B 0631FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPE.RTINO BUILDING - ELECTRICAL, �f rnnntu nv. 2Q-5-64
'�.n � f, e
BUILDING DIVISION APPLICATION/PERMIT I PLUMBING - MECHANICAL. C.y�ppi ■.c,O `/2 X64
300
CONTACT; PHUNB:
n S.L %vim' ❑ Consultant Fees Paid by Applicant (Initial) -
I.ICENSHD CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT
1 hereby nf. that I em licensed under provisions of Chapter 9 (commencing
qaZ with Sedinn]INI(Ilaf Division3afrhe Business and liofessions Cafe andmylicenseis
010— i PERMIT ISSUANCE.
n e force and cacct.
C U F License la. C� Lie, #
6 U aG s e / APPLIANCLS-RESIDENTIAL
F!a W Dine _ TS DEContractor
Fly ARCHITECTS DECLARATION PANELS
OZ �.Z. 1 understand my plans shall be, used as public records UP TO 2M AMPS
I..4 FFW Licensed Pomfooinual 201-IINIOAMPS
4 F�; OWNER -BUILDER DECLARATION OVER HaVAMPS
L 101EE''�a 1 hereby al'lirm Ibal 1 ran exam,, from the Cnulruemr's License Law Iia the
daxd O L U following reason. (Section 7031.5. Business and Professions Gbe: Any city or county SIGNS ELECHOCAL
W 3 (y Fm¢ which requires a permit to construct, alter, improve, demolish, or repair anfCh.p
prior to its issuance, aim requtrca the applicant for such permit mlileas nedSPECIAL CIRCUIT/MISE.
that he is licensed pursuant to the provisions of Ne Cantnemrs License I sxl TIBORMSUZORPOLEINST.
shot he is exempt Iberefmm and the basis for Ne alleged exemPoor. An v
m Section ]031.5 by any uppl' ant for a permit subjmts the oppii n as c it penalty of POWER DEVICES
not more thenflvehundrc ddmrs($5g0.
=O ❑ Lasnwnerofthepm ny.mnnyemplaFm,iwithwage. Their pensmion, SWIMMING POOL ELECTRIC
willdmhe work, andthe wcwmis oatimendW ITertre, r: o(Sri Oq4, Business fess
m and Pmfassinns Code: he Crown 's Licenm I ply m an mune ill OUTLETS
- SWITCHES - FIXTURES
property who builds o mproves therton, end who himself or through
his own anpinyecs, p avided that such improvement I tmended or offered for ::IEEE ELECTTt SQ FT.
ade.1forsever,the itdingorimpmve Idwit year ill completion, the
awnerhuilder will h 'c the burden of P v a at he did not holm or impmse for pun
pone of sale.). TOTAL:
❑ 1, as muter of the pro, Fvely so sating with licensed contractors to
mswd the pmjed (Sec. ]W a and 14mfe i ms Cale:) The Contmcwr's Li
ansa Law does oat apply m an o natal' propcny who halms or improves thereon,and QTY. PLUMBING PERMIT
whocomrecrsforsuchpmjmtswi commensals) licensed pursuanuo the Contractors
License Low. PERMIT ISSUANCE
0 I am exempt under Sec. ,B&P C for his reasan
ALTER -DRAIN & VENT' -WATER (EA)
Owner Data
WORKER'S F mmhyof SAT30N DE CL9RATION BACK FLOW PROTECT. I3F.VICIi
I hand M. under penahyofperjuryone ofthe iromefollowing decalwartWorlons ❑Ihavc and will maimninn Cenifcate of Cnnsennn self -insure for Workers Co.,..Co,RAINS -FLOOR, BOOK AREA, COND,
satiaa, as Flats ided for by Section 37M of the Labor Coda, for Ne penformanre of the
work for which this permit is issued. FIXTURES-PERTRAP
❑ I have and will maintain Workers Compensation Insurance, as required by Section
work For
My urk•the 1 1gp{bya�fo^wnh�r/f1trmmcca carriermance
and Policy auwhcch this permit is issued. GAS-�.SYSTfiM OVER
OUTLETS
Cartier: i�-{, Policy Na.:� ja?--'>76
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
(Throwdonaeod nothrecmpleei if thcpermit isforsmehounraddiduars($100) GREASETRAP
ret less.)
(certify therm the permannro as
become
which this permit isissued, 'Comhnll SEWER - SAN ITARY-ti'FORM BA, 200 FF.
not employ any person in any manner m as to become subject m the Worker' Compen-
Z cation laws of California. Data WATER HEATER W/VENT/ELEC'Ut
Z O Applicant t
NOTICE TO APPLICANT: IL after making this CeniOcate of Exemption, you should WATER SYSTEMITREATING
a; became subject at the Workers Compcamonn pmvisinna of the Lahnr Cale, you must
(T -I forthwith comply with such provisions or this pe—it shall he deemed revoked. WAFER SERVICE
ca
�z CONhen is a'IONLI?NDINGACENCY NEW REti11lF.Nl'IAL PLMH, SQ. 17.
L%0 t hereby ah thispuhcm issued sSuction lemling agency for the performance of
'he wark for which this permit is issuer, (Sec. 3fM)7, Civ. CJ
0 U Leader's Name
TOTAL:
Lender's Address
C6 1 certify that I have mad this application and state that the above information is
..rA cmort.I agreeto mmply with all city and county ordinances and slate laws relating m QTY MECHANICAL PERMIT
V building construction, and hereby authorize reptsurtatives ofthis city to enter upon the
aMrve-meationed property fill inspection purposes PERMIT ISSUANCE
(We) agree to sase, indemnify and keep less d.
City of Cupertino against
livhilitics, judgments, costs and expenses whit many way vccme against said City AI.TERORADDTOMECH.
in consequence of
ingo perm
in 1` CA DE SA D L COMPLY WITH ALL NON -POINT AIR HANDLING UNIT (TO 10,10X1 CFM)
SOI RP O AIR HAN DLING UNIT (OVER 10,000 CFM)
Signatureof ApplicinVCommetor Date EXHAUST HOOD(W/DUCq
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or more building oceupanl store or handle humblous material IICATING UNIT (TO 1011,000 BTU)
as Rprom by the Caperton Municipal Code, Chapter 9.12, and the Health and Safety HEATING UNIT (OVER 100,000 BTU)
Code. Section 25532(x)^
El Yes C1 No VENTILATION FAN(SINGLE RESID)
Will the applicant or future building occupant use equipment or devices which BOILER- COMP OHP OR 100.000 BTU)
emit havtrdous air contaminants as deBnW by the Buy Area Air Quality Maaagen era
District? BOILER - COMP (OVER 100.000 BTU)
El Yes 0 N
AIR CONDITIONER
1 have rtod the haznNous materials quiremcnts sealer Chapter 6.95 of Ne Cali-
fomiu Heultb y t ms 2 S, 25573 and 25534. 1 undersmnd Nat tithe NEW RESIDENTIAL NIECE. SQ. FT.
,oildin not r it is my responsibility to notify the occupant
f ntsw' mere 'oto issuanre ata CyGfi
cr or amhactual a t m TOTAL
OFFICE
PEE
FEE
0
INFO
BLDG EL�EC , PLUMB MECH J6
❑ ❑ ❑
JOB DESCRIPTION
RESIDENTIAL'
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑ PLUMBING RE PIPE
❑MULTI -UNIT
❑STRUCTURAL,
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
0SWIMMING POOLS
❑ BATH REMO EU PAIR ❑ DEMOLITION
❑OTHER
a, Ang
COMMERCIAL,
❑NEWBLDG/ADDITION
[]DEMOLITION
[]TENANT
❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
FLOORARF.A
A* R
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Dare Receipt#
BUILDING PEE
FTSE SEISMIC PER
ELECTRIC FEE
PLUMBING FEE
MECHANICALFEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt p