S 0394APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
SignawreofApplicanUContmctnr Dam
URE
HAZiAWill the applicant coRuim huild goMATERacopSat DlSCreorhan le havmdnus material
as defined by the Culteraino Municipal Code, Chapter 9.12, and the Health and Safety
Code Section 25532(a)'!I1EA'1'ING
[I Yes (JNn
Will the applicant or furore building occupant use equipment or devices which
emit hazardous air contaminants Afa °t
aminanas defined by the Bey Arca Air Quality nngane
District!
❑Yes V11—
I have mod the hamrdons m.mdokv reampcments under Chapter 6.95 of the Cali-
firms Health & Safely Cade, Sections 25505, 255]3 and 25534. 1 undetsund Ihm if the
It Idin• I note cony have a mann that it is my respnnabmty to notify heiae pant
oft s hien moat be tact prionnlavuunm ofaCertlRr a
/
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PING PRODB NG E TIDENTMECHANIFIC
BUILDING PROJECT IDENTIFICATION
- PI ITNO.
�J 0394
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HEATING UNIT TU 100,000 BTU) l�TT�,
BUILDING ADDRESS: �f at�
SANITARY NO.
APPLICA'190N SUBAIITI'AI. DA'II
,
OWNH SNA*r'',x ,,x (�/�x a� PfIQNIIi//a
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CONI'ItA '( 'S'iIJAME,' ii LGN} -
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NIC
CON'I'SULX
❑
ISSUANCE DATE
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ARCHITECT/ENGINEER: LIC NO:
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CONTACT: �� PUONIi�
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❑ Consultant Fees Paid by Applicant (Initial)
NUILDING PERMITINFO
BLDG ELECT . PLUMB
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LICENSED CONTRACTOR'S DECLARATION
1 hereby atfirin anal 1 aa, licensed under pnwiainn: of Chapter 9 (mmmcm'ing
with Section7M)).fl)ivision3ofaheBusiness and Prumosion%Code.and mylicense is
in full form and of /['��,'/J��
Licenve CP sv LiaX
Dom Convector— 2dE
RCIII'IECT'SDECLARATION
I understand my plans shall M used as public records
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RF-SIDENTIAL:
❑SI'DWI. ❑ KITCHEN REMODEL
❑AUDITION ❑ PLUMBING RIS PIPE
❑MUhI1d1NIT ❑S'TRUQ'URAI.
MODIFICATION
❑INTERIOR ❑ CHIMN17Y REPAIR
IMPROVEMENT E] SWIMMING P(IOIS
❑ BATH REMODCUREPAIR ❑ DEMOLITION
❑ OTHER
/�
PERMIT ISSUANCE.
APPLIANCES- RESIDENTIAL
PANELS
UPT020o AKIPS
Licensed Pmfessional
OWNER -BUILDER DIiCLARATION
1 hereby affrn, last I tan exempt fon aha Commit"" Limnse Law Tr the
following reason. (Section 70313, Bmum,v and Pmfessions Code: Any day or county
which requires a permit to consortia, alter. improve, demolish, or repair any structure
to its issnmee,elso mr,mars theapplicam for such permit to file. signedsmmamrI
201-INX)AMPS
OVER 1000AMPS
SIGNS ELHCTRICAL
SPECIAL CIRCUTUMISC.
'a�
gygprim
96�
00 q
4W,
^m
Spmm
a .Hr
al �_
L 3
that he is licenmd p ..... a, 1. provisions of the Conwmors License Law (Chapmr9
(oomncaningwinSeednn]INNBmIDivision 3ofth,IlasincasondPromo,ion,Code)nr
that he is exempt therefrom and the haviv for the alleged exemption. Any violation of
Section 703 LS by any applicant for a permit subjects the applicant to a civil penalty of
marc than five hundred dollars ISSmpl
❑I,asowner opine property, or lay employee.vwith wages as thcirsnle compensation,
will dolhcwofk.Cde:Tmcmmlxnot, Liocave Lonwmdforsdcl,ply to so RosinessXz
and Professions Code: The Comrannr's Liccnve law does no, apply to un owner of
property who builds or improves thereon, and who does such work himself or thnmgh
his own anployeez, provided tbar such improvements arc not intended or ufamol for
sada If,however, the building or improvement is sold within one year of completion, the
TEMP. ME PER OR POLEINST.
COMMERCIAL:
❑ NEW HLDG/ADDITION ❑ DEMOLITION
❑IMPROV ❑FDOD SERVICE
IMPROVEMENT
❑OTIIER
POWER DEVICES
SWIMMING POOL ELIiCfRIC
OUTLETS - SWI'fClllis- PIXTUNES
NEW RESIDENTIAL ELIiCfR SQ FT.
SQ. FT FLOOR AREA
S/SQ.1T
owner have the burden oil paining that he did nal build or improve for por-
posc mf sola.).-
❑ 1, as owner of the property, am exclusively contracting with licensed comrunors m
'TOTAL.
i-
ntrum the project (Sec. ]Dhf, Bu.viness and Ymfcssions Cade:) The Cnntmctnr's Li-
-
curvewho builds or iinproves whereon,and
QTY, PLUMBING PERMIT F-•
wnvelawdoesnotapplytoanownerofprnpiny
ho cmnrams for such pmioct, with a mmmeto,O0 licensed puamnt m ane Cantrmmes
PERM11ISSUANCE
License law.
❑ I um exempt under Sec. ,B& P C for this reason
Owner Date
ALTER - DRAIN & VENT- WATER IEA)
VALUATION
WORKERS under COMPENSATION DECLARATION lowing
I hereby
mai under penalty of perjury one of the following dedor's
BACK PLOW PROt1iC1: DEVICE
ill Cra:
❑Ihave and will for Section 37Mficate of the Ln0oCode, for to Worker'sce of the
satinn, as provided for by Section P00 of the IaMn Code, for the performance of the
DRAINS - FLOOR, ROOF, ARG,COND.
S'1'ORIFS
TYPE CONSTRUCTION
wo forwhichthis,orm is issued.
FIXTURES - PER TRAP
I have and will ra sin Wnrkoe, Compensation Insurance, ns required by Section
3700 (if the Labor Code, for the performance of the work for which this permit is Issued.
GAS-EA.SYSTEM-I 1vC40IITL2TS
OCC. GROUP
APN
My Workers m yti,m renttc 'er and Policy number are
Cardec Policy No.: 6,j6G `j09'�
,
GAS -C•A SYSTEM-UVIiR4(F.A)
L'RTIIICATF.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
section need not be completed ifhe permit is forma, hundred dollar, ISl(k)
or ]a..)GREA
GREASIVINDUSTRI, WASTE INTERCEI'fOR
BUILDING DIVISION FEES
SERAP
T
PLANCIIECK FEE
Icenify Nat in the performance of the work forwhich thizpeamia isissued, Ishall
not employ any perum in any mar-mr.vm as m become subjcet to the Worker,' Com,r-
SEWER -SANITARY -STORM EA. 2W FT.
ENERGY FEE
WAITOO iIsrF.RW/VEN'UELECIR
aZcationLowsofCnffornis.Data
Z Q
h
a;
{1J
aQ
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LUil
Applicata
GRADING FEE
N0UCD TO APPLICAN'C If, after making this Cenificom of Exemption, you should
become subjecnn the Workers Compensation provisions of the labor Code. you must
forthwith comply with such provision, or this permit shall Its, deemed revoked.
CONSTRUCTION isaHON LENDINGAGENCY
agent
that issed(Se.construction0 lendingagency for de per6rmuncc of
the work for which Chic permit is issue] (Sm. 31N], Co.iv. CJ
Iforhereby which
Lenders Name
WATER SYS 'IEMIfR BATING
SOILS FEE
WATER SFRVICE
PAID
Dme Receipt
D
NEW NCMDI3NTIAI. I'hMB. SQ, PT.
Lendcr's Address
1 mnify tout I have read this appliewion mal ,.,a that the above Infatuation is
TOTAL:
BUILDING FEE
Q'fY. MECHANICAL PERMIT FEE
A
SEISMIC PEE
(4
Liz
CntmcL l agree to comply with all city and county udieancev and state laws relating te
building convection, and hereby anthurixe representatives of this city to enter upnthe
PERM IT ISS DANCE
IiLECT,E
abovomentloned property for inspection purples.
(We) agree m.vnve, indemnity and keep Mundess the City of Cupeninn ngninst
ALTER OR ADD'FOMECILIl[
iahillties,judgmenra, costs and expenses which any in any way accrue againut said City
in consequence of the granting of this Permit
PLUMH + .E JjG
AIR HANDLING UNITITO 10,1111(1 CFM)
..�1¢NC�I. FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER I took) CFM)
... .... ,,, Hilt
SignawreofApplicanUContmctnr Dam
URE
HAZiAWill the applicant coRuim huild goMATERacopSat DlSCreorhan le havmdnus material
as defined by the Culteraino Municipal Code, Chapter 9.12, and the Health and Safety
Code Section 25532(a)'!I1EA'1'ING
[I Yes (JNn
Will the applicant or furore building occupant use equipment or devices which
emit hazardous air contaminants Afa °t
aminanas defined by the Bey Arca Air Quality nngane
District!
❑Yes V11—
I have mod the hamrdons m.mdokv reampcments under Chapter 6.95 of the Cali-
firms Health & Safely Cade, Sections 25505, 255]3 and 25534. 1 undetsund Ihm if the
It Idin• I note cony have a mann that it is my respnnabmty to notify heiae pant
oft s hien moat be tact prionnlavuunm ofaCertlRr a
/
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
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HEATING UNIT TU 100,000 BTU) l�TT�,
UNIT LOVER BXotou BTU)
PAID
Dam Receipt
VENI'11.A'1'[ON PAN (SINGLE R&SID)
BOILER-COMP(311POR 100000 BTU)
,
'I'OIAI
BOILER - GGMP(DYER 100,000 BTII)
AIR CONDI'i'IONEN
ISSUANCE DATE
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......._._.... e\ T Il IN a
NEW RBSIDEWTAL MECIC SQ. FL
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