99090114APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY %LJ
CITY OF'CUPERTINO BUILDING - ELECTRICAL P[RMIT N�
BUILDING DIVISION APPLICATIONIFERMIT PLUMBING - MECHANICAL.
CONTACT.
❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affirm that 1 am licensed under proGsiom m Chapter 9 m ommendng
�aZ with force
Division lofthe 9usines and ProfessionsCWe. and mylicense is
FU� In cenw me and cB«I.
U U hiccnsc cin... Lic. a
1- W Dale Cnnu'I:wm
N 6
ACTS DECLARATION
ZpNZ t q a used as public records
OZ—'0
f: s3 J Ge and Tonal
G IiI lU1LDER DECLARATION
0
a I ¢rrcby affirm GT
r rxcntpl Inmt the Conum,oa's Licence Low for the
X O L U following reymn. (s«dnnlv0 5. Business and Professions Code: Any city or manly
LL LL FQ which rtyuirtx a permit u, answer, alter, improve, drmnllsb, or repair any treenre
F'LL�J prior to its issuance, also requires the applicant for such permit to rile a signed. statement
E } that he I, licensed pursua.' the pmv,ssion,cflh, Commends License Law (Chapter 9
I��� orunmmidng with Seel 7mV)oFDivision Sof the Business and Profes,inn. Code)or
6 q o C that he is exempt Ihemin nt Iced the basis for the alleged excinpllun. Any vinlulinn of
LL � yr Sectio 7031.5 by any applicant for a prrmit umijem, the applicant m a civil penaltyof
not more Nan five hundred dollars ($50I).
S p D Las owtrcr ofthe propcny, or my employees with wages as their sole compensation.
p.. will do the work. and the structure is not imended or offered fonale(See. 76,14, Business
{ail- m and linden s Code Be Conlmeor'n License Law docs not apply ,, an
owner of
ri .. property who builds or improves thereon, unit who does such work himselfor Ihmugh 27
his own employers, provided that such improvements an not intended or o02red for
sale. If. however, the building or improvement is sold within otic year memodnion, the
ter -builder will have the burden of proving that he did not build or improve for pur-
Pnm A sale.).
❑ 1, its owner of the Property, am cxclu%MvIy canlra flag with Ilcenred connacmm to
construct the pojcn (See 7(W, Business and Processions Cnde:) The Conti nmor'x Li-
enor Low does not apply to an owner of property who builds or improves thereon, and QTY.
who contracts for such projects with a commnogs) licensed pursuant in the Contreclart
Liceme Law.
❑ I am exempt under See. ,B& P C for this reason,
.caner ])am declarations:
WORKER'S COMPENSATION DECLARATION
I herehyill matunderpenalty oeperjury oneof Ihe lffnllowinginker'
❑ I have and will maintain a Certifcae of Consent taself-insure for WOAcr's Cumpen-
swion, m provided for by See a 37M of the Labor Cade, Bin the perfomm we of the
work for which this pcnuil is issu d.
D I have and will Maintain Workers Compensation Insurance, as myuired by Section
3700 of the Inbar Qde, for the performance ,I he work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Cemicr: Policy No.:
CERTI EICAI 17 OF EXIiMPI'ION FROM WORKERS'
COMPENSAl]ON INS U RANCH
[This section need not be completed it the Permil isfor one hundred dollars 1$100)
or less)
1 certify Nat in the Performance of the work for which this permit is issued. I shall
not employ any person in any manner.ar as In become subject o the Workers Compen-
Z, anlion Laws orculifunaw. Date
ZAft,heant
�-I Nun CE TO APPLICAN'E If, after making this Cenifcane of Exemption, you should
F I I,ecane subject to the Workers Compensation previsions of the Labor Cale, you nmsl
7 forthwith comply with such provisions or this permit shall M1e deemed revoked.
CONSTRUCTION LENDING AGENCY
UZ I herehy, affirm Nnl them is a congrumioo lending agency for Ne perfonnlutec of
L� P the work lin, which this pennil is issued(See3097. Co. C.)
0 U Lender, Name
rLender's Address
0.. I certify that I hove read this application and ,cele that the above information is
LF. In c Amt. I mfrrr u, comply with IJP city and courtly nrdram,r, and xmle lows relating to QTY
U Z building aongmcnon, anti hereby umhoriv.e lnpm,rtrui es of suis citym enmr upon be
abo,c.mcmimrd property for Inspection partow,
twit) agrte m sa, indemnify and keep harmless the City of Cu in
against
liabilities. judgments, costs and expenses which may in any way accrue against said City
in nseyuence of the grin mgyfthis permit.
npm ICnLT181f�.K5 =MA AND WILL COMPLY WITH AJ.L NON -POINT
/ HA% OUSMA'1'HRIALS DISCL(ISUKE -
Wllllheuppllcnnl -more handing te,uproloomor handle M1umrdons inertial
as definad by the C.Benlno Morepul Codc, Chape, 9.12, and Lha HrnIN and Safety
Code. Section 25532m)?
El Ye, o
Wdl the applicant nr (wore building macupant use equipment or devices which
c it hunudo I, air onaz inars as defined by the ISay Arca Air Qmlhy Mu ulleanem
District?
D Yl) /�j��t/�'��
1 have mad the hwnldo daE myuiremem, under Chirpier 6.95 of he Cali-
too,IHea Safe, oda, x 25505, 25533 and 25534. I'ndrra dthin if the
huild,t Ic yb1 al r Llhw it in my respnnsibi li lonnli Punt
oft a I ouWorlorlo Nwriceor; I tjiGAII/A
ELEC-FRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDEN'I'I N,
PANELS
UPT02MAMPS
SIGNS ELECTRICAL
SPECIAL. CIRCUTDMISC.
'TEMP MEI lilt OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIX 'I
NEW RESIDENTIAL ELECTR
SQ ff..
91 ie�
❑ (e' 2.
BUILDING PERMITINFO
BLD ELECT PLUMB MECf
-0- ❑
FEE JOB DESCRIPTION
RESIDENTIAL
D SFDWL D KITCHEN REMODEL
[]ADDITION [IPLUMBING RE-PIPI!
D MULTI -UNIT ElSTRUCTURAL
MODIFICATION
D INTERIOR [ICHIMNEY REPAIR
IMPROVEMENJ _ E] SWIMMING POOLS
D BATH gEMWIiUREPAIR�D DGM0LIT10N�-n
SQ. BE
TOTAL: G
PERMIT FEL I� I 60
D FOOD
ALTER — TRAIN& VTkT — WMIR CA) VALUATION
BACK FLOW PROTECT. DEVICE k
DRAINS— FLOOR, ROOF, AREA. GOND. ST IF_S TYPE CONSTRUCTION
FIXTURES — PER TRAP r L 1�
GAS- EA.SYSTEM-I INC.4 OUT S OCC.. sCROUP APN "-I�,�,��
GAS -EA. SYSTEM-OVF. ITA'77) AO L-/gy
vnr;no�aa.o,..o ..,.., .. . ..,.......,..
BUILDING DIVISION ITHS
GREASE1
PLANCHECK FEE
SEW,,JI-SANITARY-STORM EA. 200 FT.
ENERGY IsEE
WATER HEATER WNENVELECPR
GRADING FEE
WATER SYSTENITREATING
SOILS FEE
WATER SERVICE
PAID
Date R« ipt w
NEW RESIDENTIAL PLMIL SQ. 14.
TOTAL.:
TOTAL:
BUILDING FEE
MECHANICAL PERMIT
FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
ANTER OR ADD TO MECIL
PLUMBING FEE
AIR HANDLING UNIT LTO 10.000 CFM)
MECHANICAL $
AIR HANDLING UNIT (OVER 10." CFM)
CONSTRUCTION T,
EXHAUST HOLD OVIDUCT)
HOUSING MITIGATION FEE
HEATING ONI'F(TO 100,0(1 BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID
VENTILATION EAN ISINGLit RES ID)
Date Rve6ful4
BOILER -COMP (3HP OR 100,000 BTID
TOPHI
BOILER - COMP (OVER 100.000 BTU)
AIR CONDITIONER
ISSUANCE DATE.
n r� /,
NEW RESIDENTIAL MECIL SQ. Ef.
OFFICE