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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. -MECHANICAL
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79
BUILDING PROJECP IDENTIFICATION
1
BUILDING ADDRESS:
z
SANITARY NO.
11
APPLICATION SUBMITTAL DAT[
-�
O '. NAM is ` PHONE:
r4. G/
CO 1 ACTOR'S NAME: LIC NO:
NIC
❑
COMROL11
RCUIDECUENGINEER: LIC NO:
ADDRESS:
CONTACT:- PHONE: -
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial)
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
QTY ELECTRIC PERMIT 17EE
JOB DFSCRIPTION
with Section IINIB),I Division 3.f the Business and Pndessirm Code, and my license is
in full force and coeur �J
Clss_ Lic.p 7 r�
Date Cnmmnor
RESIDENTIAL:
❑ SF'DWL- [I KITCHEN REMODEL.
[]ADDITION C1 PLUMBING RE -PIPE
PERMIT ISSUANCE!
APPLIANCES—RISIUCNTIAI.
A HITECI-S DECLAR fl
1 undersand my plans shall he used as public records
El MULTI -UNIT ❑STRUCTURAL
MODIFICATION
PANELS
UPTO20(AMI:S
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR El DEMOLITION
O 1A ER
ILwhich
\
Licensed Prnfunitnd -
OWNER- OUILDCR DECLARATION
1 hereby reaso ,(firm thatI L assault from the Cssions o License Law forthe nty
following reason, (Section ]imus, Business and offence, emoli Code: Any city or county
requires a permit coma eller, impmve, demolish, or repay any suudure
21)1-I00)AMI'S
OVER I" AMPS
SIGNS ELECTRICAL
re do, nonsuch fe o file
thovisiosofthe
prior(. itscensed
SPECIAL CIRCUITIMISC.
_tlJl
prluantto the
malbeisliamcd pursuant to the provisions Comoattm'v Licarm Low
License..i (Chapter 9
'TEMP. MISTER OR POLE INS"C
COMMERCIAL:
3 mtsCnmranm's
Icnmmenaing with Sectlon70IX)pfDivlxlon9 o(thn ❑uelness vnJ Wnfcyainns Code)
that he is exempt therefrom and the Ennis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7831.5 hying upplieart fora permit sibjectsthe.,pliant to a civil penaltyof
not more than five hundred dollars ($up).
❑ hes ownttnf em property. nr my employes with wages as thei...lecumpcnmtion,
will do the work, and the stmctum is not intended or offered for side (Sec. 7844. Business
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
OUTLETS—SWn'CHES— FIXTURES
and Professions Code: The Contractor's License Law does not apply to as owner of
property who hal Ws or improves thereon, and who duos such work hion,anor through
his own employees, provided that such Improvements are not intended or .Rend for
sale, If. however the building or improvement is sold within one yearn( completion, the
NEW RESIDENTIAL ELECI'R SQ FT.
SQ.FTb81WA EA
$/SQ. FT.
-
owner -builder will have the barden of proving thm he did not build m impmve far pm-
ILII tILAC
poseofmle.),
I, as owner of the property, am exclusively contracting with licensed contractors to
contrast the project (Sec. 7(v L Business and Professions Code:) The Cnmmemr's Li-
s
t/
81996
A
cense Law docs nm apply to an owner of property who builds or improves thereon, and
QTY PLUMBING PERMIT FEE
Cary
whocontmcls for such ps.jects with. con ) Ii ur's
rmloo censedpurauu
onotho Commm
License Low.
ptder Sec. - ,B&PCforthisreason
El lamdxemun
VN
I,
LVrr
hIIJyU
PCRMIT ISSUANCE
Owner Dam
ALTER—DRAIN&VENT—W F.N A)
VALUATION
WORKERS COMPENSATION DECLARATION
BACK FLOW PROTECT. DEV
I herehyoffirmunder voids, of perjury one of the fnBuwingdeclimtions:
DRAINS—FLOOR, RO 0
] I have and will maintain a Certificate of Comm to self -aur, for Workers Compen.
satinn, as provided for by Section 3700 of the Ichor Code, for the performance.( the
STORIES
TYPE CONSTRUCTION
work for whish this parish is issued.
FIXTURES — PER TRAP
❑ I have and will maintain Workers Compensation insurance, as required by Section
3700.6 the Labra Code, for the perfnsanceof the work for which this permit is ismed.
GAS—EA.SYSTEM-IINC.40
OCC. GROUP
APN
My Worker's Compensation Insurance carrier and Policy number urs:
Carrier: Policy N(,.:
GAS — F.A. SYSTEM -OVER 4 (EA)
CER'TIFICA'TE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thk,axethm sued not he campined if Be permit is Inroad hundred dollars ($IBTO
ur le'..)PLANCHF.CK
GRPASPJINDUSTRL WASTE. INTERCEPTOR
BUILDING DIVISION AMS
GREASETRAP
FEE
I verify that in the performance.fdo work for which this permit is issued.[shall
not employ any person in any manner so as m become subject to the Workers' Compdn-
SEWER—SANITARY—STORM EA. 200 PT.
-
FNFRGY FEE
WATER HEATER W/VGN'TIELECT'R
cation Laws of California. Date,
Applicata
GRADING AEE
NOTICE 10 APPLICANT. If, Our making this Ccnipcutc of Exemption, you should
become subject to the Worker's Compensation provisions of the Inbor Code, you must
WATER SYSTEM/fRBATING
SOILS PEE
forthwith comply with such provisions or this pemtit shall he deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
Ihereby affirm thin there is a communion lending agency for the performance of
NEW RESIDFN'TIAL PLMB. SQ. FT.
PAID -
Date Receiptp
the work for which this permit Is Issued (Sec 3097, Civ, C.)
Lender's Name
TOTAL:
Lenders Address
TOTAL:
BUILDING AEE
1 certify that I have mad this application and sine thin the above infommrion is
correct l agree to comply with all city and county ordinances and state laws relining m
building commencer, and hereby authb'e msenmtives of this to upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEC
PERMIT ISSUANCE
ELMTEmptim
shove -mentioned progeny for inspec - m pu
(Wel agree it) save.' o ymi fienrn sans the City nl' Cupenion again"
AL7ERORADDTOMF.CH.
lamilihes., got cos an ensul may loony way aceme against said City
¢
in nseque of dgr min this pe it.
PLUMBING FEE -
AIR HANDLING UNITHO IB0d0CPM)
FE
MECHANICAL E
APPLIC T 1 D 'TA f ' ANI ILL COMPLY WITH ALI. NON -POINT
SOU . RE L ' INS
AIR HANDLING UNIT (OVER 10,M) CFM)
CONSTBUCTIONTAX a
,i(v /�
1 mofAPPllcunUComractnr I Data
HAZARDOU: IAIS DISCLOSURE
IWIAUST HOOD (W/DUC19
HOUSING MITIGATION PEE - -
HEATING UNIT (TO RXE000 BTU)
Willmeepplicant or future building cecupantame,ohandie haeardnus materiel
an defined by rhe Cupertino Municipal Code, Chapter 9.I2, and the Health and Safety
Code, Smti.n 25532(¢)?
HEATING UNIT (OVER 100,(K0 BTU)
❑Yes ❑Nn
%J
Will thcappurounlicant rfus a definedding by occupant
Bay Aea AirQtamdManage antich
mil haamdauiSSir nmmminunts as defined by the Bay Area Air Quality Management
"Inct7
PYea 0 N
PAID
Date Receiptp
VENTILATION PAN (SINGLE BESIDE
BOILER—COMP(3HPOR IEg1100 BTU)
-
TOTAL:
BOILER — COME (OVER 100,000 BTU)
AIR CONDITIONER
Ihave hesitations under Chapter dund95 thethat Cali-
ISSUANCE DA
NIiW RES IDE SI'IAl. MUCH. SQ. Irl'.
Safetad y
om,S,nnr,, 2555,als
2553 art mut if the
-Health&Sn[ery Coda, Sa tina 43505,2553]and25594.I .notify the
I, tion not currently have u tenant that it is myce Cer ifi ca notify the neculppancy, m
iswhich
quircments which must M1e met End ormissuence nfe Certificate of Occupancy.
of.
.
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— VV/�\
ISSUED BP
aathndeed agent Dam
TOTAL:
„OFFICE,...
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