S 3362I6
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE _
CITY OF CUPERTINO - BUILDING - ELECTRICAL
BUILDING DIVISION • APPLICATION/PERMIT PLUMBING -MECHANICAL
'BUILDING PROJECT IDENTIFICATION
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SANITARY NO.
APPLICA'T'ION SUBMITTAL DATE
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OWV PHONES
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ARCHITDC1'/ENGINEER:, LIC No:
ADDRESS: -
CONTACT: - PHONE.
` , BUILDING PERMITHNPO
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❑ Consultant Fecs Paid by Applicant (Initial)
H❑DG ELECT - PLUMB ME❑CH
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LICENSED CONTRACTORS DECLARATION
1 herchy an rm that I r - d e p f Chapter 9 (commencing
with Section 7000) ofD , 'ou3 ollhe nus m Business and Pnfussi Code, and my license is
in fell onad it effect
license Class Lief# -
Comemr
Dote m
QTy ", ELEGPRIGPERMIT
JOB DESCRIPTION -
RESIDENTIAL:
ElSPDWL El KITCHEN REMODEL
❑ADDITION E] PLUMBING RE -PIPE
RAL
❑MULTI -UNIT ❑MODIFI MODIFICATION
MODIFICATION
[:1 INTERIOR ❑ CHIMNEY REPAIR'
IMPROVEMENT E]SWIMMING POOLS
❑ BATH REM D r OLI
OTHER
(--rte-
PERMIT ISSUANCE .1 V
APPLIANCES - RESIDENTIAL -
ARCHITECT'S DECLARATION
1 understand my plans shall M used a, public records
_
PANELS
UP'TO 200AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 70315, Business and Professions Grde. Any city normally
which requircx it permit m l anood, dta t ailed, improve, demolish, or repair any statement
prior I 'l. y' .th ppl tf M1permit t is L (Clement
trbut am licensedp a then in lar he t t r L la (Chapler9
(came n' g with i "1000)fl) 3 fill codex and Pf. Code)or
That io v exempt tang a li and the bas s for the alleged p mann it) Any violation Pen of
Section than by anyapplicanlfor apw'mil subjects the applicant to vetvll Penalty of
nl marc Nva five hundred dollars ($SUBJ. -.
wdir caner o[the property, or my employees wiN wages av lheinole compensation,
will dothewonsCde TheCamLanai Licence of apply 9o44, owner
and Professions Code: The Con thereto L nd wh Law does not apply is an owner of
Law
.property who bods, or improves thenad, and who does such wmk himself or Nmu,b
hisownoweer,the provided that such not iyearof nralone, for
is he ithinone build or improve for the
ment is sold
sale, lEhowevegthe have
et -builder will have the harden of proving that he did not build or improve for pur-
th burden
201-1000AMPS
SIGN ELECTRIC
SIGNS ELP.[TRICAI.
SPECIAL CIRCUIT/MING.
_
�q
TAMP METIER OR P01.6INST. V�
COMMERCIAL:
I ION
❑ NEW BLDG/ADDITION ❑ FOOD S RVI
❑TENANT ❑FOODSERVICE
IMPROVEMENT
[]OTHER
POWI?R DEVICES
SWIMMING POOL ELECTRIC
OU'T'LETS -SWITCHP.S-PIXTIIRES
NEW RBSIDEN'TIAL EhF:CI'R SQ PI'.
-
SQ. FI'. FLOOR AREA
$ISQ.IrI'.
p seor,lde.). -
❑ 1, as owner of the propsny, am exclusively conhaeting with licensed contractors to
T
onstracn id project (Seo. 7044. Bovines, and Pmfesamo, Code:) The Cameron is Li-
- -
censeLawdocsnotapplytoanowner of property who builds or impmve, (heman,and
QTY, - PLUMBING PERMIT FEE
who contracts for such projects with a cenhnctod s) licensed pursuant o the Qmtractor's
License Law.
❑.1 `m exempt under Sea , B & P C fortis reason
r
PERMIT ISSUANCE
_
Ownnr Dam
ALTER- DRAIN A VENT- WATER (EA)
VALUATION
BACK FLOW PROTECT. DEVICE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury ane of the following decluralion¢
-
--
I have and bill maintain a CediGcate of Consenl In self-lnsum for Worker's Cmnpen-
salion, as provided for by Section 37M of the Labor Code, for tire performance of the
DRAINS- FLOOR, ROOF, AREA, GOND.
STORIES
TYPE CONS'CRUOTION
-
work for which Ibis permit i,isaued.
FIXTURES -PER TRAP
❑ I have and will moral Worker's Compensation Tmemnm, as requited by Scetion
37W oflhe Labor Codd, for the performance cattle, work for which this permit is issued
GAS -EA. SYSTEM -I INC. 4 OUTLETS.
OCC.GROUP
APN
My Worker's Gunnison smtrun Insurance curie, and Policy number are:
Cartier: Policy No,:
GAS -EA. SYSTEM -OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TMs section need not be completed 011e permit is for one hundred dollars($100)
or lua.)'
GREASMNDUSTRL WASTE INTERCEPTORtr
it 14 G DIVISION FEE.S4 d ry y
••�-^'-""""'"""""""""-'-"`o
GREASE 'I'RAP —
PLANCHECK FEE
SEWER - SA RARY=STORM EA. 200 EL.
I corny that in the parformance of the .,it for which this permit is issued, Ichall
not employ any puson in any manner so as to become subject to the Workers' Compen-
ENERGY PER.
WA'T'ER HEA ER W/VE F CTR
I -
%s
�j� 0
q y
s�'I ti
Wforthwith
a z
U
Gabon Laws of California. Date
Applicant i
GRADING PEE
SOILS FEE
'
NOTICE TO APPLICANT: IL after making this Cormorant of Exemption, you should
heurme subject m the Workeis Compensation pmvisiona of the Lahnr Coda, normal
comply with such provisions or this """itshoji be dcemedtevoked.
CONSTRUCTION LENDING AGENCY
IThereby aff that there isaconstruction lending for the per[mmtnce of
the work fotwhieh this permit is issued (Sec. 3097.Civ. CJ
WATER SYSTE IM/IRP. -7
^
WATER SERV!i� j
PAID
Data eiptN -
NEW RESIDE 'iptA PLM
0E✓
U
Na
r+ (Al
fJ Z
'x Tami Name
..
- 'TOTAL
-TOTAL:
Lender:. Address
BUILDINGFEE
I codify that l have read this application and state that Thabove infortachumn is
correct l agree TO comply ME all city and county tordincence, arcanelow,nalmun,r'
nialmlve. f this cry In role' 1pon Ne
nding con9clm and hereby ualhnru repet
bom
it -
QTY' - MECHANICAL PERMIT FEE'
'I
SEISMIC PEE
PERMIT' ISSUANCE
H1.HCTRIC FEE
above-mentioned property for inspection pmmu,d..,
(we) ",reoo, harmless lheCity of Caperlino against
etr�IND
ALTER ORAUD'TOMECII.
Ilebllities,jn nls,iehmnyinuny way muruengainvl Haid Gly
usn,e ren .
PLUMNINO PEE
gIR11ANDLING UNIT(TOIg000CFM)
MECHANICAL FEF.
APPI. 'LL COMPLY WIT'HA LNON-P(INT
T
AIR HANDLING UNIT (OVER IB,nOBCPM)
CONSTRUCTION TAX
�Z 1�
gnamre of AppliennVCommemr - - um
' HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicanl orfuturehuildingocomonl,had or handle har.Net,maredol
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,000 BTU)
as defined by the Colombo Municipal Code, Chapter 9.12, and The Health and Safety
Code, Section 25532(x)?
HEATING UNIT (OVER 100,000 BTU)'
Yes ❑No
Will the eir amna or future building by the Bay A., ,At,Qucardeviceswhich
emir hvallou, air conmminanw as Jelined by the Bay Areu Air Quality Management
PAID
VENTILATION FAN (SINGLE RESID)
Dela Rarript it
BOILER- COME (311P OR 100,000 HTU)
1 :
BOILER - COME (OVER 100,000 BTU)
D xvict?
[3 Yb, ❑No
,
AIR CONDITIONER
- -
Ihmve read the h Jmaterial5 1' is undo Chapter d95ofthe
ISSUANCED TEforma
NEW RESIDENTIAL SUCH. SQ FP.
itCut, the
that TNc
builds Heahh&Sa(aty Cad Sections 255B5 mun,n25533 ad25A41 unity the
building otifycrapan
tenet
ll y soldG
t2minate
Gerity
is whichly
uinameoes
of the ragmrcmema which muse be and ptiomoisvumrm old Ctllillfdte of Owupaney.
pea y.
-
TOTAL:
ISSUED BY:
Owner or auNerized agent Dale
OFFICE _