99100127APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY OR 11:310 1 a, 17--
OFFICE '
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- MECHANICAL
.; BUII. DINGPROJECTIDEN'YIPICA'1'ION' ^; t,'i t "t- e
PERMT N
'
BUILDING ADDRESS:
SANITARY NIT. _
APPLICATION SU13MITI'AL GATE
to e, mL
W ER:S NAME: PHONE:
CONTRACTOR'S NAME: LIC NO:
t t
NIC
❑
CONTROL#
CHITECT/ENGINEER: LIC NO:
A RESS:
o Be $ c ajA A,
CONTACT: PHONE :
j„ j: ' BUILDING PERMIT INFO, ,
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S? 972
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB ME?CH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
north, affirm that 1 licensed " d It ' LCbPle9( b
wens«hnn9Wn7 nrD .nn 3nr de. can drrareaaipnc e,m let my Bee so s
in full force and afford.
License Class Lich
Data Comm��. t.�dlmv 9Iltn
QTY
.i
;.; i ELECTRICPFRMiT, r
.. - . - -,- 8
FEES' I
1"
JOB DESCRIPTION `
RESIDENTIAL'
El SCOWL O KIOMBINREMODIE
71 ADDITION OI'Ll1MBING R6 -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
[I INTERIOR El CHIMNEY REPAIR
PERMIT ISSUANCE
APPLIANCES
ARCHITECTS" AAR5RIN
l undadiddmyplansn.111e usednspublic reveal.,
PANELS
UP'102MAMPS
_
Licensed Professional -
OWNER - BUILDER DECLARATION
1 hereby vffnd that 1 am exempt from de Contractors License Low for the
following r'easen, (Section 9031.5, Business and Prefesdians Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
priorm its issuance, also requires the applicant forsueh permit to file a signed xlalemant
licensedpursmml mlhe provisions of tfthe Banners Licensessio (C ode)or•
(commencing with S «Iion90110l th Division r ofthe cged iennum e, Any , Code) or
he in exempt Ihuefrom anA the basis for the tl exemption. Any violahnn of
201- IOOOAMPS r
W
Q
4 O
W y
�6
y"'Ithatbeen
c eu•
IMPROVEMENT E] SWIMMING POOLS
❑PATH REMODELBEPAIR ❑DEMOLITION
❑ OTI {ER
OVER 10110 AMPS
SIGNS ELECTRICAL
'
SPECIAL CIRCUITMISC.
TEMP METER OR POhE INSI'. -
COMMERCIAL'
❑ NEW RhDGIADIIITION 'O
4:
m
�.r m
a..
Section 9031.5 by any appliwmfora permit suhjmalhe aOPliwnl loacivil penuhy of
Sce object, th
out more owner five hundred dollars y employees
❑ Loeownor of the property,
ad e,amen miss mnployeenwlmwages m their IScinto 044,Ea Wioq
will dothc won, Cusle The Cis cedes Incense Law do s netl.,ply.. in Runor or
and erofwho h, Code: The Cos there's h net w Law does not apply to Ito owner of
property who huilJs or improves thereon, and who does such work himself or through
POWER DEVICES
❑TENANT - ❑FOOD SERVICE
FOOD SERVI
IMPROVEMENT
D Ol'HhiR
SWIMMING POOL ELECTRIC
OUTLB1'S- SWI'I'CIIES- PIX'CURES
his own employees, pounded that such unpmvements ore not Intended ter otic,,d for
NEW RESIDENTIAL ELECT R SQfT
sale. [owever, inch m
bfif,,rim oweent is sulJ within one year of «mpluion.lhe
.PLOD RBA
%ISQ. ME
neolmilder will have the burden of proving that he did not build or improve for pur-
-
paw of sale')
❑ 1 f the property, exclusively contracting with licensed continuants to
T(yFAI .
'
pnd t th p racial (Sea 7044 Business ad Profession, Cef en The Ca ite Li--
cense Law does Corruptly t owner fproperty who builds or improves thereon, and
Q7Y t d PLUMBING PERMITS .i
ti PEE'=
was contracts for such projects is ith a«nlr ta(s) licensed prsumn to the Canrai
PERMIT ISSUANCE
License Law.,
O Id.wwmplunder Sao. ,B &PCforthisrwwn
,
ALTER - DRAIN & VENT - WATER (EA)
N per Dam
VALUATION
WORKER'S COMPENSATION DECLARATION
...
1 hereby off tm under penrdry of perjury one of the fallowing Aednrati:
BACK FLOW PROTECT'. DEVICE
^
(D40
DRAINS - FLOOR, RODE, AREA, COND.
_
I hove and will mainwina CenificatenfCannenno n elf -irvsum fnrWod; ern Cmnpen-
sailo as provided for by Section 3700 of the Labor Code. for lheperfonemose of the
r,
S'I'ORIF
TYPECONS'I'RUC'I'ION
work for which this permit is iswal.
F'I XI'URF.S - PER TRAP
I leave and will maintain Worker Compensation Insurance, as requiod by Section
-
-
39WoftheLab nr Gnle. for the performance oflhe work for which this permit is issued.
My Worker's Compe action Inwmnm rnrticmnit Polley
GAS - EA. SYSTEM -I INC. 4 OUTLETS
OCC. GROUP
'/� APN�
Carrieet4n ..�'.!,_!..•'- :QT= ie' ^ °olicy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
-(This section need not be complued if the permit Is got hundred dollars ($100)
nr lesx)
GAS- P.A.SYSTF,M- OVP,R4(EA)
['J
-7
GREASIVINDU_STRI, WASTE INTERCEPTOR
-
BUILDING DIVISION FEES
GRF:ASF. "I'kAP
PLANCHGCK PEE
SEWER- SANITARY -STORM EA. 200 FL
-
i O
w y
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I cedify that in the pieformnince ofthe work forwhich this permit is issued, l shall
not employ any person in any manner so as to become subject o the Workes'Compen-
nation Laws of California. Date
Applicant I
ENERGY Fi {rte—•- �.__..._...,_...�...
,WATER I IEA'I'ER WNEN'IYELECTR
c'
GRADING En8
r rr --
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you .should
became vuhj «t m the Workers Commeetsn um provisions of the Lab Code you muss
forthwith lherehynffirrb sorb provisions or permitshall he deemed revoked.
CONSTRUCTION LENDING AGENCY-
m that there isa construction lending agency for performance of
the work for which this pennll is ivaued [SCe 3099, Civ. CJ
Lender's Name
WATER SYS I EM11'REAI ING
-
SOILS HE
WATERSERVICB
_
��� ����
PAID -
NEW RESIDENT ]AL PLMB, SQ. ET
eta, le Receipt#
_
Z�7 'CUI'AL'.
Lend Add...
U
t ps
l) .fn y
TOTAL.
BUILUINC FFFi�""'�"
I rt fy th t I h d thi ppl al 1 son that the above ratiocination -.
correct. 1 agree to ply with ad city and counly radiances and state krosueltaneg
building construction, a hereby authorize repoescondivesofthis tty In ante- upnthe
QTYa' , ,M. E1, C HAN'6LpEt RMIT
- ' {F. F F .
SEISMIC FEE
PERMIT ISSUANCE
P.LEC'I'RIC FEE
-
abovo-memioned propary 6r inspection purposea' -
(We) agree to save, indemnify and keep harmless the City of Cupertino against
ALTER OR AUU TO MECII.
PLUMBING THE
-`
linbilitics, judgments, costs and expenses which may in any way accrue against said City
in nu ce en of the granting of this permit.
m
AIR HANDLING UNITDO I0.000CFMI
MECHANICAL PLE '
APPLICANT UNDERSTANDS AND ILL JO PLY WILL ALL NON -POINT
SOURCERt A'1'IONS.
AIR HANDLING UNIT (OVER Ig000 CFI)
CONS'I'RUGI'ION' FAX
iDOm
signature Appliwnl/Cnndrudnr
HAZARDOUS MATERIALS DISCLOSURE
II XIIAUS'CHOODUV /DUC)
HOUSINGMIDGAGONFEE
Will thaappllcmnl or future building occupant store or handle humNou nmmdal
HEATING UNIT (TO 100,000 BTU)
as defined by the Coterino Municipal Code, Chapter 9.12, and the Health and Safety
'
Code. Section 2553260? ,
HEATING ON IT (OVER I WJXX) ETU)
❑Yen E:1 No
WI Il the apply cent ter fair c bnlldimg pavement nee equipment ter devices which
int hazardous air contaminants m defined by the Buy Area Air Quality Management
lather ".
❑Yes E] No
PAID
^"
VENTILATION FAN (SINGLE RESID)
Date Receia#
BOILER -COMP (3HPOR 100,(100 BTU)
TOTAL:
BOILER -COMP (OVER 100,001 BTU)
AIR CONDITIONER
I hew read the hnrurdoasmalerialsregdiremenrs nndef Chapter 6.95 oftha Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. tN.-
Contain Ilealth & Safety Cade' Sections 25505, 25533 and 2,5534. I understand Thal if the
noddingdoesrootcnnemllyhav vmmnenL Nnl it inmyrenponsihimfiaaIa iOhe «uapnm
of the re cots which ml rte el p' m ace of a CutiCiram of a pane
'Date
.r TOTAL:
ISSUED BY
ri�m mha oz agem -
OFFICE '