S 1167■'
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO nuu.DlNr.. ELECTRICAL FERMI iNo.
BUILDINGDIVISION APPLICATIONIPERMIT vol- snrvC.. nu!cuANllJn1. S 1167
n
96)' I El Consultant Pees Paid by Applicant (Initial)
LICENSED CONTRACI0I43 UBCLAKAItON
1 hereby affirm Nat I am licensed under Provisions of Chapter 9 (commencing
wit Section WXIO) of Division 3 of the Business and Paid,...... Cole, and my license is
in full fora and ofil,
License Class Lic. p
Dam Contractor
ARCHI'IECT'SDECLARATION ,
I undemland my plan, skull be usnl ns public ruaoMs
Licensed Prefiessimand
OWNER -BUILDER DECLARATION
1 hereby altinn that I ant exempt from Ilie Conimemr's Llcanse Law Brt the
following season. (Section 7631.5, Business and Pndeshions C ole: Any city or county
which requires a Lenoir to construct. alter, improve, demolish, or repair any vmeTum
prior m its issuance, at,. requires the.,dimtnt for such permit In filo a simell.Iate neon
that he is licensed pursuant In the provisions of he Cnntro nr's License Low (Chapter 9
(rommencing svlth Section 7(1)(6 ill Division 3 of she Business and Professions Cndel or
that he is exempt Therefrom and the basis for the alleged exemption. Any violation of
Section 90 ,�I.5 by any applicant n fm. pornal eaccO, the applicant rosy u pplicant fm a permit eaccO' the applicu nt to a tied penalty of
mn more than five hundred differs ($50()). -
❑ L as owner of the pmpeny, or is employees with wages as their sNen 4, Bax tion,
will Pr m work, andcis Inc structure is on intended or offered for sale (Sec. VBJJ, wri, of
and eny who
Crvlc: The onetime License Luo Anus urn apply to un owner ill'
property who build, or improves thereon, and who docs such work deed o r or Through
his oxo employees, huddin J that such mentis said
w are not ;mended or offered for
mvrlc (however, ldor withe handing or improvement is old within one ycmof completion, the
wnerhuilAcr will have the hunlcn of proving that he did not build nr improve for Lur-
Iwsc.1sudeJ. _
L as owner of The Property, am exclusively contracting with licensed comma tors to
construct the project (See 7044 Business I Precisions C d ) The Count.Orwer s Li-
vena,,i-
veha,, Law does not apply to air owner olproper(, Inds I, -i prcive, d Id
who contracts for Suds prefer, with a eormaam gs) licensed pursuant o the Contractors
lam
t
ELEC"fRIQPGR
r
1117 MD'ISSUANCE
APPLIANCES -RES I DEN 'I']AL
PANELS
UP TO 200 AMPS -
OVER RMID AMPS
SIGNS ELECTRICAL
SPE`CIAI, CIRCUITIMISC.
TFMP MET ER OR MOLE INS'1',
POWER DEVICES
SWIMMING POOL ELECTRIC
(OUTLETS - SWITC( ES -FIXTURES
NEW RESIDENTIAL. ELECT
r
r BUILDING PERMIT INFO
m nc PI Io -1 PLUMB MECII
,ra.: JON
73
❑SFDWL ❑ KIT CII EN REMODEL.
YOU ]ON El PLUMBING RIb I'IPIi
MULL -UNIT ❑STRUCTURAL
MODIFICATION
ERIOR [I CHIMNEY REPAIR
IMPROVEMENTC]SWIMMING POOPS
❑ 13ATI1 REMGODEU�REP.A+IR1 ❑M I TION
t❑OTHER �Ci�-
� `�
DRAINS- FLOOR, ROOF, AREA. CONI
FIXTURES - PER TRAP,
GAS - PA. SYSTEM -I INC. 4 OU'rl.li'I:S
GAS - EA. SYSTEAIAVERJ(IiA)
QTY. - ,MECHANICALI'ERM IT,
-
My Worker's Compensation Insurance came, and Policy numhr are:
Cartier: Policy No.:
CI?ItTIPICA'I'Ii OF EXEMPT ION PIIOM WORKERS'.
COMPENSA'l'ION INSURANCE:
GREASI'IINDOS'I'RI, WAS'I[I IN I'ERC I!P'IOR.
SG[;73�_ISl11Vt_IMM[ NCIAVI �
❑ NEW BLDGIADDITION ❑DEMOUFION
❑TENANT ❑FOODSERVICE
IMPROVUMBS11'
❑ OTHER
-
;PLUM HINCPERMIT, •'J�,
PERMIT ISSUANCE
ALTER 'DRAIN&VENT -WA (.
BACK FLOW PROTECT. DEVICE
VQ
w
0 U
UJ
9L.
UC•pl
Z
I Lomhy a6irn nndnr penalY of ledury anemone mlloss ildeclaralonp:
] l have and will notation a Certilicatenf Coosenn,, wif-imure for W.. Lear, Camper-
saran, as Provided far by Section 37W of the Labor Cof for the perf rmnnce of the
work far which this Permit is issued.
El i have and will maintain Wnfked, Cntnpea,ation Inwranec, u, requiral by Section
3700ofthe Labor Gee, forthe perlormanccoflhe workfmwhich this permit is issued.
DRAINS- FLOOR, ROOF, AREA. CONI
FIXTURES - PER TRAP,
GAS - PA. SYSTEM -I INC. 4 OU'rl.li'I:S
GAS - EA. SYSTEAIAVERJ(IiA)
QTY. - ,MECHANICALI'ERM IT,
-
My Worker's Compensation Insurance came, and Policy numhr are:
Cartier: Policy No.:
CI?ItTIPICA'I'Ii OF EXEMPT ION PIIOM WORKERS'.
COMPENSA'l'ION INSURANCE:
GREASI'IINDOS'I'RI, WAS'I[I IN I'ERC I!P'IOR.
GREASETRAP, -
(Thissection mOdmm he completed ifthe lemeiT is foliate hundred dollan(SHXB
or It,,.)
Ia, any shut,, the performance,, (bea sI w ecria subjectisperniokesC.m all
notentployanYpersT anY manner, pct atm Menne soblunnthe Wnders'Comjem
SBWEIt - SAN I'T'ARY-STOItMCA, 21)6IT-
_
WATER HEAIER W,VENT/1 fR
z
potion lrws of Coliferam.[)are
'z
APplicanl ) -
SignaturedApplicanUC ry nr Date
- HAZARDOUS MATERIAL S OSURF,
Will the applicant of Bnune hnildiageeeupl amrenr hati Intimations material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the stealth and Stilly
Cade, Section 25532(a)?
0
NOTICE TO APPLICANT. If. after making this Ccniferm of Exemption, you shnuld
WATER SYS'LEMOO REAL INC.
ialJ�
A
become suhj,ct Io the Workers Compettxation previsions of the labor Cae, you must
forthwith comply with such pmvisinnsnrthispemtit shall M denoted revoked.
- CONST RUCTION LENDING AGENCY
WATER S17RVICI:
NEW RESIDES '1'IAl. I'LMI3, SQ. EL
VQ
w
0 U
UJ
9L.
UC•pl
Z
Ihcrehy aRmthat here is a conovelion lending agency forthe performance of
,The work for which this permit is issued (Sec. 30)7, Civ. C.)
1 -coder', Name
T
_
Lenders Address
I certify ❑tor I have read this application and state tbar the above information is
crev't.leset comply eiihall city and county ordinances and state law, relating to
agre
build ing construct lin, note hcrchy authori w repfesemmti les oft ltlscily to cnmrurym The
QTY. - ,MECHANICALI'ERM IT,
-
PERMIT ISSUANCE
ALTER OR ADD TO MECH,
-
.bnvetnemimmed property for inspection purposes.
(We) agree m save, indemnify and keep homeless the City of Cnpcnino against
Iishili lies, judgments, costsand expenseswhich may in any way acerae against suld City
in consequence art the granting of this permit.
APPLICANT DGRSTANDS AN WILL C MPLY W ITFi ALL NON POINT
AIR HANDLING ON I'r (TO RLIXXt CI'M)
TOTAL.
SOURCE; .:ULATIONS.
AIR HANDLING UNIT (OVER IB.fXXl CFM)
EXHAUST GOOD(W/DUCT)
-'
SignaturedApplicanUC ry nr Date
- HAZARDOUS MATERIAL S OSURF,
Will the applicant of Bnune hnildiageeeupl amrenr hati Intimations material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the stealth and Stilly
Cade, Section 25532(a)?
REAL I NG UNIT ( 10100,000 (ITU)
HEATING UNIT (OVER IOILSX) BTU)
VENT] LATION FAN SING 1.13 RES IPO)
PLUMB( GFEE
❑Yes [D No
MECH.ICAL FET!
Will the applicant nr future building iNapant use equipment of device, which
emit haturdnus air contaminants as defined by the Bay Arca Air Quality Management
BOILER-COMP(31APOR KIP(LOX)ETU)
BOILER - COME (OVER RX oxill BTU)
DOUSING 'MITIGA NFEE
Districff
E]Ycs E] No
,
I have read the hrmadmis materials requirements under Chapter 6,95 of the Cali.
AIR CONDITIONER
NEW RESIDLI UAL NOTICE 1. SQ. FT.
Rsmia (Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand thin if to
building does nal cotren0y have. tenant, that it is illy msporsciloday m notify the weupon
of Oce requirements which must M mart Point Io issuance of a Certificate of Occupancy.
Owner nroutheri reel agent - Dilm
OFFICE
SQ. FL.. FLO( R AREA SISQ, vL
2�09e�1.
P_`dd
J
,/i V L l ON
Sq
c � ,
SIO 11;S - YUi CfONSTRUCTION
PLANCHECK PEI;
ENERGY Ell . (L
GRADING Iq?E
SOILS lilt:
PAM
me Receipt 9
TOTAL.
BUILDING Fl
FEE"
SEISMIC FT/
ELEC IM FEE
PLUMB( GFEE
MECH.ICAL FET!
CONSTRUCT1'AX
DOUSING 'MITIGA NFEE
('AID
_ Unto Re. •iplN