S 0286 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT'RICAL EIL51T N0. O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBINGMECHANICAL
286
BUILDING LDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NQ APPLICATION SUBMITI'AI.UA'1'L
105 g t -r �srATs
(l 1AS NAME I^HO�fi: (ANTRACTQRS NAME: IT }.IC NO
f5 A � &T `� l f (lP Il / [v. M11I 4 I I WC CONTROL,#
tjWARCHTECT/ENGINEER: Al LIC NO: �D� ADDRESS
r J ❑
C
ONTACT'. PHONE: 'll BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MEGA
❑ ❑ ❑
LICENSED CONTRACnOB8 DECLARATION QTY. ELECTRIC PERMIT FEE
by(dean Tho nm of the
Bu render and
Proom ofchama n intmnenany JOB DESCRIPTION
rsa'Z with Section DivisinnJofehc Business and Professions Calc.and into license lk NESIDENTIAI:
1�0pnd eB t PERMIT ISSUANCIi
ulF5191 ❑SIT)WL ITCIIPaY RIiMODEf.
�UO pica �('` le/es�Lx:3 APPLIANCES-RUSIDENTIAL El ADDITION LUMBING RE PIPE
h�.i til 1 eomm-
ARCHITEC'SDECLARATION ❑MULTI-UNIT OS UC1_RAI.
ZONz I understand my plans shall INC u:a.2s public records
PANELS MODIILCATION
OZ�2-0 UPTO200AMPS [I INTERIOR ❑CHIMNEY REPAIR
a F j LicennJ Profession^I 201-I000AMP5 IMPROVEMENT OSWIMMINGPOOLS
OWNERBUILDERDECLARATION OVER 10100 AMPS ❑BATH RIiMODEUR1iPAIR ODEMOLI'TION
C C Q 1 hereby affirm that[;air excemot from The Comme nr's hlccmc Law for the
2 O L U following reason.(Send..7031.5.Business and Professi.ns Cade:Any City or county SIGNS ELFCTRICAL ❑OTHER
W 3 a h nslmamo
which retains a Tom to n, ,almr,improve.demolish,or repair Cay atumm a -
Oa promo its issuance.also requires the applicant rnr wen permiuo BlcusigneJ emtement M'ECInI,CIRCULI'/MISC.
,S Y that he is licensed punaantmtnc provisions of mm
he contcr's License law(chapter)
W CCpO (turnamming with Section](101D of Division 3 of the Bminess and Professions Code)., TEMP.METER OR MILE INST. COMMERCIAL:
la.
c.cy� that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION
cel+ Scaioa7031,5hya^y eppl,out,fapermit s.bjeca,hC applicant ,,a civillx^aliyol POWER DEVICES
W El TENANT FOOD SERVICE
not morethanfvehundred dollars empl. IMPROVEMENT
FZQ Q Las^wnerk,the property,sermy no,ormyttswith Bred aaTheir sale
ec. 04TBBusiness
compensation. SWIMMING POOL ELECTRIC
will do The work,Code:he Cont is nut s Livens o Law does of apply Loan, caner os OTHER
63 m am property
WI.ns Calc The Contractors therrt.s License Law does not apply s if owner of OUTLETS-SWITCIIF:S-hIXTURES
his own who builds or improves thereon,and who daa such work himself or through
his own employeesro
huiprovided that.such improvementsm anot intended..,.firma.for NEW RESIDENTIALRESIDENTIALELECI'R SQ P-f.
rule.IL however.the lding n,impnrvanent is n,IJ within nncywnJamlplctiolt,IM1c SQ.FI'.FLOOR AREA $ISQ.II'.
,builder will have the burden of proving that he did not build or improve for PUT
TOTAL: ^
owner
irate). r A ! D
F7 1,as owner of the properly,am exclusively contracting with licensed contractors m /i ll
mlmct the pn,jal(Sec.9046,Business and Protes4^nx Cale)'Ihe Commcter's Li-
ansclawdue,not apply to an owrmrofpmpcny who build,orimproves memo^.and QTY. PLUMBING PERMIT FEE (iQB� y
Who Ammcsfnrmch PmjCcls with a cnmraeads)licensed pnl.uant,,the Conlmetors JUL
g O['pryg
License law. PERMIT ISSUANCE RC4 9
1 am exempt more,Sec. .B&P C for This reason
Owner DepALTER-DRAIN&VENT-WATER((HA TION
�
WOR KERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty Ofpequry one of The following declarations
O lhavc and will maintaineCenificmc of Conwntmself-Insure for Workers C.mpen- DRAINS-FLOOR.ROOF,AREA,COND. NI'(IRIES TYPE CONST RUCTION
sanon,as provided for by Section 3](0 of The Lahr Code,Iia the performance of'he
work for which this permit is issued. FIXTURES-PER TRAP
�A')have and will maintain Worker's Compensation Insurance,as required by Section
]Wof The Labor Code,for the if ounce ofons work lin which This permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Workermlwnm
's Coti9u Insurep�ccarrierend Policy nut�pega
Canicc S iATE/-Ut.IU Policy N., FDO�Iea-� GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASHANDUSTRLWASTE INTERCEPTOR
OEis ratio^need nm be completed if the pemdt is for one hundred dollar.(S W) BUILDING DIVISION FEES
or less.] GREASE TRAP PLANCHECK FEE
Loy any Rotor the peymnnrca s to harrow
a The Wik6,'Conahnll SEWER-SANITARY-STORM 8a..41X1lT.
not employ any peso.in any manner so as to become wbjecuo the Worken'Compcn- ENERGY FEE
ration Laws of Califomia.Dae
z O Applicant 1 WATER HEATER W/VENT/fiLECTR GRADING PIAT
y
NOTICE 10 APPLICANT:If,after making this Certificate of Exemption.you should WATER SYSTEM/IREATING
a ; :come wbject m the Worker's C......to.provision of the Lahr Code,you most SOILS FEE
fonhwith Comply with,mh ma,isions orchis permit shall be Jecmcd revoked. WATER SERVICE
DCONSTRUCTION LENDINGAGENCY NEW RE.SIDENTIALPLMB. SQ.I'll PAID
L) p k Far by W hafhrhithat entat i isacalSpe,1on 3047.lending agency for the performance of 1 m Recciptp
f~ the work lin wM1ich This prnnie is issued(Sec.3(14],Civ,C.1
Q leader's Name TOTAL:
V
Leader,Address TOTAL:
y 1 Certify That 1 have read this application and state that the alive inarection is BUIL l t
fa. Curnet.I agree 1.comply With vel city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby authonic representatives of Nis city to enter upon the SETS, 'F .
.. ahve-mentioned property for inspection pmpnscs' I'ERMI'1't$SUANCE
(We).,me to sole,indemnify and kap harmless me City or Cupeninn ngninsl ELECT FEE
Iiobilieiesjudgmems,costs and expenxs which may in any way aceruengalmt said City ALTER OR ADD TO N1EED. O
in consequence of The granting of This permit. PLU LNG FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'(TO IO,(NN)CIM)
SOURCE REGULATIONS ML' APICAL FEE
AIR HANDLING UNII'(OVF.R IgOX)CFAD GONSTRU LUN TA'
Signature of Applamo/C.mmcmr Date EXHAUST HOOD(W/DUCT) HOUSING MI'1 CATION FEE
MATERIALS DISCLOSURE
Will The applicant or future building Occupant score or handle haeardous nmtcrial IIEATING UNIT('TO 100,00 BTU)
it,defined by the Capetian Municipal Cndc,Chapter 9.13,and Ise Hcnllh and Safety
Code.Section 25532(.),^ HEATING UNIT(OVER 100.000 BTU)
❑Yes ON.
VI:WILAI'ION FAN SINGLE RESID) PAID
Dam Receipt#
Will the app ustomrrna,aom,Cleared occupantuse yAea Air Qualitment y
vlcuswhich BOILER-COST UUP OR 100.0X0 BTU)
mit District,
us Thr contaminants as def sed by the Bay Area Air Quality A1anagemnenl
Distdn? TOL\L:
0Ycs No BOILER-COMP(OVCR IW,INX)BTU)
1 b:me sad the hamrdsms materials AIR CONDITIONER
r5,a 5menu under Chapter h95 of t:Cali- ISSUANCE DATE
fomia gdoHeales&Safelyrre Code,Sections,that i 2553}and 25Pi.1 t orcmmnd that if the NIiW RBSIDIiNTiAI.MECH. SQ.FI'.
building dres currently have umna e,that it is my respomsihilieymratify the rccupvm
Ow.8,ntoram nlswhich
ent 'o to'ssuanre ofa Cenifca'c 11)
iQ �/f/X/�I
Ow IhnneeJ agent TOTAL: ISSUED I3 Y:
OFFICE