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CITY OF CUPERTINO BUILDING - ELECTRICAL.
ECHANICA
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -ML.
CSOM
ILULLDING PHOJP:CT IDENTIFICATION
PERMIT NO.
0 211
BUILDING ADDRESS:
a.2 Cristo Re �a orf ria
SANITARY NO.
APPLICATION SUBMITTAL DATE.
-0& -/ ?9
OWNER'S NAME:PHONEICONTRACTOR'S
of Q^� /I _ r,
(•M ��D�L�IC
NAME: LIC NO,
NIC
❑
CONTROI.P
A
ITECT NGINEER: . NO:
ADDRESS:
NG IG J
CO ACI': PHONE:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
❑ ❑ 0
�e t5 i h ie rv►so r
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED RACTOR:S DECLA TION
I hereby affirm the I am anted under provisions of Chapter 9 (commencing
with Smtion ]dept of Division J ofthe Nosiness and Professions Cnde, anJ my license is
in full force and eBecl
QTY ELECTRIC PERMiT FGE
JOB DESCRIPTION
RESIDENTIAL'
❑SFDWI. [I KITCHEN REMODEL
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
-
License Class Lia#
Date Conumbur
❑ADDITION [I PLUMBING RE -PIPE.
❑MULTI -UNIT E3 STRUCTURAL
MODIFICATION
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT (3 SWIMMING POOLS
❑ BATH REMODEL/REPAIR C3 DEMOLITION
[]OTHER
ARCHITECT'S DECLARATIONPANELS
I understand my plans shall he used as public records
UPTO20fAMPS
1 Licensed Pmfessinrul
1 OWNER -BUILDER DIiCLARATION
I hereby aRrm that 1 am exempt from she Comfucmr's License Low for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
281-11100 AMPS
AVER LIMB AMPS
SIGNS ELECTRICAL
1 which requires a pends to construct. alter. improve, demolish, or repair any structure
C prior to its issuance, also requires the applicant for such permit o file a signed samment
that he is licensed pursuant o Ne provisions of she Committers License Law lChapmr 9
(commencing with Sminat700aof Division Sof the Business end Professions Cade) or
( stmt he is exempt therefrom and the basin for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
SPECIAL CIRCU [TIM ISC.
TEMH METER OR POLE INST.
COMMERCIAL,
❑ NEW BLDG/AUDITION ❑ DEMOIATION
[]TENANT ❑FOODSERVICE
POWER DEVICES
of mom than fns hundred dollars (Video.
[:j 1, as owner of me property, or my employees with wages as chair compensation,
will do me work, and me structure is not intended or offered for sale (Sec. 70OL Business
a and Professions Cale: The Contractors License Law does am apply to an owner of
IMPROVEMENT
-
[]OTHER
SWIM M ING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENDAL ELECTR SQ FT.
'
property who builds or itnpmves thereon, and who does such work himself m -rough
his own employees, provided that such improvements am not intended or offered for
axle. IL however, the building or improvement is sold within one yc..f completion.the
SQ. FT. FLOOR AREA
LSQ. FT.
ncr-builder will have the buden of proving that W did not build or improve for par-
TOTAL: 5
fasse of sale.),
1, as nwmer of the pmpeny. am exclusively contracting with licensed contractors to
construct the project (Sec. 70e4, Business eed profession, CrN,)'Me Commemr's Li-
nmLaw does not apply to an owner f property who builch, or improves thereon,and
QTY. PLUMBING PERMIT FEE
who contracts for such projects with a rostra nate) licensed puts.....she Ciamosurs
once- law.
I nm enemIs under Sm. . B & P C for this reason
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
VALUATION
Uac
Owrs
WO :EH:S COMPENSATION -CI.ARAIION
1 hereby affim under Penalty of perjury one of me following decluotions:
❑ I have and will maintain a Certificate of Consen..o self -insure far Worker's Compen-
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOEARE:A, COND.
STORIES
TYPE CONSTRUCTION
saint, as provided for by Secu.n 3] W of me Labor Cade, for the performance of the
work for which this permit is issued.
FIXTURES -PER TRAP
❑ I have and will bushmanWorkers Compensation Insurance. reuired by Section
J]0ofme Labor Code. forth¢ Performance ofme work for which this permit is issued
GAS-P.A. SYSTEM-] INCA OUTLETS
PCC GROUP
APN
GAS- EA. SYSTEM -OVER 4 (EA)
My Workers Compensation Insurance carrier and Policy number am:
Carrie. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASMNDUSTRL WASTE INTERCEPTOR 10
HULLOING UI VISION S
GREASETRAP
NCHECK FEE
-
ENERGY FEE
(Thissecdoo need not bee.ruldeaed how permit is fomne hundmddellam(SIW)
nr lessJ
I certify that in the performance of the work for which this Permit is issued, Ishall
not employ any person in any manner so as to become subject o the Workers' Compen-
SEWER -SANITARY -STORM HA. 200 FT.
WATER HEATER W/VENT/ELECTR -tGRA
WATER SYSTEMfBEA'TING `rU
ING PEE
[ saiom l.tws of California. Date
w Applicant
3 NOTICE TO APPLICANT. If, after making his Cendleme of Exemption, you should
lemma subject to he Workers Compenamino provisions of she Lahm Code, you muss
LMwim comply with such provisions nr this permit shall bedremed revoked.
SOILS FEE
WATER SERVICE
CONSTRUM10N LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
j the work for which this permit is issued (Sec. 3097, Co. C.)
Ixnder's Name
PAID
Dae Receiptp
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
TOTAL:
Lenders Address
BUILDING FEE
Best I have nand this application .d scale the the above infonnetion is
L. I certify m
III rimed. l agree to comply with all city and county ordinances and state laws relainlo
S building amearediom,mnd hereby authorize represem uses.fthis city to mumble me
above-mentioned property for inspection purposes.
(We) agree to use. indemnify and keep harmless she City of Cup arbab agai.t
lishilities,judgments, costs and expenses which may in any way berme almost said City
as c ..sequence of the granting at this permit.
APPLICANTUNDERSTANDSANDWILLCOMPLYWITHALLNON-POINT
QTY, MECHANICALPFRMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ALTER OR ADDTO MECH.
ELECTRIC FEE
PLUMBING FEE
-
AIR HANDLING UNIT CTO to." CFM)
MECHANICAL FEE
SOURCEREGULATIONS.
AIR HANDLING UNIT (OVER 10.000 CFM)
CONS -- ---ION TA%
Signature of Applicara Contrecmr Dvtc
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding excupont store or handle hazardous material
as defined by the CuNnin. Municipal Cade, Chapter 9.12, and he Heath and Safety
Code, Section 25532(¢)?
EXHAUST HOOD OVMUCO
HOUSING MITIGATION ITE
14PATING UNIT (TO 100,00) BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RESID)
❑Yes ON.
PAID --
Date Receipt# J
Will the applicant or future building omupam use equipment or devices which
emit hazardous air emtamin.ts as defined by she Bay Are. Air Quality Managemem
BOILER -COMP (3HP OR 100,010 BTU)
TMAJ,
BOILER-COMP(OVER100,011 BTU)
Dionct?
❑Yee ❑No
AIR CONDITIONER
ISSUANCE DATE
I have read the bazmdous materials rcquiremcnes under Chapter 6 95o the Cali-
NEW RESIDENTIAL MECH. SQ. FE
fomite Haltb & Safety Cak, Sections 25505, 25533.,1 25534.1 understand that if the
building dm not comedy have atan.t mat'. is my responsibility to notify the occupant
—b---b(L-q—^ 1 t 0
of the requircinems which must W met prior to noccom of a Certificate of Occupancy.
ISSUED BY: — _
TOTAL
orizeent Date
Owner m amhd ag
OFFICE