S 1943 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. 1943
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
NUILDING PROJECT IDENTIF'ICA'TION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
YIN% CONfNACTI)I)'.S A lit ,rICrNO: N/C CONTROLp
ARC IITC"f/ENGI`N/I%il?YR,A LIC%O: ADDRESS: �Vl� YJ F-1
HONE: BUILDINGPERMITINFO
/Ji.ix`�f/��f� Consonant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑ ❑ ❑
1 herebynirm Thu I um license)under QTY. ELECTRIC PERMIT FEE
n pmvisianx of Chapter 9(commencing JOB DESCRIPTION
HOZ da Scene.9000)of Division Sof the Bisineesand Profession.Cade,and my license i. RESIDENTIAL:
F nm full I,,.and effect. PERMIEISSUANCE
yUZV License ClassLi<.M ❑SFDWL [I KITCHEN REMODEL.
yQL Date Convector APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
'Do, ARCHITECTS DECLARATION PANELS [I MULTI-UNIT El STRUCTURAL
Z Oy zy I amhor lid my plana shall he used ax public records MODIFICATION
OZ-0 UPTO 200 AMPS 0INT17RIOR [I CHIMNEY REPAIR
r+.h.~LD Licensed Note..innal 201-1000AMPS IMPROVEMENT
❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1100AMPS ❑BATH REMODFUREPAIR El DEMOLITION
W6 1 hcmhy affmmm Ihnl I am exemps from the Comecmrls License Law I the
O6U following reason,(Section T831.5,Business add'Pnrfessions CWC Any city or county SIGNS Iih[LTRICAL El HUGE D
F+W WO y< which requires n Pemmil to mmuvucl,eller,improve,Jemnllsh,lir repair any.rwemre 0
40 A f
ss J priormits issuance,afw requiresthe applicam fnrmch Permian RleasignW smmmem SPECIALCIRCUIT/MISC. / T—
gggr4�411} Ihathcislicenudlmcs..... o c,ao,cionsoffhe Cn...rai s Lwrrc Law(Chose,9 COMMERCIAL:
of C, nommmcing with Section 7000)of Division)of are[business and Professions Code)or TEMP.METER OR POLE DIST.
d q C that he is exempt themborm and the basis for me alleged exemption.Any viulntion of ❑NEW BLDGIADDITION ❑DEMOLITION
iC LL.
Section?031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of POWER DEVICES
100-rn ANT ❑FOOD SERVICE,
C'Z"y n nn osvnerfividi mcg WOyi.,n,cropl VE T
SD of the properly, rmyemntended with wages n lafe(Se 7044.[nsmion, SWIMMING POOL ELECTRIC ❑ 'T11
F. will do the work.Cosle:and nhodare is tors License offereddo is net apply t 844.Business .Iw�J
L3 m and Professions Code:The Contractors License Law Jus net apply m an comer of OUTLETS-SWITCHES-FIXTURES
Property who build,art improves thereon,and who dues such work himself lir through Q
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL.ELECTR SQ Fr.
sale.If.however,The building or improvement is sold within one year in ampletion,the SQ.FP.FLOOR AREA E/SQ.IT.
nwner-builder will have the burden of proving that he did not build or improve for pur-
Pasa of sole.).
I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
conswcl the project(Sec 9814.Business and Professions Cod,)no Connector's L,
imose Law does,not apply to an owner of property whit builds or hiproves dicatear,and QTY. PLUM IT FEE
who contracts for such projects with a emnracior(n)licensed punmmun the Contra ior's
License Law. PERMITISSUA h
❑Iameaemptund Sec. - ,B&P C fnnhis mason
ALTER- IN& NT- R(EA) VALUATION
Own Dam
WORKER'S COMPENSATION DECLARATION BACK FLO ' .DEVICE
1 herby affirm under Penalty of Perjury one of the following dalumtions:
-� ❑I have and will maintain a Certificate of Con.sentto self-marc for Worker's Conifer- DRAINS- R,ROMs EA, 'OND. STUR1.S I'YPF:CONS UEHJC7RON
sundries pro,tried for by Section 390(1 of the Later Cede.for The pedormonce of he
.,,,it for which this pemtil is issued. FIXTURES STRAP
❑ 1 have and will maintain Workers Compemoeon Insurance,as required by Section
3900 of the Labor Code.lot he performance of the work for which this permit is issued GAS-EA.SYSTF.A C.4 ,TS 0(7c.GROUP AYN
My Workers Compensat inn Insurance comer and Policy number are:
Cartier: Policy No.: GAS-F .S VER ('A)
CIIMFICATE OF EXEMITION FROM WORKERS' GRIiAS1lINUUS E NTERCE
COMPENSATION INSURANCE BUILDING DIVISION IF.ES
(This.section need not No completed if the(Tmant is for one hundred dollars($100) - - --_—
ar IessJ GRI'ASIi TRAP PLANCHECK 17EE
Loy any that in the anyner performance o the astolwork for which this o patiothe W isis'Comaall SEWER-SANITARY-STORM EA.
not employ tory person in any manner m as to lucdme xubjecs to the Workers'ComPen- ENERGY PEE
zZ stolon Lows of California.Date WATER IIHATI?RW/VENT/ELECI'R
0 Applicant s GRAVING FEE
N NOTICE TO APPLICANT:If,after making his Certificate of Escondido,you should WAI FR SYS1 I?M/I'REA'1'ING S
OILS
a 54 Meme subject lathe Workers Cmu,sio ainn provisions of the Loam Code,you mast
s13 Z/
W forthwith edmPlY with such provisions lir this pcmmit shall be deemed mvakeJ. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. te Receipt M
V Q Iherehy affirm th:n flier,isacunslmdidn lending agency for the PeTfarmnnce of
the work for which this Permit is issued(Sec.31PU.Civ,C.)
C)U. H I.coders Nance TOTAL:
LUkI Lenders Address TOTAL:
1 certify that 1 have read This application and stone that the above inform:nion is
!/41 correct,l agree m comply with all city and county oninances ordinate laws reforms m QTY. MECHANICAL PERMIT FEE
V hnilding construction.and hereby authorize represcronses of this city menter upon the above mcnnionW progeny for inspection purposes.(We)agree,save,rode ntly and keep larmlexs the Cityof Cupeina agaiml PENMIT ISSUANCE n��llabilldn,judgmers.costs and expenses which may in anyway acme againmsaid City g1.TCk OR AOD TO MECH. p,JE:l)
in saluance of the granting lir this Penni T. "-_ E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR I IANDLING UNIT(TO 10.000 CFM) I I I I M
SOURCE RHGUI. ' ONS
AIR HANDLING UNIT(OVER 10,000 CFM) CONS'fRUC'TION TAX
Signature of APPlicoadViontratfur HAZARDf1US MATERIALS DISCLOSURI? Date EXHAUST HOOD(W/DULT) ,, . rm INDM ,,,((3rJ1b'I
r.nr HQ
WIND ITIGATI(
Will rhe applirant or furore building occupant store or handle hazardous mmcnal HEATINGUNn'(TO 100d00RTU) / , CUPERTINO'
os defined by the Capenina Municipal Come.Chapter 912,and the Health and Safety
Cede.Section 25532(a)? HEATING UNIT(OVER 100.0100 BTU)
❑Vets ❑No VENTILATION PAN(SINGLE RESID) PAID
Dane RecaipnN
Will the applicant or furore handing by the B use ea Air Qu or devices which BOILER-COMP DIIP OR IDLWO BTU)
emit hacvdnus air cdmuminwrs m Jcfined by the Bay Area Art Quality Management TO'
District? BOILER-COMP(OVER 110.000 BTU)
2 . ("96-
0 yes No
I have must Once hNou
ueas mscrud,"arm nnnts under Chupter 6,95 of the Cali- AIR CONDITIONER p ISSUANCE DATE
hmrnia Hcalth Fe S:dcty Cale,Sceime,255115,25533 and 25534.1 rude..Omd fl m if the NEW RESIDENTIAL.MECH. SQ,FE I/ �prs �S O
building dces nmcurrently have.mins,that it is my rear mxiluntymramify Ne revolt
of The requimau ms which must led and prim nm issuance cel a Cenificure of Occupancy.
Owner oranthonzed users Date TOTAL: ISSUEDBY:
OFFICE