B 0315 (2)ucnnu nrtnN lunrulN REV I IIdFR. IIRF HALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION)TERMIT PLUMBING - MECHANICAL
tlUILDING PROJF,CT IDENTIFICATION
PERMIT N°
S0001 ,a 0 315
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DAT'[
O 'S IN AME: P ^
CONTRACTOR'S NAME: LIC
7/7
NIC
CON I'ItOL#
Jl
QLl
ADDRESS, PA'"it
1:1—
`ARCHIL ECUENGINEER: LIC NO:
I
PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MHCH
ED
LICENSED CONTRACTOR'S DECLARATION
firm that 1 um licensed under Farrel ns of Chapher 9 (commercial
)ofDi...ioo3°f(he Business and Professions Coda snA my license is
F70M)
lfec
tQTY, ELECTRIC PERM? P FEE
JOB DESCRI ION
TI L:
SFDWL ❑ KITCHEN REMODEL
PERMIT ISSUANCE
APPLIANCES-RESIDP.NTIAL
Lil-
ADDITION ❑PLUMBING RE-PIPITIC,
❑MULTI -UNIT ❑SI'RIICTURAL
MODIFICATION
❑INTERIOR LJ CHIMNEY REPAIR
IMPROVEMENT El SWIMMING POOLS
DEC
ARCHITECTS DECLARATION
I understood my plarw shalt be used as puhh, records
PANELS
UP TO 200 AMPS
1 Leered Professional
201-IOMAMPS
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
t following rcaaon. (Section 9031.5. Business and Pmfessiona Cndc: Any city or county
El RATE REMOUP.UREPAIR DEMOLITION
Gr4/4
OVER 1000AMPS
SIGNS ELECTRICAL
jwhich requires a permit to conswct, alter, improve, demolish, or repair any stmcture
' priarta its issuance, also reaches the applicantforsuch permit Wide aligned smtmnent
that he is licensed pursuant to the provisions of the Coastal License Law (Chapter 9
j Icommemeing with Section 700(fed Division 3 ofthe Busineasaad Professions Code).,
that he is exempt therefrom and the basis for the alleged exempting. Any vi Nacho of
SPECIAL CIRCUIUMISC.
TEMP. MET ER OR POLE LIST
COMMERCIAL:
❑ NEW BLDGIADDITION ❑ DEMOLITION
Section 9031.5 by any applicant forapermit snbjeots the oppllcanuo a cold penalty of
not more than live hundred dollars ($500).
I] 1,asnwneroftheprop ny,orinyemployeenwithwug"va (ileirsolecompertation,
'Il do the work, and thaanu mine loner (mended proffered for sele(Sec.9044, Business
i and Phonetical Code: Tho Contractor's License Law docs not reply man owner of
POWER DEVICES
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT'
El OTHER
SWIMMING POOL ELECTRIC
OUTLETS -SWITCH S -FIXTURES
s property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sales lLhowever, the an orwithin oral yclunfwmpletiaathe
NEW RESIDENTIA ELECTR SQ CL
xt OOR A n
$ISQ. PC
owner -budder will have the burden of proving that he did not build or improve for poo
I II
T°`"''
On
1, as owner of the properly, em exclusively contacting with licensed enmtucmrs to
E]Iatwo
m.[,net the projent (Seo. 7044, Business and Professions ow;, rhe C.Iran cmr'x Li-
erase Law does not apply to an owner of property who builds or improves thereon,and
JUN 2 8 1999
'
QTY,, PLUNiBING Ph&t FEE
who contracts for such project& with a anntmetor(s) licensed Pat to the Conlracmrs
License Law,
❑ I am exempt under Sec , B & P C forthis reuson
PERMIT ISSUANCE
ALTER- DRAIN & VENT- WATER (EA)
y _
VALUATION
_
S�
Owner Date
WORKERS COMPENSATION DECLARATION
BACK PLOW PROTECT. DEVICE
1 bachy affrm under penalty of perjury one of the following doe h ratimp:
E] I haveaed will maintew. Certifiwmol'Corasent tel nsure for Worker's Carl
soar as provided for by Section 3700 of the Labor Code, for tine performance of the
w for which this permit is issued.
CI�J
DRAINS- FLOOR, ROOP, AREA. CORD.
STORIES
TY PECONSTRUCI'IOI
_
FIXTURES - PER TRAP
GAS -EA.SYSTEM -I INC. 4 OUfLETS
I have and will mailown Worker's Compensation Insurance, as required by Section
Ed ofthe Labor ONE, for the performance of th, work for which this permit is issued.
OCC. GROUP
APN
Work o Iola ranee dPollcy `r
Currier: Policy No.:
GAS -EA. SYSTEM OVER4(EA)
GREASFIINDUS'I'RL WASTE INTERCEPTOR
CERTUFICATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(This section need not becoatpRted ifthe Penult is fornne hundred dollars isHad
or less)
I mnifythul in de, porformanoeafthc work for which this permit is issued, Ishan
not employ any person in any answer so as m become subject m the Workers' Compmt-
sones Laws of Califomia. Date
i Applicant
GREASETRAP
PLANCHECK FEF.
SEWER -SANITARY -STORM EA. 200Ff.
-
ENERGY FEE
)�
/ WATER HEATER WNTNUELECfR 4,00
GRADING PEE
NOTICE TO APPLICANT if, after making this Certificate efExemption, You should
became subject m the Worker's Compensation pmvisions of the Labor Code Ypu must
forthwith comply with such Pon islons or this permit shall be deemed moral
WATER SYSTP.MITREATING
SOILS PEC
WATER SERVICE
i
CONSTRUCTION LENDING AGENCY
� Iherehy affirm that them isaconstm<tinn lending Blaney for the perfmmanee of
s I work for which this permit is issued (So, 3099. Cie C.)
Leader, Name
Leader'
PAID
NEW RESIDENTIAL PLMB. SQ, FT.
Date kecap14
. v TOTAL:
' POI'AL:
'
I Lenders Address
is
BUILDING FEE
I certify that 1 have read this application and state that the above infomtatiou
�contest. Iagree (I)comply with all city and county ordinnmes and state laws rehning to
r huddinguonarustior, and hereby anishoutrcprexentwives ofthiachy to enter Upon the
QTY, ', MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ALT ER OR ADD' 10 MECH.
ELECTRIC A.
ahovwmentioned property for inspection purposes
(We) after to save, Indemnity and keep harmless the City of Carl against
localitiesjudgders, costsand expenses which ntayinany way tame egaimlaald City
PLUMPING FEE
in consequence of ate gating of this permit.
APPLICANT UNDHRRSS'TAN/AND WILL COM PLY WITH A LL NON- EDINT
AIR I IANDLING UNIT(TO I lCFM)
MECHANICAL
SOURCE RF.GULAf1y¢—D�S/— —DWV
AIR HANDLING UNIT (GVHR IB,SN) Cl
CONSTRUCTION TA
\
\
Signnmre of,opplicam/Contmelor Date
.
EXHAUST UOOD(WIDUC'G
HOUSING MITIGATION 'EB
HAZARDOUS MATERIALS DISCLOSURE.
HEAPING UNIT 670100,010 BTU)
Will the applicant or future twitting occupant Imre°, handle htaallous mamrfal
as defined by the Cupertino Municipal Codc, Chapter 9.12, and the Health and Safety
Code, Section 25532FIC
HEATING UNI'P (OVER 100,000 BTU)
V ENTILATION FAN (SINGLE RBSI D)
El Yea 7 N
PAID Date Rao to
Will the appllcent or Nmre building occupant axe equipment ordevfees which
mit hanardons air conmminatna us defined by the day Area At, Quality Monrgement
gOILP.R-COMP (3HP OR 101,000 BTU)
OTAL:
District?-
❑Yrs E] No
BOILER-COMP(OVER IOOp00 BTU)
I sr
AIR CONDITIONER
I have read the hamrdeus molands requirements under Chapter 6V5 of the Cl
fomia Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that IP the
ISSUA14CE DATE �t
J I(% e�
NEW RESIDENTIAL SUCH. SQ. FC
building does not clrrently have a tenant, that it is my responsibility to notify the occupant
ofthere(yul�uenyen must he met prio,roisxnancenfa� tfic °f0ecu
C6 (J/I-
dip
ISSUED BY. : t
TOTAL:
an
O or halt razed seentl
OFFICE