28719 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO, 28719
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
^ M IIIIILI)LNG PHO.I FCT IDFINI'I FICATION
BNLDIN KESS: I �V ' SANITARY NO. APPLICATION SUBMUILL DATE
ills
OWNER, M `lI1-/ PHONE:
CO ACI'O A ': SIC NO; qb
t.1 N/C CONTROL#
•ARCHITECT/ENGINEER: LICNO: ADDRESS: - iri-T ❑
CONTACT: PRONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LOG ELECT PLUMB MF.CH
❑ ❑ ❑
LIC thatI CT)NTRAO'Iderp DEGons of hap QTY ELECTRIC PERMIT FEE
I hereby affirm that am licenud under provisions of Chapmr9(wmmencing 4 JOB DESCRIPTION
az withllfarrn7000)of Division3ofdm Business end Pmfessions Codc,and my licensees RESIDENTIAL:
in full force and effect. PERMIT ISSUANCE •
KUIZ _ OSFDWL ❑KITCHEN REMODEL
FU License Class LicX
Dam Contractor APPLIANCES,-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
1n GZ
F,py ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Z C y 1 undemmnd my plans shall be used as public records Qs MODIFICATION
CZr40 UPT02q)AMPS MODIFICATION
JE�HIMNF.Y REPAIR
Ow^ Wcenud Pm(cssionnl 201-1000AMPS IMPROVEMENT N
�aJ OWNER-BUILDER DECLARATION OVER I1XN1AMP5 ❑PATH RCMODIiIJREPAIR O DEMOLITION
yy 1 hereby affirm that 1 um exempt from the Contractor's License Law for the
Dd CGU following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL 0 OTHER
ttiill C which requires a Permit to construct.Plus,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such Permit o rite a signed statemem SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions of the Conaacmrs License Law(Chapter 9
M.2 (cOmnuncing with Semi.n70(Rb of Di vision 3 of the Business and Professions Code)or IPMP.METER OR POLE INST. COMMERCIAL:
tY that he is exempt thercfmm and the haus(at.the Pllcged exemption.Any vialmion of [I NEW BLDG/ADDITION 0 DEMOLITION
� Section7011.Shy any applicant for a permit,abjects the applicant me civil Penalty of POWER DEVICES y []TENANT El FOOD SERVICE
F not more Nan live hundred dollars(EStx)' IMPROVEMENT
Lasowner.f Nepropeny..,my, employees with wagesasiheirsule compcmithm. SWIMMING POOL ELECTRIC
Cl
ME do Ne work,and the swnure is not intended oa offered f.rsnle(Sec.IM4,Business OOTHER
and Professions Calc:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIM ORES
6 3^ property who builds or improves thereon,and who does such work himself or through
his own employees,pmvidal that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ FT. %t.]a.If,however Ne building or improvement is sold within one year of completion,the SQ!PIT.FLOOR AREA S/SQ.PT.
owner builder will have the burden of proving that he did not build or improve for put. YO
peso of sole . � ']
❑I, r owner of the property,am exclusively contracting with licensed contractors t. TOTAL: d
tamer the project(San.7194,Business and Pmfessions Cade)The Contmctors U.
. cense law docs not apply to an owner of propsny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
ch Ll-LU "k/
who contracts far suprojects with a cannot pursuanuo Ne Controllers VY`
License law_ PERMIT ISSUANCE `t7)I/(r(J
O l am exempt under Sec. ,B&P C for this resat
Owner Dmc ALTER-DRAIN&VENT-WATER(EA) _ VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby oRrm under person,of perjury one nfma following declarations:
• ❑I have and will maintain u Certificate ofComent to selbiname for Worker's Condition. DRAINS-FLOOR,ROOF,AREA.GOND. STORIES TYPE CONSTRUCTION
soden,as provided for by Section 37M of the Labor Code,for Ne pro x....of the / w,^
work for which this permit is issued. FIXTURES-PERTRAP !
❑I havePad will maintain Worker's Co nourtat]on lnmmnce,as required by Section
3700.(the Labor Code.future performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 1JAIMS ts OCC.GROUP APN
My Worker's Compensation Insurance carver unit Policy number rate:
Careicr: Policy No: GAS-EA.SYSTEM-O E (IA)
CERTIFICATE OF IiXEMPTION FROM WORKERS'
COMPENSA'1'IONINSURANCE GRHASU )U. WASTE INT RCv R
(This section need not he completed tithe permit is forone hundred dollars(a iota BUILDING DIVISION FEES
or less.) GREASE^ PLANCHL'CK FEE
I certify that in Ne pert.mmnce.fthc work far which this permit is issued,l shall SEWER-SANITA -STO MF.A.200 FT. -
not employ any person in any manner so as to serrate subject to the Workers'Compcn- ENERGY FEE
C) .it..Laws of Celifomm Uste WR'I'ER HIATER WNENT/ELECTR
Z 0 Applicant GRADING FEE
i.y Cl) NOTICE TO APPLICANT.Il;after making this Certificate of Exemption,you should WATER SYSTEM,TREATING
become subject to the Worker's Cmnpensation Provisions of the Labor Coda,you most SOILS I>EL'
81 forthwith comply with such provisions m this Permit shall ba deemed revoked. WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT PAID
I hereby affirm that there is a construction lending agency for the Performance of Rairript#
P the work for which this permit is issued(Sec.3197,Civ.C.) -
Q U Lender's Name TOTAL:
W Lenders Address TOTAL:
I certify that I lave raadlhis application and nam Nm the Plnwe information is BU1LD1 Il,
Val correct.l agree to comply with all city and county ordinances and state laws mimingm QTY. MECHANICAL PERMIT FEE
U building construction.and hereby aithodra representatives of this city to ws,%pon the SEISMIC17
above-mentionnl property for inspection purposes.
PERMIT ISSUANCE
(We) gree to save,im]enify and keep harmless the Cdyaf Cufenn against
mniELECTRIC HE
liabllities,judgmems,costs and expenses which may in any way accrue against said City ALI Ell OR ADD TO MECH,
in consequence of the granting of this permit. PLUMBING FEL?
APP LIC NT UNDERSTANDS AND WILL COMPLY WITH ALI NON OINT AIR HANDLING UNIT ITO 10,000,CFM)
SOURC R GULATIONS. MECHANICAL E
A DLING UNIT 10,000 CFM) CGNBTRUCTIO TAX
Sig t sof plicant/C ntracmr me E 1A T OOD(W/DUC'T)
HAZARDOUS MATERIALS DISCL UBE HOUSING MRI ON HE
Will1 he applicant or future building occupant score handle rax nun materiel HEATING UNIT(10100,000 BT I
as defined jry the Cupenin.Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(aj7 I HEATING UNIT(OVER 100,000 B'N)
I
C3 yes , CNn
VENTILATION FAN(SINGLE RP_SID) PAID
eeipt#
Will the air comtorfms a building by the Buy
uyAuse ea Air Quarnent ality
dManagees ant BOILER-COMP IMP OR I D0,000 BTU) Data-
cmit hazardous air contaminants as defined by the Ray Area Air Quality Management TOTAL:
DiariRf
❑Yes Otho BOILER-COMP(OVER 100,000 R'FU)
(have mad she houNous materials regnirementsunder
Chapter 695of the Cali- AIR CONDITIONER ISSUANCE D/ATE�,
fomia Harthh&Safety Code,Smiom 25505,25533 and 25534.I wNentm l that if the NEW RESIDENTIAL MECII. SQ.FT.
j building does not currently have a tenant,that it is my responsibility to notify Ne occupant
tt of Ne requirements which most be met prior to issuance of o Certificate of Occupancy.
711 Owner or authorized,gent Data AL: ISSUED BY:
'' OFFICE