S 3005 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC'rRICAI. PE'SIT N°. 3005
BUILDING DIVISION APPLICATION/PERMIT PING PROTB NGECT
CT IDENTIFICATION BUILDING PROJF:CI'IDF:NTL4'ICA9'IUN
' OUILDINC ADDRESS: SANITARY NO. APPLICATION SUBMITI'AI:DATE
� q0 9
PHONB3 C RACT) 'S & LIC NO:
NEC CON'fRUL N
ITA T iNGINEIiR: LI N ADUBIISS: ❑ J1
2—
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CONrACC p O liBUILDINGPERMIT IT INFO
M w ❑ Consultant Fees Paid by Applicant(Initial) Bu)G/ Fit ECT / PLUMB MliC�i�
LICENSED CONTRA R'S DF. .DRAT QTY.gUI1TO2WAMPS
ELECTRIC PERMIT FEE JOB DESCRIPTION I�
I hemby allirm that I am licensed u r Pmvicitine of C ap¢r 9(commencing
On'Z thSmion]Wlp of Division3tifthc Business and Professions Csde,wJ my fccvais RESIDENTIAL
FOO wa full force and effect. UANCE ❑SFOWL ❑KITCHEN REMODEL
WUiF to
aU License Class Coma $-REgIUPNTIAL ❑ADDITION [I PLUMBING RE-PIPE
F ZZ til
Date GS DEC r
,=oo ❑MULTI-UNIT ❑STRUCTURAL.
ARCI{ITEC'rs DF.CLARA'TION
F Z I underaand my plans shall he used as public records MODIFICATION
OZ-0 MPS ❑INTIiRIOR ❑CHIMNEY REPAIR
4hO Licensed Professional PS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION AMPS ❑BATH REMODELIREPAIR ❑DEMOLITION
1 hereby affirm that I am emmla from the Contractoh LwO,oa Law far therixx•O MUfallowing taco..(Section]03 L5,Badness and Professions Cale:Any airy or ctiun y fRICAI. .❑OTHER
W 3 W(" which requires a permit to commuct,alter,improve,demolish,or repair any no
� 0 prior m its issuance,also requires the applicant for such permit In the a.,dowd smrememt SPECIAL CIRCUIa'/MISC.
'Id
y
that he licensed prs Itthe p "o 17thC t m LicenseLs,(Chapter') OMMFR IAL:
W �� (e emito with Set TIDO) fD' I 3 fth Baine dP f.:'ms Csde)or TEMP MCIF17R OR POLE INST —
L a e C
hot h ', exempt thercf d the basis f Ih II geJ epi Any violation of _ - ❑NEW BLDG/ADDITION ❑Df:MOLITION
Non Secann]NI5 by any applicant far.permit subjects the appl a tt it Penally of POWER DEVICES ENANT' ❑FOOD SERVICE.
Zp, nm marc than five hundred dollars(SSW),
1 ROVEMENT
SSC ❑ Lion rarofthe pmpery.many employees with wagesas lheirsole etmpensasiom, SWIMMINGPOOLELECfRIC
[]OTHER
will do the ,an
workd rhe amcmm is nm Immoded proffered for sde(Sec.]054 Business
IWalt and pmR,,iotm Cash: poc Comdor's raLicenw Law doe's not apply 1.an owner of OUTLETS-SWITCI S-FIXTURES
3.. propny who builds or improves theme ,and who docs such work himself or throng s
his own employees,provided that such improvement are not intended m uttered fur NEW BESIDE T L F.LEC IR SQ 11'.
sale.If.however,the building or improvement is sold within one year ofcamplelum,the SQ.FT.FLUOR AREA s;/SQ,FT
wner-huilder will have the hunlen of proving that he did not build ur improve for par,
,,a of sa c). //
El I,as owner of the pita 104 am exclusively contractingfess ,with licensed roommate,]m _ p
orstma the es not ISec.o an owner
of and rly who Profession,CncO The Cmmraaam Li. YS
chow Law lawls f not apply m an with
a cot pmpors who Nei . or improves thereon,and QTY. PLUMBING p FEE
who rnmracts for such prnjems with a comramoas)IicenseJ purxuan,m the Cnmracmr's
Ic
License Law. PERMIT ISSUANCE
❑Ism esempl under Sec. ,B&P C for this reawn
ALTER-BRAIN&VENT-WATER(EA) VALUATION
Dwmer, Date t 060
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby anion under penahy of Perjury tine of the following declarations:
• ❑Ihave and will maintain a Certifcae of Conesm to self-insure for Worker's Comon- DRAINS-MOOR,ROOF AREA,COND. STORIE• TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the labor Cale,for the performance of the
work for which his Permit is issued. FIXTURES-PER T RAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section _
3700 o1h Labor Code,far the prfarmancc oRhe walk for which this pnnir is kaadl GAS-EA.SYSTEM-I INC.4 OUTLETS OCC CROUP APN
My Worket's Compensation Insurance carrier and Policy number are:
Carrier: Policy Na: GAS-PA.SYSTEM. 4 CEA)
CERTIFICATE OF EXEMPT ION FROM WOR KERS' GREASEANUUSTRI. EI � CEP
COMPENSATION INSURANCE BUILDING DIVISION FERS_
This sec,inn need not be completed if the permit is for one hundred dollars($IW) GREASE TRAP
or less)ThisPLANCHF.CK PF.F. D
I certify that in the Performance ufthe work for which this permit is issued,l shall SEWER-SAN['OAR TORM EA,200 FT.
ma emloy any person in any manner so ac re become subject the Worker.Compa- ENERGY FEE
p
Z Nation Laws of Ccilifomia.Data WATER HEATER W ENT/ELECfR GRADIN
0 Applicam
NOTICE TO APPLICAN'C If,dor making this Cenifii of Rsemptian,you should WATER SYSTEM/IR
a Femme subject to the Worker's Compensation poremons of the Ltbor Code,you mast ---- ^^ SOILS
forthwith ouiply with cueh fravimmne or this pemut shall be deemed mvakeJ. WATER SERVICE
i Q
CONSTRUCTION LENDING AGENCY NEW RF.SIUr;NTIAI.PLMH. SQ.Ff. PAID
'Z Dan Ream p
P hereby affirm that there is couslmmion lending agency fnmhe performance of
O P the work for which this pmtir is issued(Sea.3097,Civ.C-) OTPLt
lender's Name
Lender's Add,nss TOTAL. p
I�.•.", G I cenify,hat I have read this application and state' the above information is BI LUWG FEE �Z
tr h correct.I agree to comply with all city and county ordinances and state Paws relating to QTY. MECHANICAL PERMIT FEE MICFEE Q
L) Z building umswmian.and hereby.uthnrim rcprenemmives ofthis city memcrmpn Ne
above-mentioned property fur inspection purposes. PERMIT ISSUANCE 'LE TRIC FEE
(We)agree m save,indemnify and keep hatmlus the City of Cuprino against
liabilities,judgments,costs and expenses which may in any way accocagtinsf said City ALTER OR AUUTO MECH. s Q LU PIING FEE
on.cequenceo Ihegmmingaf 's
APPL1 NTl DEBST 'D . I LL COMPLY WITI{ .1,NO. POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICALF'cE
SOU _F EG ATIO .
ti ZIP AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TAX
co Appli,mUC It otos Data EXHAUST GOOD(W/)UCf) HOUSING 111711 At'ION MG
H .ARDOUS 6 TERIAM DISCLOSURE
Will theapplicator future hot Jing eacupamnmre or handle baaurdaur,material HEATING UNIT LTO BI(I.D00B1U)
as Jefncd by,he Cuprtimo Municipal Calc,Chapter 9.12,and the Health and Safety HEATING UNIT OVER 1110.01)0 Bq'U)
Code,Seed..25532(.)9 F•
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID t
Cate Bca'elpt#
Will the applicant or future building occupant use computer'or devices which BOILER-COMP(3H1.OR 100)100 BTU)
emit hevrdiv s air contaminants as defined by the flay Arca Air Quality Management
District? BOILER-COMP(OVER 100,000 ID U)
❑Yes ❑No
I have read the ha:arkas materials requirement under Chapter 6.95 of the Cid- AIR CONDITIONER / ISSUANCE DATE
forma Health&Safety Cock,Sections 25505,25533 and 25534.1 understand that tithe NEW RESIDENTIAL MECH, SQ.FT.
hmldingdacs nm carremly have a mnam,and it is my mspnslbility m notify the occupant (((
ofthe reyuiremems which must bo and prior m issuance of a Cenifea¢of Occupancy, y
Owner or amhorimJ agent Data AL: ISSUED BY:
OFFICE