28852APPLICANTTO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
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CITE OF CUPERTINO BUILDING ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING. MECHANICAL
PHRMITNO. 28852 ^ /N a s
L l8 ]8 5 L
BUILDING PROJECT IDENTIFICATION
-
BUILDINGADDRESS: - -•
SANITARY NO
APPLICATION SUBMITTAL DATE
OW R'S NAME: PHO E:
CONTRACJQR'S NAME: LIC NO:.
NIC
OMR�O�LkN
_
❑
� ��
.ARCHIIECT/ENGINEER: LIC NO:
ADDRESS, _
CONTACT: PHONE:
BUILDINGPERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG PLUMB MF.CH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 um licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Busincssand Profes.sionsCode, and my license is
'" full farce and effect. s
License Class Licp
Dare Contract.,
QTY ELECTRICPERMIT FEE
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JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE-PIPE
❑MULTI-UNIT OSTRUCTURAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
0ATH REMO EfJRF.PAIR ❑DEMOLITION
❑ OTHER
-
PERM IT ISSUANCE
-
APPLIANCES RESIDENTIAL
ARCHITECTS DECLARATION
undestand my plans shall bo used as public records
-
PANELS
UP TO 200 AMPS
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Comraeors License Law for me
following reason. (Section 9031.5, Business and Professions Code: Any oily or anntY
which rogues a to consume. alter, improve, demolish, ar repair any stmcmrc
20FUXUAMPS
OVER 1000AMPS
SIGNS ELECTRICAL
-
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SPECIAL CIRCUIT/MISC.
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permit
prior to its issuance, also cultures the applicant for such permit o file a signed statement
Nat he is licensed pursuant to the previsions ofthe Contractors License Law (Chapter 9
(commencing with Section 7")of Division 3 ofthe Business and Professions Collator
but he is exempt therefrom and frothe basis for the alleged exemption. Any violation of
Section 2031.5 by any applicant for. permit objects the applicant, a civil penalty of
ore than five hundred dollars ($$BB).
n I, as owner of me property, or my employees with wages as their sole crnnpcnsation.
iIdo me work, and the stmamm is not intended oreffured far sale (See. 91N4. 11uxinexs
and Professions Cont: The Contracmr, License Law des not apply m an owner of
property who builds or improves thereon, and who tees such work himself or through
TEMPMETERORPOLEINST.
AMM R JAI;
❑ NEW BLDG/ADDITION 0 DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC' r
OUTLLTS-SWITCHES-PI%TURES r
his awn employees, provided that .such impowcmcros arc not inronded or.bored for
NEW RESIDENTIAL EITCTR SQ PI'.
SQ. FT.00E
'FLR AREA
VSQ. FT.
sale. IL however. thibuilding or improvement issold within one year ofcompleinn,the
r-
ea-builder will havethe burden oI Is in, that he did not buildor improve for por-
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p e f I ).
❑1. as owner ofthepropertylusisclv contracting withlicensed contractorsto
st ,,hp j r (S "1044 8 .. d P f : C 1 'J D C t t, I.,
{/
OCT'rsio
A
nseL d t apply to fp pry 1 b k ' p st d
w1b.c.drics fta,uhe nvolh., r mn,)lcnsed pu ... I in ti Cnuatr
QTY. PLUMBING PERMIT FEE
�� 5
CI
PERMIT ISSUANCP,
..
License 1 1 am oder Svc B & 1 C f Nie .
(./h (,UP't HI #1110
ALTER- DRAIN&VENT- WATER(E
Owner ,Dote
VALUATION
/—
WORKFRSCOM SAIIONDICLARAIION
RACK FLOW PROTECT DEVICE.
Ih by ft penalty rl Y film invur 1,I t nc:
DRNNS- FLUOR, ROOE,AREA, COND.
i o
❑Lha J 'II t CertificateIC a II 'esu f Worker's Compcn
satin previded for by Section Tits) of the Labor Code. fu the performance of the
STORIES
I'YPECONSTRUCHON
work for which this permit is issued
FIXTURES -PER TRAP
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700ofine Labor Code. forthe performance oflhe work for which this Permit is issued.
GAS -EA. SYSTEM-I INC. 4 OUTLETS '"
OCC. CROUP
APN
My Workers Compensation Insurance carver and Policy rummer are:01
Carrier: Policy No.:
-
GAS -EA. SYSTEM -OVER 4 (EA) -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sedionnttdnot be armpleteJ if rhe permit is fnnme hmmmddoBan(9Hp)
or less)
.14
GREASEINDUSTRL WASTE. INTERCEPTOR
B LU C IV,. iES
PLANCHECK .F.
GREASE'TRAP
SEWER-SANITARY-STORM EA. 200 FT .
(certify Nain the painficarromisany..are, ofthework fee wobject i,,,heW,ladn'Compinl
no, employ any person in any manner su as in metates subject ur the Wartcri Compcn-
ENERG R
WATER HEATER WNENT/ELECTR
-
ZZunimi
2
Los ml Califomia.Dme
Applicant
GR. 1 - E
NOTICE TO APPLICANT: If, attar making this Ccrtificata of Exemption, you should
become subject to the Worker's Compensation provisions of the Libor Code. Yma most
foMwia comply wise tech provisions unM1is permit shall be Jcemed mucked.
CONSTRUCTION LENDING AGENCY
t hereby affimt mat them is construction leading agency for the perfuarrom of
to weak for which this permit in issued (Sec. 3097. Or. C.)
WATER SYSTEM/IREATING
WATER SERVICE
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SOILS
PAID
Date RecciptN
NEW RESIDENTIAL PLMH. SQ. FT.
BUILDING FEE
Lenders Name
lender's Address
TOTAL:
1 certify mal I have mail this application ad touched the above information is
correct.) agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby aumoriu repmwnMLiveS clans city to enter uponthe
QTY. MECHANICAL PERMIT FEE
SEISMIC FEF,
PERMIT ISSUANCE '
ELECTRIC FEE
above-mentioned Property for inspection P."-s'
(We) agree to save, indemnify and keep hannless,he City of Cupertino egoimt
ALTER OR ADDTO MECH.
PLUMBING FEE
liabilities,judgments. costs and expenses which may in anyway accrue against olid City
in conuqucnce ofthe granting of this permit.
AIR HANDLING UNIT CTO 10,000 CFM)
MECHANICAL. FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTIONTA%
'
SignaturcofApplicantlContractor Dae
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOLD(VMUCI)
HOUSING MITIGATION FEE
HEATING UNIT TYO 100,000 BTU)
Will me applicant or future building occupant eorc'or handle hazardous material
as defined by the Coliseum Municipal Code. Chapter 9.12, ant the Health unit Salary
UNIT (OVER 100,000 BTU)
PAID
Date Receipt p
.Diss
Code. See,.on 25532(x)'1HEATING
[I yes. Visit,
Will the applicant or future r building occupant n use equipment or novices which
-oil It dons air conormlisids, a: didinaid by the Bay Arca Air Quality M.mage Hent
VENT HATION FAN (SINGLE RESID)
BOILER -COMP (311P OR 100.000 BTU)
TOTAL
ROLLER- COMP (OVER 100,000 BTU)
ic,. Yes XNn
❑
AIR CONDITIONER
I have mailth hour d t 1 1 orderChapter 95 I lif I
ISSUANCE
NEW kESIDFNTIA,MECH.SQFL
cl Health Cd S i :3553 nd255}41 Iesu caif it,,
build'6d ,ntcruetlylamount,(hit(?, oc,on,lohlyt tlythcossspam
o
,if me is which m t t n«"I. Coni t If cupv
TOTAL:
ISSUED
Own
OFFICE
FROM HRRDESTV ASSOC.
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(E) POOL
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