S 3882APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLW119NG-SIECHANI
BUILDING 1'RfIJF.CT IDENTIFICFIC ATION
PERMIT NO.
C 3 O O 2
J o 0
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
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OWNER'S NAME PHONE:
I11Ci� OF y16af6yaGry
CONDIAC'1'OH:S NAME' LIC NO:
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CHIFECAINGINEER: LIC NO,
ADDRESS:
CONTACT; PHONE
BUILDING PERMIT INFO
❑ Consultant Fuca Paid by Applicant(Initial)
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LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions or chapter 9 (commencing
with Section 700B.IlDivision 3 ufthe Business and Professions Rsdcad.ty licence isRESIDENTIAL;
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m lull force unJ ellcuu 3 / 3 / ys'
Licenm Cl ys l Y C. W
Dale I/ Contmcmr
QTY. ELECTRIC PERMIT FEE
DESCRIPTION
SFDWL Q KITCHEN RHMOUIih
[]ADDITION El PLUMBING BETTE
[I MULTI -UNI ❑STRUCTURAL.
MODIFICATION
[I INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
C) BATH REMOUEUREPAIR ❑DEMOLITION
[]OTHER
PCHMIT ISSUANCE
APPI,IgNC[S-RISIDBNTIAI.
ARCHITECT'. DI?GEAR TIN
I understand my plan.v sholl be used ns public records
PANELS
UP TO 20P AMPS
Licemcd l'mf—ional
OWNER -BUILDER DECLARATION
's License Law for the
1 hereby affirm that I am exempt from the Contractoren
following remora (Sema 7031.5. Busi.cvs and 11nd'cssla,s Code Any city m ummy
which require, a permit ,o cro,rrel, alter, improve, demolish. of repair any smucmre
to its issuance, also requires the apPlicam for such perming file a signed succulent
that he is plumed ponamat,,he ao,i,umvcf the Conloamns Liwmv Low (Chapter9
(cmmaanc'mg with Section 0(W) of Division 3 of the Business and Professions CWe)or
that he is exempt themfmm and the basis for the alleged exemption. Any violation of
Semon 7031.5 byany upplicanl lis a permit>.hjc,. the applicant too civil penaltyof
m refire than live hundred dollars ($500).
Dhas owner oRhc pmpeny, or my e.nploYees with waFn as theirvsleu+mpcnsahon,
will du the work. and the structure is not inandedor offcovd far %ale(Sec. 70W..Tu1in111
and 11rafecdonc Code: The Contmcsr's License Luw dues nut apply to on —net of
prupcny who builds or improves thereon, and who docs such work It If ,r thrmglt
his own employees, provided Plotsuch improvemnas fire nal imcnder or ,ITcreA for
side. If, M1oweverJhe hniliingormi,mtermal is sold wuhiclar ndcompletion.the
201-1000AMPS
OVER I000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCLE UM ISC.
TEMP. METER OR POLE 1>14.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
FOOD SERVICE
IMP VEMENI'
R
POWER DEVICESTENANT
SWIMMINGPOIilLECTRIC
zahI : WHCHIS-FIXTURES Q
_
N : DF. A SQ FT.
SQ. FT. ,LOOK AREA
E/SQ. FT.
ovioner-builder will have the burden of proving that he did not build or improve for per-
.t
prse ofsalc.).
un, owner of the pmpenY, um exelu.visely contracting with liccnrer wmmnorx m
T01
instruct the pri (Sec. 704 4, Business and Pmfessi,ns Cde:)The Cnnma<mr's Li-
extrelawdoesnalapplyu+an owle,in groped, who build s ... ... tpmvec.hcru+n, and
QTY. .l RING PE
who canuans for such projens with a ennoacrnr(s) licenced parsmat to the Contrneton-
PERMIT ISSUANCE
Licence L.P.
I am exempt under See .B& P C tic this na,cr
ALTER- DRAIN & VENT -WATER (CA)
Dam
vALUAI'ION
Y3 Qo
Won'
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
1 bcre r, Wort under penalty of perjury one of the following declarations:
✓
I have and will maintain a Certificate of Conseen to self -insure for Workers Comped.
cation, as provided for by Section 300) of Ilse Ialart Cade, to, the purfon.utcc of thu
/// k for which This permil is issued.
rj�' I have and will maintain Workers Compensation Insurance, as nNuire l by Section
1 )of the lobar Cade. for due performance of the work for which this permil is Issued.
DRAINS- FLOOR. HOOF AREA. COND.
STORIES
OCC GROUP
TYPE CONSTRUCTION
APN
FIXTURES - E'ER TRAP
GAS- EA. SYSTEM. I I NC. J OUTLETS
My
Carticrrkers CyyypcA�yy ry.ftyk� rill Poh,"o.Y n�.�"�z. 6.r q%
�1 l� 4gI
GAS-EA.SYS1EM OVER4 EA)
GREASI➢INDUSTRI, WASTE IN'rEHCEI'TOR
CERT[FICA] 1i Oh EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(This section need not he completed Hire arannit is foram hundrd do][. (S 100)
of less)
GREASETRAP
PLANCHIiCK FEE
SEWER - SANITARY - STORM EA. 200 FT.
ENERGY FEF.
Icenifythat In the pc,fdulammdthc work for whichihis permit is issued, Ishall
nm employ arty person in any manner so as 1. become subject m the Worker: Cumpea-
WATER DEAL ER W/VENTlELECTR '
GRADING ME'fir
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saiion I,wv ,`Califamia. Date
Applicant
NOTICE TO APPLICANT: If, afar making this Certificate of Exemption, you should
heusme xabjcd m the Worker's Compensation pnot,inal of the Labor Clads. you muss
fi nhwilh amply all such pr -mons aphis permit shall be deemed revoker.
CONSTRUCTION LENDING AGENCY
Thereby aflirnthat there is a conafcitn lending agency for the performance of
the ,,,it for which this pert.:. is icsud(Sce. 3097, Cts. C.)
Lender's Name
WATER SYSTEM,TREADNG
SOILS FEC
WATER SERVICE
PAID fie Receipt It
NEW RIiSIDEN'I'IAh P].MB. SQ. FT.
TOTAL:
TOTAL:
Linda, Address
I <enify that I hast read this application and state that the above information is
a+rtem.l agree fit amply with all city and county ordinances amt some lows relating m
building construction. and hereby authorial representatives of this city In emer.pan the
BUILDING iE
QTY. MECHANICAL PERMIT FEE
SEISMIC
PERMIT ISSUANCE(We)
ELECTRIC FEE
uhovc-mma.ioncd oopcny for Inspection punvw sl
agree m cave, indemnify and keep harmless the the City of C.,mi t against
liobilincs.judgmeux, ants and expenses which may in any way loamoilumnstsnid City
ACT ER OR ADD TO MECII.
PLUMBING PEE
S -(N
n,c,u,s,c rf the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI. NON -POINT
AIR HANDLING UNIT (TO IB.(MCFM)
MECHANICAL ME
SOURCE RECIILATIONS. #MY
Iice EGUI- (�I���pW-Y G-�-:��
AIN HANDLING UNIT (OVER IB.IMYJ CPM)
CONSTRUCTION TAX
Signal urcof Apphca (lmrauor Dam
I IAZARDOUS MATERIALS DISCLOSURE
F,XI MUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HCAI'ING UNI 'IIIU]in)(Xid ltd'
Willtheapplicant or future building wc...nlvorcarhandlehauan)ous r.umrial
an defined by the Cuper ino Municipal Cde, Chapmr, 9.12 and fie Iicalth and Safety
face. Section 25532(a)'I
❑Yes fR No
HEATING UNI 'r(OVER 100 BID)
PAID Dam Receipt#
VENT] LATION FANS GLE RES)D)
Will the upplica,... fmnrc huilAing uemtp:nu esu eyuipmemfir devices whish
us rtmi.ms as defined by the Day Area Air Quality Ma ergemem
mi. hazardoair co.m
BOILER -COMP POR 100,000 BTU)
'TOTAL;[a
•/off
v
BOILER -C 1P(OVER 100,000 B' 1' U)
District?
E3 Ycs �Na
AIRC UITIONER
of the Cale
1 have mad the Codrdims mamdldx 5, 2553 ema under Chapter understand
h+mdigdw,v&rcome Code. Swoons 25505, 25531mW2553x. ,n dem:md .ha.if the
ISSUANCE DATE
N RF.SID]iNTIAL MF,CH. SQ. 4T.
building Jiwx n,. curtently havcmmnani, that it is my rcsrymsiM1ilitym notify the occupant
/VEL-•
iddre is xwaircchnmu/s.I��e��i mrsuarxxofa Ced iioce.Ff,lk(g�y /��p
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'TOTAL:
/f'
- ", 1 �IA.(iY#'� / /p-/cy
ISSUED BY.
Owners uuthn oro ng n Un.e
OFFICE