S1332APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - Ei,EcTRICAI,
BUILDING DIVISION APPLICATION/PERMIT r1.uMIt N; - MECHANICAL
BUILDING PROJECT IDENTIFICA'I'[ON
PFIW IT "°. 1332
BUILDING ADDRESS
SANITARY
SANITARY NO.
APPLICV'ION SUBMI'1'1'AL DAIS
�f/f y�
J /G �L
OWN R'S NAME: PHONE:
et.,Tfiit
CONTRACT((R S NAME LIC NO:
L/ed /Q'{ 3�
NIC
ElIj
CONTkOLp
1
1A CHI I'E:CUENGINEER: LIC NO:
A)DR'SS �/
/51 c- ii 4O ///f
CONI'AC'I': PHONE:
HUILDING PERMITINFO
^
? ^� / 6 -?-y
K(C ' Y ?-
❑ Consultant Fees Paid by Applicant (Initial)
HL❑DO ELECT/ PLUMB MECH
rldt�
LICENSED CONTRACT OR'S DECLARATION
t hereby affirm that 1 am licensed under pmvisiom of Chapmr 9 R,..ntoumdng
Q'I'Y. ELECTRIC PERMIT FEE
JOU DESCRIPTION
PERMIT ISSUANCE �!6
with Scnio 17000) of Division S of the BusiOOvs and Purfmaions Cock. and my licOrec is
in lull fusesu1y.IY �S
.�(a C-30 a�Q� 3
RESIDENTIAL;
❑sEim, ❑ KITCHEN REMODEL.
APPLIANCES - RESIDENTIAL
PANELS
UP'I020)AMI'S
a%stlye)
Liens C4c.M
Comms R t' L✓fig
ARCHITECTS DECLARNTION
I undic,dand my plans shall be usaf a puhlic neonL,
[]ADDITION 0PI.UMBING RE -PIPE
RAL
❑MULTI -UNIT ❑MOD[FI A1[O
ClHMN CATION
❑IN'TIiR10R ❑GIILMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
Licensed Professional
201-100AMPS
OWNER BUILDER DECLARATION
1 hereby affirm that 1 am exempt o-ont the Contractor s Licunxc Law for the
following mason. (Section 7031.5. Business and Pr..leisure, Cafe: Any city or coumy
El BATH REMODEL/REPAIR El DEMOLITION
❑ OTHER
�%
OVER light AMPS
SIGNS ELECTRICAL
which requirea permit to commuct, alter, improve, demolish, or repair any %mature
SPECIAL CIRCUIT/MISC.
jinu,ma, isxrmcc, at so require, the aptllcatn ftrsuch annot to file anignedelaument
that he is licensed pursvum to the provisions at the COmaticbtr% License Law (Chapter9
(commencing with Section 7") of Division 3 of the Business and Professions Cdc)or
TEMP. MET ER OR POLE INST
comm I
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 90115 by an, nppbcant for u permit subjects the applicant ear a civil penalty of
POWER DEVICES
❑ TENANT ❑ FOOD SERVICE
nut more mon five hundred dollar, D500).
I] Las owner of the propeny, or my employees with wages as their vole compensation.
7044
will do the work, and the structure is not intended or offend frraale (See. 7044, It
and Pr..l'essionx Calc: The Cn unmtar% I, ccnsa Law &,o,not apply m tut ownenreof
IMPROVEMENT
OTHER
SWIMMING POOL ELECTRIC
T OUTLETS -SWITCHES -FIXTURE'S �
NEW RESIDENTIAL ELECTR SQ IT.
property who builds or i mpmve% thereon, and who does such work himself or through
his own employees, provided but such improvement, am not intended or offered for
sale If, however the building or improvement is sold within one year of completion, the
SQ. PI'.Iq.WRAkGA S/SQ. FT.
cr-buildar, will have the burden of proving that he Aid not build or v intpru a R)r Our
prow is"sle.).
I. a, ..or of the pperty, an exclusively contracting with licensed vintlocmrs 1.
ro
it
'TOI'A L:
QTY PLUMBING PERMIT .FEE
ru,d t the project (s 7044 lb : % d P r :: nx Code:) The Contract.", Li
% Law does ronapply if property who builds or halprcvvv: to reon and
n w
C mcmrs
who ablras fouch prolannrt- ithacrd)1 ca : u d peause n
rs
Y' Fe
PERMIT ISSUANCE
Lu
License w.
El I am exempt ander See , B Ar P C far this tesaum
. I
AL:1'GR - DRAIN A V IiN'I'- WA'I'IrR (EA )
MAR IAA'I'171
Owner Date
WORKER'S COMPENSNI'ION DECLARATION
I hereby alfinn under penalty of perjury one of the following declamtions.
RACK FLOW PRCr TC7E DEVICE
' CR 1 Bilk)
I M1ave and will maintain aCaetilicom nTConvent nr xdf-insure for Worker's Compen-
A'ND'
RAINS-I'R,ROOI',ARBCO
DLOO
ST� IGS 'TYPE CONS I'RUCTION
cation, as provided for by Section 37(0 of the Labor Cott, for the performance of the
work for which this peanut is %surd,
FIXTURES - PER TRAP
❑ 1 have and will maintain Workers Cmnper,an 1 --avec, as required by Section
3700o,' the l C%de. tonheperformwanuf the rY for which la,pennit isl%sucdJ.
GAS-EA.SY5'TEM-1 INGYOU'I'I.ETS
CGI
AI'N
GAS -EA. SYSTEM -OVER 4(EA)
My Wo Ohm ,m a ' cW
Career 'X A-_eI Rcyb a //
S,
CERTIFICATE Op EXF,MI'1'ION FROM WORKERS'
COMPENSATION INSURANCE
<iREASEIINOUSTRI. WASTE IN'I'Y,ItCEP1011
RHUDING DIVISION fFFS
(This section and not becomplemd if the Permit i% Gaon, hundred dollar, (5100)
or less)
GREASE] RAP
PLANCHECK PER
SEWER -SANIPARY-STORM HA. 20017L
ENERGY IT717
I county mat in the perfunwnmol be work for which nu,mona is l ssual, Ishall
notemp1 Ype Yt a rbcs uIs tv"Il:erd Compen-
nrnt n w.w}
``fir
WATER HEN] ER WNI:NT/ELECfR
GRADING HE
%atinn Ww /\ty�s_
NOTICE 10 APPLICANT If, aft,, making, this Certificate of Exemptimv yen should
Become subject m the Worker's Compensation provision, of the Labor Cad, you must
WATER SYS' I'EMONEXI INC,
SOILS PGE
WATER SERVICE
forthwith or ly wins such pmvi%ions .,,his Permit ludl be deemed revoked
CONS I ROCI'ION LENDING AGENCY
Ill, per uldnvrof
me% etier lending agency for thra
I hereby afirntbwere iso rom
NEW RLSIUEN IIAL I'LMB. SQ, FT.
PAID
Dam Necxiptp
T(YfAL-
the work for which this permit is issued (Sec 3097, Ci, CJ
Lender', Name
'IYTPAL:
i Leadcds Address
BUILDING FEE
1 certifyud thI ha%c read this applicaion zed .ante that the aMwe in0mnuloo is
SEISMIC FEF:
cored l agree tocomply with all city and county ordinances and state laws mlating to
building congmrnin i. and hereby authmirc rcpre,enaelvax of this city m enter upon the
above-mmntionod pro)eny for Inslv,v ion purposes
ess the City of Cuagainst
(We)agree to base. indemnify and keep heartless
QTY. MECHANICAL PERMIT FEE
/- I'IiRMI"f ISSUANCE 'S
ElAdn'R IC Iq;E
ALTER OR ADD TO M BCH.-
PLUM1IHING Ilili
liabilities.judgments, cords and expenses which may i n any way rectus against said City
le nscuI 11d, N ofthispe
APPLICANTUNDERSTANDS AND WILL COMI'hV WITIi ALL NON -POINT
AIN HANDLING UNI'I'(l'O IQfXNI CPM)
NCI. PEE
$OURC' GULA �Gy
AIR HANDLING UNIT (OVF,R10,X0CFM)
CONSTRUCTION TAX
CO
3-6
Signature tl'ApplicunUComdm Uwe
EXIIAUS'I'IIQOD(WIDULT)
DISCLOSUREWill the applicant or future buddingsrccnpam,lore or handle haeudus material
HEATING UNIT TO 100.000 BLU)
de@ted by lie Cupn'tino ManklpuI C'ude, Chapter 9.12, andme I Iulthand Safety
Care, Section 25532(a)"
HEATING UNIT(OVER Wsm)If'I'Lb
nHOUSINUMUIGAHONFEEHAZARDOUSMATERIALS
VENTIATION CAN(SINGLE RESID)DDal
El Vex ❑No
Rocapi a
a Will the radvantor linure building occupant use equipment erdevicev which
hasnrlous air contaminants as defin al by the Bay Area Air Quality Management
IIOILISR-C'OMP(pll'OR Ifx),O00 BTU)mit
RHALDistrict?BOILER-COMP
(OVER Ip).(XX) BTU)
I] Yes I] NnI have read the hmardous matedelx requirements under Chirac, 6.95 of the Cul i-
At R CON Of I l ONER
ISSUANCE DAIE
NEW RESIDENTIAL MECH. SQ. FI'.
harm Ilealth & Safety Cade, Sections 25505.'_9533 and 25534.1 mdertund the if the
building Jdks urn atrnntly h: ¢wet. thad'n is my respomibiliry ear notify the nccupam
of the �rtom to wb ,t,,tb elpa 3 c uCerfileeofO punct.
Gq% rte
ISSUED BY:
�/ p
TOTAL' 1.30
Ownefofauthamed a goal Date
OFFICE