24512 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY /a�1 1
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI'1'NO. Z 4 512
APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: �\ SANITARY NO. APPLICATION SUBMITTAL DAM
LL3 w UNIT# LOTH ` 1�1Z Si^
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LICNO:
_I rfl \J N/C CONTROL It
011 1RCHIT A1' ' GINEER LIC NO: ADDR SS: ` < ❑
ckt� C ArW
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG E .CT LU
PERMIT ISSUANCE !•� INTI/'
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
p0F [hereby affirm thatl ma 3 ofth Bused undernd Professions
Coer and my licensng e is
�BOFSCRI 1ION
t��l
�i100 Semon 7010) IfDivision i of the Business and Profexsi.n Cale,and mylicenu is in PANELS
W full f and effc t �\Q I�
1¢„ZW I' nu Ch m Lic.p UI'T'02(10 AMPS -
y�y ane Contmaor 201-IOW AMPS °
Zp�Z ARCIIITMCTS DECLARATION OVER IWU AMS SQ.FI'.FLOOR AREA $/SQ,FT.
O z.. l undoatan y plans shall be used us public records. J —.;
SIGNS ELECIRI AL
Licensed Profusionvl
E*C)U
OWNER-BUILDER m the CoATION SPECIAL IRCUIT'/ .I a:
xj,6 F 1 hereby affirm.(Se thus 1 am exempt from the Conions Co e:Any
Law for the
W,Otn following reason(Section]U3 L5.Business and Professions Code:Any city or<oumy TI3MP.M OR POLE[NST.
F Q which requires a permit to construct,alter,improve,demolish,or repair any sWetum
=�}7 poor to its issuance,also requires the applicant.-cath Pennitm lileusigned statement POWER DEVICES
,W<0 that he is licensed pursuamtothe provisions of1he Contrnmor's License Law(CTapmr
n KOLL 9(commencing with Section 700()of Division 3 ofthe Business and Professions Cd,,) SWIMMING POOL ELECTRIC /� � Ry DATION�/aj
py,y or that he is exempt therefrom and the basis for the ai,ext exemption.Any violation.( - �a C
�ZQ
Section 7031.5 by any applicant for v prni
ct subjects the applicant to a civil penalty of VITETS-SWITCHES FIXTURES V L
� G
not more than fivu hundred dollars($5(10).
o ❑ I,nownerofthepropeny,ormyempinyecswithwagesaxtheirsolecompcnsatio —SQ FC STORIES TYPE CONSTRUCTION
y3=e will Jo the work.and the structure is ner intended or offered for sale(Sce, Bmincs
and Pmfessions C de:TTe Contractor's Licevc law dues not apply m an owner o
property whobuildsorlmprovesthemon,and whodoes such work himaelforthroughhis
employecs,pmvidcd 111-1 such improvememsartnot intendwrlm.ffered l'orsale.If, OCC GROUP RBS.UNITS
however,the building or improvement is sold within oncycarofcomplction,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
❑ Las owner.(the property,arnexclusively contracting with licenudeentmemmu QTY' PLUMBING PERMIT FEE ILOOD ZONE 00th
construct the project(Sec.7044,Business and Professions Code:)The Co.....ar's
Licenu Lewd«snot apply to an ownerofpropery who builds.-improves doormen,and PERMIT ISSUANCE ✓
whocomrvcts forsuch Projects with vcmdrack r(s)licensed pursuant m the Contractors
Liana law. ALTER-DRAIN&VENT-WATER(EA7 FEE SUMMARY
❑ I um ammpt under Sec. ,B&P C for this mason BACK PLOW PROTECT.DEVICE OUTSIDE PF.F.S
Owner SANITARY YN__
Date DRAINS-FLOOR.ROOF,AREA,COND. RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOLTA% Y N
❑
Workers'
pelsat Natlhavcacota cendof copy bemc(Sm.3,or Lab C.icam of FI%'fURES-PF.R TRAP RECEIPI'N
0111 Worken'C.mpnlsltion Insurance oracenified copy Nertof(So.1800.Lab C.)which PARKFEE Y N
rs all nnployec'x under this pemtil. GAS-EA.SYSTEM.I INC.4 OUTLETS RECEIPT.
Policy N—s BU DING D [if ION FEES
Company
❑ Cmlfied copy 1s hereby famished. GAS-EA.$YSTEM-OVPR
A
C3 Certified copy GREAS;7 I GRADING K FE[ ,
is tiled with the inxpenion division.
• OR GRADING F �
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE 1 SOILS FE
COMPENSATION INSURANCE
(This section need not becsnnpleted if Ne permit is femme hundred dollars IS 100) SEWER-SANIT Y .2(0FT. ENE !t�
.r razz.) 11
4
I certify Nat in the performance of the work for which mos permit is issued.l shall WATER A iRW /ELI!CTR O
of employ any Person in any manner so as to become subject to the Workers PAID
CoroKmationlawsof Culifumin. Date WATMRSYSTEMRREATING
0 Z Applicant Dale Bee ,
z NODCE TO APPLICANT:If.afar making this Certificate of Exemption,you should NEW RESIDENTIAL PCMB. SQ.ET. 'TOTAL:
become s-hject to the Worker's Compensation provision of the labor Cade,you must
a > forthwith comply with such provisions or this pcmN shall be domed revoked. BUILDING FEE A
V
y ❑ CO NSTBUCo ONLENDWG AGENCY SEISMICFlt
Z 1hereby aucht that them isicon (Sec.3lending agency for the perfimmwce of
L1 O Leaders Name
for which this pcmtit is issued(Sec.409],Civ,C.) ELECTRIC FE
lenders Namc
O U finders Address QTY. MECHANICAL PERMIT FEE PLUMB[
1 certify that I have read this application and ane that he above informwine is L
correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECH IC G �.
rn M1uildingcanstruction.vlJ hereby emhodurepreuntatives of Nis city memerupon the `—
;,J Z shove-mentioned property for inspection purynus. t ALTERORADDTOMECIL
C S'TR ION TAX
(Wed me m snag pe
indemnify and keep harmless the City of Cunlno against r
Iiabili' ,bLiSs-)Jemenls,cosb and c my way accrue.,test said Coy AIR HANDLING UNIT(TO HL"CFM)
in c.nsexam FRseg f
1. 1 D AIR HANDLING UNIT(OVER I0.0dd CEM)
ignammof APPI nnt/Conuumor Date EXHAUST HOOD(W/DUC)
PAID
HAZARDOUS Ming aceALSDISGLOSURE HEATING UNIT(TO 100,0110 BTU) Da¢ ReeciptM
Will the a ejCtpe or forum building Code.Chapter
or handle hazardous material
as defined N5332mnino Municipal CWe.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW,OtJp BTU[
COJe,Stttiat 253i2fa)'!
CI Yes 11 No VENTILATION FAN(SINGLE RESID) `
WaldoaP�licanmrfmurc buildinguocupamne equipper,nr deviceswhichemit BOILER-COMP(3HP OR 1(0.001(1 B'TU) ISSUA EDATE
ramous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP BS p B py
isWm? (OVER I10.g10 BTU) ,. V' P4 E e
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.P-L
I have read the hazardous mammals requirements under Chapter 6.95.f the MAR 3 0 1gg3
California Health&Safety Cale,Sections 25505,25533 and 25534. 1 understand thus
If the building does not currently have a tenant.that it is my responsibility to notify the /s
occupant of the requirements which must to nm1 prior m issuance of a Certificate of
Occupancy. C1 I I VE V UI Lfl I II\
Owner or uuthnmed-gem Dam ISSUED BY:
OFFICE
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