors License Law for the
following reason. (Section 91315, Business and Pmfe,dicnx Coda: Any city or county
❑BATH REMODCUREPAIR [I DEMOLITION
❑ OTHER
OVER IBWAMPS
SIGNS ELECTRICAL
which requires a pa"ohm amnaad, alma improve, demolish, .'repair any s[mature
SPECIAL CIRCUITIMISC.
prior to its'n'e, also q the applicant fh fictiont Man signedLsentenced
,bar [at is fire Minimums ma prov,,faibofmac Contra tn:License L (Chaplet9
(emnmencing w A Section 7000) of Division 3 ul the Business and Protestants Code) at
ohm Be is cxurd themfmor ,,to the hast, far the alleged exemption. Any violation of
TEMP. METER OR POLE INS I'.
COMMERCIAL'
:W BLDG/ADDITION 91DEMOI.ITION
Section 7031.5 by any applicant dor v,trash mhjec¢ the applicant m a civil goodly or
am are than five hundred dollar, CNo).
01,asowncrtd'tbepmgerty,or my emplayces with wage, rbar.,ala wmttraction,
will de the work, and the ssmcuue is notantended or offers(] for sale (Sec. 704, Busmaxs
POWER DEVICES
ENANT ❑ FOOD SERVICE
PROVEMEN'1 '
El OTHER
SWIMMING POOL ELECTRIC
and Professions Code The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work hhnselror through
his own employees, provided that .such improvements are nm intended m orfeed lot
sale. If, however, the building or improvement ix sold within one year ofatmpnmicn. the
will have tireh handed of proving that he did not mild or improve for Pur
OU1I.ETS- 'YF,MEN-FIXTURES
NEW R rNTIAI. ELECTR SQ Ff.
SQ. FT. FLOOR AREA
$ISQ, FT.
,escerTailder
arole),
❑ h as owner or the property. atm exclusively contracting with licensed contractors In
TOTAL.
�ft�
762 iMPeUW
construct the pnriecl (Sce. 004, Hwtne,x and Pmfcsai Coded The Counselors Li-
canto
QTY. PLUMBI PE -T FEE'
who canonicals for each projects with it aommemr(s) Incensed pummrlAo the CmnOaaory
PERMIT ISSUANCE
License Law.
❑ l um exempt trader Sec. ,B& P C forthis rutson
Owner Dale
Ald 17R -DRAIN & VENT'- WATER LAa
VALUATION
3 Do O
WOR SEWS CDM PENSAI'[ON DECLARATION
I hereby affirm trader penally O perjury one of the following declaration.'.
BACK FLOW PROTECT. DEVICE
0RHIS
'I'Y'E CONSTRUCTION
I haveand will maintain aCeai i as of Consenuoself-inxumlhr Worker's Cmpet-
DRAINS- FLOOR, ROOF, AREA, COND.
smion, ev provided for by Section 3704) of the Labor Coca, for performance of the
work far wharf, this permit is issued
%
�(
l%
FIXTURES -PER "TRAP
1 have and will indiction Workers Compensation Insurance, as required by Section
3700 of he Labor Code, for the performance ofthe work for which this per mit is stated.
My Wnr m's Com ematinn lrvsu,rWWaw earrierand Policy )
Carried _OWi [ rA+9 Policy No n a�'-1 ,�
CERTIFICATE 2.P EX useFROM WORKERS'
COMPENSATION INSURANCE.
OCC. GROUP
s�7
1L3
®�
3��AP ��
ri
GAS -UA SYSTFyA(;yLNGII.O
EASY t - VBR4(:)
ii SEIINUUSTNL WASTE INTERCE
BUICDINh DIVUSIONERES
L A' �
(This section need not he completed Hurt permit is for one hundred dollars (SInot
nrlencJ
Rf�A5H 71t P 6 O
-- �—
PLANCIIP.CK PEES
Iwdiry theninthe performancco[thcwork forwhichthispc....disisoed,10rd
not employ any person in any manner so as to become subject m the Workes'Comper-
[[�ER-SANIIARY-STORMEA.100j'�Tii
p�J
ENERGY FEEO i
VAIERITHATERWYENUELECTR
GRADING FSE
saticn Laws of CAifomie. Date
t Applicant
NOTICE TO APPLICANT: If, after making this Ceripcare of Exemption, you should
e bjuet miss Worker, Compensation provisions of the Labor Cale, you meal
hcomsu
SOILS FEE -
WATER SERVICE
fohhwith comply with xueh pmvisium or lhic pencil Shull be deemed revoked.
aUCTIONLENDINGAGENCY
� Thereby afsvconswctinn lending a6oncy for the perfomamnce of
ambers
flimt thea there
PAID -
Unto Retain p
NEW RESIDENTIAL PLMB. Sp, Irl'.
t the work for which this pencil is issued (Sec 3099, Civ. CJ
Lender's Name
TOTAL
BUILDI FP .
TOTAL:
Lender's Address
I certify that 1 have read this application and stem than the above information is
1 wreck l agreem comply who all cityand corrynNinanms and ease laws aspiring to
building construction, and hereby stalactite representatives offs city to later upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC PIiP. f
anovembrucaed property for inspection pmP.,ae.
(We) agree it) save, Indemnify and keep hamdesc the City of Cupertino against
PERMIT ISSUANCE 3 Is 0
ELECTRIC PEE
PLUMBING FEE
listablics,judgmentd, wets andexpenees which may in any way rtecmeagminslood City
sequence of the tumbled Ibis permit.
in mga
ALTER OR ADD'I'0 MECH.
AIR HANDLING UNIT (TO IB/NIB CPM)
MECHANICAL PEE
t
APPI.IC T UNDERSTAND. ND WI , OMPLY WITH ALL NON -POINT'
SOUR EGl11.ALL
AIR HANDLING UNIT(OVER 10,000CPM)
CONS'] RUCI'ION'TAX
SIm unor pylic. actor Dom
EXHAUST HOOD(WIDUCT)
HOUSING MITIGATION FEE
IAZ.ARDOUS MATrRIALS DISCLOSURE
HEATING UNI 'P(TO 100,000 BTU)
-
Will the applicantorhtmre bouldingoccupont smmorhandle haeardeasmaheral
as d0lind by the Captain. Muni,ofrl Code. Chapter 9.12, mad the Health and Soon,
Code, Section 25532(a)"
❑Yee Uro
HUA'I'ING UNIT (OVER 100,000 BTU)
PAID
peau Receipt#
V EN'IILATION FAN (SINGLE RBSID)
BOILP.K-COMP(31IP Ok IOQB00 BTU)
Will the applicant or furore building weapons use uptipabol or devices which
-enithaeoolourmmntlnumsasdefirel by lac Boy Areas Air Quality Management
x mw
L
BOILER - COMP (OVER I0I1,)(H) B I'U)
Dosoict7
❑Yes ETRm-
AIR CONDITION ER
I have read the hawhadons mai reyuimaaeaty under Chapter 6,95 of the Cali-
fnmla Health & Safdy Cede, Sections 25505, 25533 wad 25534. 1 understand that it the
ISSUANCE DATE
NEW RESIDENTIAL MUCH.
building rines netenbecady hvvealcnnnO that i, leas espnnsihility to notify the sxcupum
(p
thrift, m torts which mast G suunee ora Conifienl of Oent' cy.
+Ila,
ISSUED BY
T TAL
aathod and
OFFICE