31256 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITN031256
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL JK L 5 FVC
BOILDING PROJECT IDENTIFICATION
BUILI�GADSS: /\��C�� 5ANI'1'ANY NO. AI'YLI/CwAT�ION SUBMITTAL DA'1'I
OWN^hI�"LS1NA/ME: •l PHONE (/ l ONTRACfOR'S NAME: LIC NO: V
laro / —;In 'v6£ eJ� 6 NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
C'tIz / /�� 7b )/� 1 ❑ Consultant Fees Paid by Applicant(Initial) BDG ELECT PLUMB MtiCx
Ale�i� 0 V ❑ ❑ ❑
LICENSEDCONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am lirensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DMZ with Section of Division 3 of the Business and Pmfcssioms Code.farm,license i. RESIDENTIAL,
00 wt n PERMII'ISSUANCE RE
iaceiveoClass effect. ❑SFDW`L ❑KITCHEN RHMODHL
-UU License Clnss Lick APPLIANCES-RESIDENTIAL
y<a Date �6�a ACanRCHITECTS
AIS ❑ADDITION ❑PLUMBIURAL IPF:
ARCHITECTS DECLARA OII N [I MULTI-UNIT ❑STRUCTURAL
ZONZ l understand my plana.shall be used as public records PANELS MODIFICATION
OZ-O UP TO 200 AMPS El INTERIOR ❑CHIMNFiY REPAIR
F�.b".W Licensed Ponfic,omal 201-10NIAMPS IMPROVEMENT
Yw
OWNER-BUILDER DECLARATION OVER ION)AMPS ❑BATH REMO 1/REP ❑DEMO ION
Q 1 hereby affirm that I am exempt from the Contrunor',License Law for the
�a�((�aV following reason.(Section]831.5.Business and Professions Code:Any city m cooly SIGNS ELECTRICAL ❑OTHER
a13LL y which rtquias a permit m conswet alter,improve,demolish,or repair any structure
Fi'O�'2nam
prior to its isnaace.also require,the applicant for.such permit to file.axgncd statement SPECIAL CIRCUIT/MISC.
} that he i,licensed puoptn to the pvisinns of the Co mon,',License Law(Chasm,9
al 0 (commencing with Second 7000)of Division 3 of the Business and Profession,Code)or TEMP.METER OR POLE INST. COMMERCIAL:
E..a c e that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
_4 Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
moo' not more than live hundred dollars(550)1. ❑TENANT ❑FOODSERVICE
7,Y IMPROVEMENT
Q 0I,,r owner of the property,or my employees with wages as their sole cangscussaon, SWIMM ING POOL ELECTRIC
will do the work.and the atacture is not intended mid ersd for sale(Sec.7000.Business ❑OTHER
W m and Professions Code:The Contactors Liconse law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
a 3 property who builds or improves thereon,and who does such work himself or through
his own employee,,provided that such improvements arc not intended or offered for NEW RESIDENTIAL SQ FT.
sale.If.however the building or improvement is sold within one year ufnnnpletion,the SQ.IT.FLOOR AREA S/SQ.FT.
,,ur-M1ui Wer will have the burden of proving that he did not hail;or improve lin pury
s mf,aleJ. P A I D
h as owner of the property,am exclusively contracting with licensed contractors I. TOTAL:
construct the project(Sec.701 Business and Permissions Code:)The Contractors I.,
case law does not apply m an owner(if property who builds or improves thereon.and QTY. PLUMBING PERM FEE
who contracts for such projects with a contractor(,)licensed mrsuanuo the Cnntrecmr's OCT --7 1996
License I,uw. PERMIT ISSUANCE
❑I am exempt under Sec. .B S P C for this reason _
ALTER-DRAIN&VENT-WAT W TION
Owner
Dae ^r
WORKER COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
1 heathy affimt under penahy of poTjury ora of the following Jedurmianr
❑I have and will maintain a Cenificam of Convert[ self-imum for Worker's Comped- DRAINS-FLOOR,ROOF,AREA,CONI3. STORIES 'fYYF,CONSTRUCTIUN
some.as provided for by Section 3700 of the labor Cede,for Ne performance of the
work for which this permit is issued. FIXTURES-PER TRAP
k-1 have and will maintain Workers Compensation Insurance,as required by Section
3900 nfthe Labor Codc,for the perfomorec of the work for which this permit lei,sued. GAS-CA.SYSTEM-I INC.4 OUTLETS OCC,CROUP APN
Carticcr C ICansd �Inrancc corrinPol cy Nay
N ] IS3a.
GAS-HA.SYSTEM"OVER 4(FA)
star
CERTIFICATE OF' .XF.MITIOI FROM WORKERS'
COMPENSATION INSURANCE GREASFnNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be compineA if the permakIntone hundred dollars(5100) GREASB"TRAP
m le,x.) PLANCHECK h1iE
I aenify that int he performance of the work for which this permit is issued.1,mll SEWER-SANITARY-STORM EA.200 Fr"
nm employ any Person in any manner so as m hecome suhject to fie Workers Comped- ENERGY FEE
zZ ,,tion laws of California.Dam WATER HEATER WNENT/ELECTR
O Applicant GRADING PEE
VJ
NOTICE 10 APPLICANT:If,after making this Cenifirme of Exemption,you should WATER SYSTEMO REAJ'ING
(-+ 5 heamm subjce m the Worker',Co n,raort inn pmvisinns of the Labor Calc,you must SOILS FEE
{ak1 forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
d
Z) Z CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Date Receipt#
V ) for which
thi that isaco nice 30 lending agency for the perfurmana of
f"t the work for which tM1is permit is issued(Sec,3119].Clv.C.)
0 Lenders Name TOTAL:
O C.1 Lender's Address TOTALLIJ :
} I codify that 1 have read this application and smic that rise above information is BUILDING FEE
Ncorrect,l agree m comply with all city and county ordinances and state laws reining m QTY. MECHANICAL PERMIT FEE
V Z building comarratiat,and hereby aahnrim repre,comovesofthis city toenterupon the SEISMIC FEE
above-mentioned papery far inspection purposes. PERMIT ISSUANCIi
(We)agree to save,indemnify and keep harnlesa the City of Crisman.against ELECTRIC hili
Iiabilitics.judgmena.costs and expenses which may in any way accrue agmnatmid City ALTER OR ADD TO MECH.in
cosequence of the granting of this permit. PLUMBING FEE
n
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNI'I(OVER 10,000 CFM) CONSTRUCTION'1'AX
Slgnamre of ApplicanUCcommair Date EXHAUST GOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant ur future Buildingnecup,orlon or handle haa.Won,material HEATING UNIT(TO 11X1.0000 BTU)
as defined by the Cupeninu Municipal Code.Chapter 212,and the Flealm and Safety
Cede,Seaton 25532(,)1 HEATING UNIT(OVER 100,0100 B U)
YesPAID
VENTILATION FAN(SINGLE RESID) Date Rcceiptk
Will ul the applicant or its a building occupant use equipment or devices which BOILER-COMP(THP OR 100.000 BTU)
emit hvuNous air cnmuminants as �Rnel by the Ray Area Air Quality Management TOTAL.
District? BOILER-COMP(OVER 100.000 BTU)
El Yes No
I have read the Intrusions materials uspiremema under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
poor Safety Code.Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildt dram teureutly t n6 then it is myresrymsibiliry mnmily the rcatpum
of th occuirof cot nu,�c`priormissu cofoCcnifcate of u yc ofoCcnifcalc of u y.
IJ 6
Owner or malociudOwner or asset Date TOTAL: ISSUED BY:
i OFFICE