S 3947APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING • MF.CIIANICAI.
PERMIT NO.
S 3947
BUILDING PROJECT IDENTIFICATION -
BUILDING ADDRESS: a?
Nr'rNI . �0 2=
SANITARY NO,
APPL/I /CATION SUBMITTAL DATE
KJ Q1
OW R'SN E: PHONE:
CO RA
SN E: LIC NO:
NIC
CONTROL«
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❑
HI T/LNGINEER: LI N(:
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CONTACT
PD NE:
BUILDING PERMIT INFO I '
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❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT; PLUMB MECH
17>14— rJr�f' ❑ ❑
LICENSED CON' TOR'S DECLARATION
1 hereby affirm nes 1 am lice a under Ineeniom of Chapter 9 (commencing
i wilM1 sermon2 XNB n(Division]rf ,h xiness dMofcsxinns CnJe. and my license is
in full fnrccard,fecv
U License Class Lie. p
W Date Contractor
o• I tCl' DECLARATION
Z 1 dr eA as public recoNs
A
QTy
ELECTRICPERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑ SP T)WL [IKI'TCHEN REMODEL
❑ADDITION [I PLUMBING RE -PIPE
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
PI?RMI'I'ISSUANCE f Q
APPLIANCES - RESIDENTIAI•
PANEIS
C
IIP TO 201 AMPS
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
❑BATH REMODEL/RF,PAIR (] DEMOLITION
❑ OTHER
Ucen J r e.....°
IIDER UECLARA9'ION
Q herehy uEl...I Ianpl torn, me Connector's License Law for the
.4 Or,.31,S,
FU following remnn. (Scc,iousiness and Professions CnJe: Any city or county
yQj which requir u permit, eller, improve. demolish, or repair any stmemre
201.1000AMPS
OVER IIXXIAMPS
SIGNS ELIECTRICAL
J prior to its issuance. also requires the applicant for such penninn rile a signed statement
SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to Ne provisions of the Cornmcmr's License Law (Chapter 9
Q (commencing with Section 7")of Division] of the Business and Professions Code)m
TEMP. MIMER OR POLE INET
COMMERCIAL
y that he is exempt therefrom and the busis for the alleged exemption. Any violation of
❑ EW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
4 Ireton ]031.5 by any applicant fin, i conn subjecw the applicant In n civil panulty of
} not more than five hundred dollars ($500)'
❑Lo the work,loddropertgmmyemnteadeswi0,wagesrsh,(Sce. contpensminn.
will do the work, and rte he Cont is not intended m Law do for salepply to an BUdnes.a
andpro Professions Code: TheContractorstherein License law dors not apply owner or
:PANT ❑FOODSERVICE
IMPROVEMENT
❑OTHER
SWIMMING POOL ELGCTRIC
OU'1 LETS-SWRCHFS-IOXTUR /J
properly who builds or improves thereon, and who does such wind himself or
s if
own employees. intended or offered for
provided Nat such improvements am for
NEW RIESIDIiNT1Al. 5LECB SQ
one
sal
saleer,milwcvcy the building wiid n
e nr completion, the
issoldlie
en
SQ. FT. FLOOR AREA
$/SQ. FT.
N pimm�l
bur r laildyear
owner-bulWei will bout the harden of proving,M1nt ha Did nm bulltl ser bnprove for pnry
pose of aowne
❑I,asownerrl the property, am exclusively connecting with
TAC: C)
mstrva the project (Sec.1UW, Business and Professions C<ale:)'Ifie Conuacmrs Li-
:)TIanCum,manrs i-
- -
ccomLawdoesnotapplytoanownerofpropcny who builds or impmves thereon, and
QTY. PLUMBING PIER ITFEE
���
who contracts for such projects with a contmcmr(s) IittnseJ pursuant to the Contractor's
PERM1'I ISSUANCE
License Law.
❑ I am exempt under Sec , B X P C for this reason
"
ER - DRAIN A VENT- WATER (EA)
r ])areALI
VALUATION
O
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declamations:0
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, GOND,
I have and will mai main a CeniEcate of Consent to ul6insim for Workers Compete
ation, as prosided for by Section 37M of the Labor Code, for the performance or the
work for which this Permit is issued
S700RIES TYPBCONSTRUCTION
FIXTURES - PER TRAP
❑ 1 have and will n eiroom Workers Compensation Insurance, as required by 9eetion
37Wof,he Luton CnJe, for performance ofthe work for which this permit is ounce,
My Workers Compensation Insurance cemicr Polit icyNo, number arc:
My We Policy No.:
GAS -IEA. SYSTEM -1 INC. 4 OUTLETS
OCC. GROUP APN
a.� �
�./�
GAS - IA. SYSTEM -OVER 4 (EAI
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSA'I'[ON INSURANCE
(This section need not be completed if nepermit is for one hundreddollars($ IIXB
or lass.)
GREASEBNDUSTRL WASTE INTERCEPTOR
BUILDING DM$ION IVES
GREASE TRAP
PLANCHP.CK PEE
/
SEWER -SANT Y -S R)RM PA. 200 FT.
I certify t hat in the Trincomalee of the work for which this permit is issued, l shall
m e employ my person in my manner sons to become subject to the Workers' Compete
(ENERGY FEE
ATER WNEMI'/ELECTR
codon laws or C.1iforam. DaleWA'IF:R
Applicant
GRADING FEE
NOTICE TO APPLICANT. IL after makingthis CeniOcote of Exemplion,you should
become subject to the Workers Compensation provisions of ,he Labor Cade, you most
WPARSYSTEMCEREATING
SOILS
forthwith comply win such pmvio.mor this permit shal l hedeemed revoked.
a
WATER S17RVICE
NEW RESIDENTIAL I'LMI3. SQ. f4.
r CONSTRUCTION LENDING AGIENCY
narrate isaed(See ion len ding agency for perfnrmantt of
I for
the work for which,his panni, is issued (Sec. 3092, Civ. C.)
PAID
ate Rueip,p
- TOTAL:
LeaName
Leel defs Address
TOTAL:I
RUILDIN FEE � S e9Q
and dna nm the shove information relation ix
certify n c 1 have read This city
ca,rec,. 1 agree w comply with all city unA county oNinanccs and stem cows rotating m
and county
builJing constninion, and herehy nunorim reprcsmnatives of lM1is city men¢r upon the
, I
QTY, MECHANICAL. PERMIT " FEE
s
SEISMIC EE"
admove-meminned property for inspection purposes,
(We) agree m save, indemnify and keep harmless the City of Cameron against
Iiabili,ies,judgments, costs and expenses which may in any way accrue against mid City
con xquence of the gra in of this permit.
PERMIT ISSUANCE
ELECTRIC E
3 p1.TT:R OR ADD TO MECH.in GO
PLUMBING
AIR HANDLING UNIT (TO 10,fXM1 CFM)
MECHANICAL PEE 'V
L 1 T1R. )S AND WILL COMPLY WITH ALI NON POINT
OU I.
�/Y
VV
AIRHANDI.INGUNTI LOVER 0,WOCFM)
CONSTRUCTION TAX
S' cot of pPli un or a¢
IIA US MATERIALS DISCLOSUR .
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT ITC, 101000 BTU)
Will the applica Lamm building aecupam store or handle haraNuus reticent
as de tied by the Cup n Man' ipu) Code, Chapter 912, and the Bunch and Safety
Code, Section 25532( ? o
HEATING UNIT (OVER 100,010 BTU)
❑Yes No
Will Nc applicant or future building by the Brt ayeea Air uor Micaswhich
A hamNoua air cnmaminanu ea defined by ,he Bay Area Air Quality Management
rsaim'!
❑ Yes n
PAID
PAID
Receip,k
VENTILATION PAN (SINGLE RESIDE
BOILER- COMP GHP OR 1Q1,000 BTU)
� ,
X10
BOILER -COMP (OVER 100,(BTU)
AIR CONDITIONER
1 eve read the hnzar u materials requirements under Chapter 6.95 of the Cali-
4 p
ISSUANCE DATE
NEW RESID5NT'IAi. MECH. SQ. lel'.
fnrnit Heart .Soft, C ons 25505, 25579 and 25574. I unJms,anA that If the
building n ell c tamnhnatisuaeporssibilityto notify euccupam
��
on e e el parr to
m iaaaance or a ancon a or yyy.
lE
ISSUED BY:
O nerd ton gem ate
OFFICE