S 1193went trw NTTO FILL IN INFORMATION WITHIN PFD LINES _ IISF BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PLUMBING - MECHANICAL
BUILDING DIVISION APPLICATION/IaERMIT1193
BUILDING PROJECT IDENTIFICATION
PITT F NO.
Cv
BUILDING ADDRESS.
SANI'T'ARY NO.
APPLICATION SUBMITTAL. DATE
Lo / 57,7.
OWN' :S NAMIi: PHONE:
. i / L J� Z ,�
CONT CTORS NAME: LIC NO:
N S f0 y r 3
NIC
CON'IROIC
I,
ARCHITEC/ENGINCF.R: LIC NO:
11,95-.?
ADDRESS: 91`J�00,
i
CONTACT': PHONE:
BUILDING PERMIT INTO
BLDG _ ELECT PLUMB ME if
LTJ/
MGS -Piss- / Z
/Ifq n
El Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I ton licensed under provisions of Chapter 9 (commencing
with Sectinn]agl)pf Division 3 O the Business and Professions Cade, and my license is
in full force and effect. 3 T
License Classy Lica •-w.''
Dam Contractor I a
QTY. ELECTRIC PERM IT FEE
JOB DESCRIPTION
RESIT ENTIAL:
❑ADWL El KITCHEN RE-PIPI,
]ADDITION [I PLUMBING R41'IPF.
MODIFICATION MULTI -UNIT ❑ STRUCTURAL
MODIFICATION
0INTUI210R MLT{II�I'PiiiIPAIR
IMPROVEMENT []SWIMMING POOIS
PERM[ 'I'ISSUANCE
APPLIANCES-RESIDENTIA1.
ARCHITECTS DECLARATION
I understand my plans shall be used as p.hlii records
PANELS
UPT0201AMPS
Licamed Professional
201400OAMPS
OWNER -BUILDER DECLARATION
1 hereby affirm but I am exempt from the Contractor's License Law It,, the
following reason. (Section 7031.5. Business and Professions Cale: Any city or county
which msmins a permit m construct, alter, improve, demolish, or repair any stmmuat
El BATH REMOUIRJR:PAIR El)IiMQ1.L ION
AOTHER
1'� �✓F1 HOG �[�P
OVER I(NIOAMI'S
SIGNS ELECTRICAL
priormitsisau..ce, also requires mcifilliemdhor such permluo file a signed stmmant
that he is licensed punttam to the pnrvl.uons of roe Contractors Late lass (Chapter 9
(commencing with Section 70B ofDivision ]ofate Busineasand Rvfeasinns Cale) or
that he is esempt dirml'mm and the bunts for the alleged esempt ton. Any violation cl
Section 7031.5 by any applicant for apmmil subjects the applicant to a civil penalty of
SPECIAL.CIRCUI'I'IMISC.
TEMP. METER OR POLE INS'I'.
COMMERCIAL'
❑ NEW BLDG/ADDITION ElDEMOLITION
❑TENANT ❑ FOOD SERVICE
POWER DEVICES
am more than five hundred dollars ($500),
01, es owner pf the pmpeny, or my empinyax wird wages as Ncir sole cpmpensmion,
willdothewnrk,and Nesantoal ais not intended ..offered lin sole(Sec.]044, Basins.
end Pmfessions Crile: The Commerce, License La. docs not apply to on owner of
IMPROVEMENT
❑GTHER
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FIXTURES
NEW RESIDENTIAL ELEC R Ff.
prormy who builds or iripmves thereon, and who does such walk himself or through
his own employees, provided that such improvements eat not intended or offered for
sale. If, however, the building or improvement is sold within one ycmof completion,the
owdcrbuilder will have the burden of proving that he did not build or improve for pur-
SU. Fn FLOOR AREA
$IgQ. PI'.
71
TOTAL:
pose of orle.).
❑ I, as owner of the praviti am exclusively contracting with licensed emnmemra 1.
construct the project (Sec. 7144, Easiness and pooh. do., Code:) The Contralto Li-
senve Law does not apply to an owner of propinly who builds or improves thomon. and
who contracts for such projects with n coomactortO licensed punuumm the Conunchncs
License low.
Aq
ry
.4� 1,0
QTY, PLUMBING PERMIT
-
PERMIT' ISSUANCE
❑ I am esempt nndcr Sec. ,II& P C for this noon
ACIER-DRAIN & VENT -WATER (EAI
h
Owner Dulc
meq, ,tV1ON
J e� 6
/> �Q Q
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
hereby
andwal mai under pertiltic oeperjuryoneol'thcfnsumfog inker''s Col
❑Ihave and will maintains Certificate of Consent to for WnrkerA Compen-
section, us provided fpr Station 3]00 of the LnMtr Calc, for the per(nnnance of the
wokl apermimif is issued.
ave and will maintain Wndefs ante of thehi ort required by issued,
for which
37M (if the Lahnr Code, for performance of the wod for whichthis permit is issued.
work
G'
DRAINS -FLOOR, ROOP.AREA. COW.
S'TORIES NC
/ �y
UCC GHOUL'
ECONSTRUCTION
APN
FI%'fUHES-PIiRTHAP
CAS -EA. SYSTEAI.I INC. YOUTLETS
My Workc(: C_ n nn�su4tnce cgmer ayd Policy "`5 arc:
My Wo Iicy Nu.:_G 40 �G—E
GAS-EA.SYSTEM-OVIiR6(I:A)
GRP.ASNINDUSTRI, WASTE INTERCEPTOR
C RTIIICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
PIUILDING DIVISION FEIiS
(This section need not he completed if the Permit is fortme hundred dollars ($100)
nr
GREASETRAI'
PLANCHECK FEEless.)
SHWER- SANITARY -S'IORM EA, 200 IT
ENERGY IEE
I certify that in thepetfomtenceuf the work for which this Permit is issued, l shall
not employ any person in any manner so as to became subject to the Workers Compen-
WATER HEATER WNEN'T110-FTO
GRADING FEF.
mtionl.awsof Califomia.Doc
s Applicant
s NOTICETO APPLICANT: If, after snaking this Cenificate of Exemption, you should
1 p
become subject to the Worker's Compensation tions of the labor Cale, you must
WAI'F.R SYS1'IiM/1'REA'TING
SOILS FT31i
i (nnhwiN comply with such pr.visionsmthis pemtir nhall The declined revoked
permit
Wq'I'EN SERVICE
NEW RESIDENTIAL. PLMB, SQ. Pf.
CONSTRUCTION LENDING AGENCY
j I hereby affirm that there isoconsuvctiun lending agency for the petfomnance of
PAID
c c°rpt#
if
TOTAL.
I the work for which this perolt is i ... ed(Sce. 31197. Civ, C.)
c Lender's Name
'TOTAL:
1 I.endn"Add les
information is
BUILDING FE
1 cendy that I have read this application and state that the above
1 toner. l agate to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city us enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE.
PERMIT ISSUANCIi
AUDER OR A DO TO MUCH.
ELECTRIC IrIiE
shove-mensianed property for inspection par msOs.
(We) agree misuse, indemand nity keep hamiless the City of Cali against
liabilities,judgments, costs and expenses which may in any way accrue against said City
PLUMBING FEE
in consequence of the grating of this permit.
APPLICANT UNDERSTANDS AND ' LL COMPLY WITH ALL NON -POINT
AIH HANDLING UNIT (TO IB,IgN)CFM)
MECHANICAL IF.E
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVF.N 10,000CFMI
GDNS'1'NHCfIQN TAX
�Z
Sign of Applicam/Conealof Dam
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD OVIDUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,00(1 BTU)
Will thacti,icam... (mmbuiliing occupxmsmmorhandle hazardous material
sea defined by doe Capetian Municipal Cas. Chapter 9.12, used the Health and Safety
Code, Sections 25532fa0:' _
HEATING UNIT(OVER 101,00) BTU)
VENTILATION FAN IS INGLE RESID)
E] Yes ON.
PAID Date licccipt#
n
BOILER -COMP OHI' OR 100,00H BTU)
Will the applicant or fumm building occupant use equipment Or devices which
emit hazardous air conlantinams as defined by the Bay Area Air Quality Management
TOTAL .
District?
❑Yes ❑No
MOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
I have read the hazardous materials m,uimments under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL SUCH. SQ. IT..
hadia Health & Safety Code, Sections 255(15, M533 and 25534. I understand that it the
building does not currently have a tenum. Nat if is my mspmsihility to notify the occupant
of the reyuir ntents which must be mel prior to issuance of a Cenilic:ne of Oveit'ncy.
ISSUED BY:
TOTAL
Owner or authorized agent Dam
OFFICE