B 0352 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERM' O90352 O 3 ^2
BUILDING DIVISION APPLICATION/PF,RMIT PINGP PRNG OJECT
(IDENTICAL S0001 �41s
' BDILDINGPROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUnMIITAL DKT-H
O ,,R'SSsNAME: T I] `/� PHONE: C M'kACTOR'S NAM&. LIJC�NO'
K� ZG2s J M N/C CONTROLp
RCHITECTIENGINGER: I.IC NO: ADDRESS: CLL7 ❑
a zasxxolo _
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
u rr cLICENSP,D CNT —666' 03 ❑ ❑ ❑
ORACTOR'S DECLARATION QTY. - ELECTRIC PERMIT PEE
1 hereby wfrnn that 1 am.,chased dna, provisions of Chapter 9(rndtmenamg _ JOB DESCRIPTION
OaZ with Seonceied aff FUiviaion3ofthe Business and Pmfuaiona Code,vnd mylicenspis RESIDENTIAL,
O p PERMIT ISSUANCG
Fly in full force andd cffec ❑SFDWL ❑KITCHEN REMODEL
FUW License Clues Lic.N-3OG%� APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
r/�IQy Dole Conlmclo[ _
ARCHITECTS DEC ❑MULTI-UNI T ❑STRUCTURAL
OZ4- Iundernand my plans shall be nsW vs public recur PANELS MODIFICATION
o4 0 PT02 AMPS EI INTERIOR El CHIMNEY REPAIR
�,r/� W Licensed Professional 201-1000 AMPS IMPROVEMENT DSWIMMING POOLS
sd 14 OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C � 1 hereby aRnn that 1 am exerm l from the Contractor's License La for the
O W U following mason.(SeeJon 7091.5,Business and Professions Coda Any Thy or county SIGNS ELECTRICAL .❑OTHER
0.I a IL E' which requires v permit to ennwweL ober,improve,demolish,or repo; my
smartie
Fq O� print issuance,also requires the applicam for such permit file a.' red statemTn( SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Cnntn Law(Chapter9
�ap0 (commencing with Section 9111Np nf0lvlaion3of rho Bus' s a rofessim'Gxle)or TEMP.METER OR POLE INST. COMMERCIAL:
G y m y' that he is exempt member,vad the howls for the alleged p ie.Any viobnion of ❑NEW BLDGIADDITION [j DEMOLITION
Semon 9031.5 by any pa am for u pe,mit sohjeds the up
'c:mt m a civil penally of POWER DEVICES
nounomdmatmahu reddcllars($500). P:NANT ❑FOODSERVICE
� -q ❑ I,as nano of the openy,or my employ if wet s oa then,or,eampensmion, SWIMMING POOL ELECTRIC IMPROVEMENT
F willcUfhpwork,and msmcmmis not intend,, r dfmxale(Sec.9M4.Business DOTTER
W`ea and Pmfes,"ione Co :The Contractor Licars vw does not apply rt,an owner of OUTLETS-SWITCHES-FIXTURES
�'3` property who huilJ or
improve"t run d who does such work himself or through
his own employees provided th uch irl renre re,art not intended or ofiomd for NEW RESIDENTIAL ELECTR SQ FT.
sole 11,however t build go mprovunent is Hold within one year nf,rompletlnn,IM1c SQ.FT.FLOOR AREA f;/SQ.PT,
owner-builder will ova(he den of proving(hat he did not build or improve fir pti
pa"e it sme.),
❑h as owact of me pmpan) o rival rely endowing with licensed coana ons to .TOTAL:
nnaw,tthe proper(Sec]d ,Business and Professions Code)The Conwanr"L)-
riseLaw does net applyb,an wrier ofpmlm^y who builds or improves thereon,and QTY. _ PLUMBINGPF,RMIT PEE '
who analown,fofsdehpmjears thacommmor(z)Iiwnoed pursuam to the Conneaut's
License Law. PERMIT ISSUANCE
l am exempt under Seo. ,13&P C for this ma"on
Owner Date ALTER-DRAI F: VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE - -
I baraby,affirm under penalty of perjury one of the following declarations:
-Q l hooccad will maintalnaCerdllevrcof Consenttnself-inaum for Workers Comped- DRAINS-FL �e FigE .p an cheek co
ation,as provided for by Section 37M of the Labor Code,for the perfnmtarec of the n k11S TYPE CONSTRUCTION
weed, h
rk for which this perC
milaissued, FIXTURES- or and/or wner acc pt complete
❑I have and will maintain Worker's Compensation Insurance,as required by Section p��pM
3900 of the Labor Code,for the performance of the work for which this permit is issued, GAS-EA.sf(MiOnsi tqT. or a rreetin a GROUP APN
MyWorker',ComparcatlodInsurance carlovand Policy number are
: ®g{� (�p�80UreVl OnSOfI
Corin Policy Ni.: GAS-EA.S�ntfm
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINT�yIVT 81ur1 tS.
COMPENSATION INSURANCE tFf♦ h .. 'BUILDINGDIVISION PEEF
(Thbourinn need not hecomplaed Pike pendit is fortune hundred delta,S HUB GREASE TR ern l�l Q0�for or ass.) &ANCIIECK FEE
Loy any thatin(in any Turner sit
work for center to pedthe
irkes'Compn- SEWEE-SANITARY-STORM EA.200 FC
not employ any person in any mvnner si ax d,become subjwl m the Workers'Compmr- ENERGY PP.E ,
,Z sation Laws of California.Date WATER HEA \
2 Applmodr \ GRADING FEE
'Z h NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYS' *MnE "LNG
become subject(o the Workers CimpcT,Tt nu pmvideas U rhe Labor Cade,you must SOILS PEE
fonhwithwmplywithoula provieinnsorthispeantshall bedeemW revoked. WATER SER
Q
7z CONS'1'RUC'1'[ON[.ENDING AGENCY NEW RG511 YLMB. SQ.FT. PAID
I hereby affirm that is a construction lending agency for the pufonnnncenf Date Ri#
The wn If..which this permit is itoned(Set.3097,Cr,C)
O n
I` lender',Name TOTAL:
U Iutle:"Address TOTAL:
>i a1 candy that I have read this application and state that he above information Is .. BUILDING FEE
u y correct.l name m munply with all city and county ordmnces and state laws relating to QTY. MECHANICAL PERMIT FEF.
U building codatmc0on,and hereby nuthorize representatives of this citymenter upon theI SEISMICFEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)aliment save,indemnify and keep h rmiloss the City of Copenim against ELECTRIC F .
liabilities,judgments,costs and expenses which may in any wayaecme against said City ALTER OR ADD TO MGCH.
in segue ce of the granting of this permit PLUMBING FE
APPLICANT UNDERSTANDS AN \iLL .GMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CPM) MECHANICAL R
SOURC, ,UUNTIONS.
XAIR HANDLING UNIT(OVER Mich;CPM) CONS]RUCT NTAX
gn of Ap read yt or u(e EXHAUST]OOD(\V/DUCT)
1,12 O MATERIALS DISCLOSURE HOUSING MITI TION FEE
Will the applicant ifiam,buildingoccipanl store.,handle hazmdous mvterial HEATING UNIT(TO 10B(1110 BTU)
as defined by the Cuptnt r unicipol Code,Chapter 9.12,and the Health and Safety
Code,Section 25532hu? !! HEATING ON II(OVER 100,000 BTU)
❑Yes 511No
. VENTILATION FAN(SINGLE RESID) PAID -'
Data Receiptis
Will the applicantorfuture building occupantdeoeiordeviceswhich BOILER COMP OR 100000 BTU)
nit hazardous air contaminants as defined by the Bay Areaa Air Quality - ,
lity Management TOTAL:
District? // BOILER-COMP(OVER 100,000 BTU)
' ❑ R]
Yes Nu
I have read the hazardous materials requirements under Chapter CONDITIONER
fi95 of the Cali- ISSUANCE DATE
thio Health&Safety Cie.Sections 25505,25533 unit 25534.I ondemivnd thin d the NEW RESIDENTIAL MECO SQ.PT. —r—ZD
build, doeanotcorrently have a ria t,thnt;(ism responsibilitymnotify tha oceupnm
of mens which m priono 1 arca of a Conircat o[Oz �',p\J�� /^y
O age Data'T TOTAL: ISSUF:II Is r 0 1
OFFICE