S 4367 (2)V
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECIIANICAL
PERMITNO.
S 4367_
BUILDING. PROJLsCT IDENTIFICATION
BUILDINGADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
Soso, "ht it
OW IiR'S NAME: P ONE
eh v%woo ��' 366-ISS�%
CON O 'S NAME: I.LC NO
N/C
❑
CONTROL#
.tRCHITEC I]INGINEER: LIC NO:
ADDRESS:
CONTACT : /+ PHONE.
(y���366'�SJ /
❑ Cansultaot Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
B�LDDG/ ELECT PLUMB MECH
J�Ch L7fQCVlN/oo.�
!� ❑ ❑
LICENSEDCONTRAC'TOR'S DECLARATION
m th
1 hereby ulGrat 1 aum licensed under provisions of Chapter 9 fcnmcncing
QTY. ELECTRIC PERMIT FEC
JOB DESCRIPTION
with Sectinn)Baq of Division3of the Business attd Profusions Calc.andmyli[eass is
e.
in fall f..ce and cftet
License Class Lica
Dare Contractor
RESIDENTIAL:
❑ SFDWL ❑KITCHEN REMODEL
❑ADDITION [I PLUMBING RE -PIPE
El MULTI -UNIT ❑STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES -RESIDEN9'IAL
ARCHITECTS DECLARATION
1 undernwnd my plans shall Beused n' public records
pANEIS
UP
UP TO 200 AMPS
[I INTERIOR [I CHIMNEY REPAIRLicensed
IMPROVEMENT SWIMMING POOLS
L4 ME REMODEUREPAIR ❑ DEMOLITION
C1 OTHER
f
Professional
Oat I am exempt R . ,hc DECLARATION
1 hereby aliitm that I am exempt from the Comracmrs Lmm. Law for the
following pension. (Section 7031.5. Business and Professions Calc: Any can or county
which requite., a pemtit to an el, ah,,mpmve, danolish, or repair any stmctore
prior to its issmmce, also requires the applicant for such permit m file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
OVER 1000AMPS
SIGNS ELECTRICAL.
SPECIAL CIRWIT/MISC2
/ . f �/
TEMP. MITER OR POLE INST.
COMMERCIAL'
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT [I 1700D SERVICE
IMPROVEMENT
❑ OTHER
(commencing with Section]B(XBof Division 3ofthe llusinessand Prnfmsmrt%Codc)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Sceann 131.5 by any applicant for a permit subjects the applicant, a civil Penalty of
no at five hundred dollars (5500).
as nwnecof thepmpcny, or my employees with wagcsas theirstilecompensation.
will Jo the work, and the stmctum is not intended or offered for sale (Sm. 7044, Business
POWER DEVICES
SWIMMING POOL ELECTRIC
and Professions Code: The Contractor's License Low does not apply to an owner of
OUTLETS - SWITCHES -FIXTURES
property who builds or improves thereon, and who docs mah work himself or through
his own employees, provided that such improvements are not intended or offered for
NEW RESIDENTIAL I:LELTR SQ FT
sale.If. however, the building or improvement is sold within one yearn(completion. the
.FL
S
owner -builder will have the harden of proving that he did not buil) or improve for pnr-
D
Pwe nl
AL:
C] I, as owner of the property, am exclusively contracting with licensed contrveors to
consumer the project (Sec. 7014, Business and Professions Code:) The Contractors Li
JUN 3 Q 1F1
'
fl
cense law does not apply to an owner of pmpeny who builds or improves thereon.and
QTY PLUMBING PERMIT FEE
's7
A
who contracts lin such projects with a enmraclod s) licensed pursuunnn the Contmcatrs
PERMIT ISSUANCE
License Law.
[]lam exempt under Sm. ,B&PC (or this rtason
By
ALTER-DRAIN&VENT -WATF. )
O A 30 99
O WORKht'S ' MPLNSATION DECLARATIONT�—•-
I herehy affirm under penahy of perjuryfoll
one of the mving declarations:
D
BACK FLOW PROD. V
❑ I have and will maintain. Cenificamof Consent,, scIf insure for Workers Campd-
for by Section 3700 of the Labor Core, for the pednrmanee of rhe
'anon, Providedmalhis
work forr which s permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, aswhich his M1y Section
DRAINS - FLOOR. ROOF.
STORIES
TYPECONSTRUCTION
FIXTURES -PER TRAP
perm
My nfulbe o Codpfonheprncmmncenmhework fnumbrathispermit is issue].
My Workers Compensation Insurance artier and Policy number are:
GAS - EA. SYSTEM (INCA OUTLETS
OCC. GROUP
APN
Carrier: Policy Nn.;
GAS - [u1. SYSTEM -OVER 0 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This motion need not be completed if the permit in forone hundred dollars (EIo01
or IcssJ se
GREASOINDUSTRI, WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHECK fEE
1 cenify that in the Performance of the work for which this permit is issued, L shall
not employ any person in any manner so its it) beeonm subject the Workers' Conipem
SF,WF.R-SANITARY-STORh11iA.2W R.
ENERGY PEE
WATER HEATER WNENT/ELECTR
'inion Laws of Celampria. Dare
Applicant
GRADING FEE
NOTICE TO APPLICANT. IL after making this Cemificam of Exemption, you should
has ne subject ,, the Worker's Compensminn p..W...n of the I.ahm Code, you must
WATER SYS'fEM/IREATING
SOILS FEE
forthwith comply wilh such provisions or this permit shall be deemed rcvnked
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I huehyaffirm thauhoreis aconamction lending agenoy for the pu(ommnce of
PAID In
ate RecetPt#
-
NEW RESIDENTIAL PLMB. SQ, FT.
the work for which this permit is issued (Sec. 309], Civ. C.)
Lender's Name
TOTAL:
Lenders Addms'
TOTAL:
BUILDING F
it
L certify that I have mad this application and state that the altfwe information is
QTY, MECHANICAL PERMIT FEE
contact. l agree m comply with all city and enutny omfirances and state laws rclwlng to
building construction, and hereby authorise representatives of this city to enter upon the
SEISMIC F . 3
0
shove -menden it lroleny for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of Calamine against
PERMIT ISSUANCE
ELECTRIC F :
ALTER OR ADD TO MECH.
PLUMBING PL
Iiabilitiv.judgmenR costs and expenses which may In any way acme agranot said City
In consequence of the granting of this permit.
AIR HANDLING UNIT TO 10,000 CFM)
MECHANICAL FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -MINT
SOURCE F )CATIONS
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCIIO T
6
MlynallumMA1p iso nmmctor ate
. ]ARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING M 1 ON FEE
HEATING UNIT (TO 100,000 BTU)
Willtheapplic of or future building occupant store or handle harardous material
as defined by the Cupeninn Municipal Cafe. Chapar 9.12, and the Health and Sxfn,
Code, Secdmt 25532(a)^
HEATING UNIT (OVRR 100,000 BTU)
El Yes -I No
Will the applicant or future building Itts the Bt use equipment or devices which
coal, incision., nus air commntinams as AdinaJ by the Bay Area Air Quality Mnnugcment
Dislritl^
❑Yes [D No
I have mad the haannlnus mamrials re airemems under Cha6.95 of the Cali-
9 p
PAID
-
VENTILATION FAN (SINGLE RESID)
Dam Recent #
BOILER - COMP (JHP OR IOl1,IX1) BTU)
TOTA
Lr
BOILER- COMP (OVER 100.0(g) BTU)
Q
AIR CONDITIONER
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. T7,
fnmiagdoesalth & Safety tly haSectinn'25505,25533
.that. is anyand255]4.1 understand theifthe
carthong dares not currently have a tempt. that it is my msptmeCarry to notify the occupant
of the rumen ch moa M oat ldm m issuance of a Cemifica¢ of tXcurytay.
ISSUED BY:
neni-mal,eri j agent Data
TOTAL
OFFICE
u
ADDITIONAL PERMIT FEES
EMP. METER OR POLE INS.
PEauITNAUDAT'0N
ISSUANCE DATE
MOTORS SEE FEE SCH.
SERVICE CHANGE
TOTAL
OTV. PLUMEINO PERMIT ERE
SLOG.
❑
ELECT. PLG.
❑ ❑
VECN.
❑
ALTER DRAIN & VENT -WATER IEA.)
0-
0