S 3133APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECIRICAL PE 11T NO
BUILDING DIVISION APPI,ICATION/PERMITPLOMIIINC.MECIIANICA1 3133
InaltiING PIRMECT IDEN'1'IfIc,1'TION
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3117071 -F-4 ,{ O t�
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PHONE:
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I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with SC1tlur7(Nhlluf Di 3 nl the ImansewalId Prifiel"nns C, mylicen,cm
in full force and effee'(j�'� % h v (
License ClassLio
❑ Consultant Fees Paid by Applicant (Initial)
ARCH] FECES DECLARATION
FN Z
O I and oulnd my plans shall be used as public records
Z�C
osi,E., u1 Licensed Professional
� W that I n usamDER DECLARA'T'ION
C W Q 1 hereby . (Sect that 1 1. exempt fromv an IM1e C,sions Cods: Arty
Law for the
C
Q. U which rg reason. Permit
71 nstr Diu alter, and improve.
de i ols h,orAny city or county
a O ti which squires a permit to mnwmm, abet. improve, demolish. or repair any .weturc
Prior er its i"nane, also requires Ile, soft cant for ouch permit o Men signed anmmul,
WA (hal he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 1)
.xaC, (commencing with Section 700(nof Division 3oflhe Busimessand Pmfessinm Corde)nr
y Q eG Etre he is Tempt Iherelrom and the basis liarthe alleged enaalpunn. Any vial, lion if
au _ as�t1• Section 7031.5 by any applicant for a perms subjects the applicam to a civil penalty of
=O Mot More than live hundred dollars ($Sill ).
0 Lav owner of the property, or my employee with wages as with wages as thel r solo compcn'tion.
CCFa will dorhe work.ardthcummre isnot intended nrofered forsale(So,. 7014, loos
Lw and Professions Code [he Contractor's License Law does not apply to an owner of
proPcny who builds or improves thereon, and who docs such work himself or through
bisinpinya.Y, pmvidcd (ar hut such impeats a ml intended o u0ercd fur
sale`If. however, the building ormpro em is%old withinone yerarmcumpleam. IM1e
huilder will have the burden of pro ing that he did not build or improve Ga par
a enr-Itvue,
DI, as owner ofth proNrI am esclaoselye t t s with licensed ct I :m
construct h it l t See, 7044It asiress and PRfl essims Code O VI he C t a: L'-
La d I pplyt fEupent h builds p thereon,d QTY.
who I e'I xl cM1l ICIvw N. ease trt(sll anealp .a moo the Ci m'vabrn
Lie ... c Low.
❑ l am exempt under Sec. B& P C for this reason
t
Owncf Dara
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following deelaxtime:
0 I have and will maintain a Cenircale ofeon¢m m self.insere far Workers Carl
sation, as provided lie by Section 3700 of the Labor Code, for the Ecom arance of the
work for which this permit is issued.
0 I have and will m� ins in Worker. Gingmnr dun I..uan., as - air J by Suclionand will m� int in Worker. Cnmlmnr lion Imuave air J by Scclion
3710 of IM1e W r G lc fort = rfmmance of the work for which this permit is issued.
My Workers ance rand Pitic' --
niF
Comer, sic Policy IN{n�: sYs Jt
CERTIFICCOMPEN.M IONIATE OF ONNUIMM4015FI St—Tt/
('Ibis section need not becomplecd ifore p rred is Rrrooe hundred dollars ($100)
Ill les)
1 certify Ilial in the performance oldie work for which this Permit is issued.I shall
In employ any person .any ni us"nn as,, hecanne subject lar te,
hWorkers Camper.
Oz dam Laws of California, Date
Z O Apphcam
0 NOTICE 10 APPLICANT: IL for making this Certificate of Esctilptiun, you should
? become object to the Worker's Compensation provisions of the Labor Code, you must
W forthwith comply with such pnwisiomonhie permit a hall be devoted revoked,
Q
0. CONSTRUCTION LENDING AGENCY
L)p work
hyuftinn thal(here i iissued(Sec.3097.nding uguncy Far the perfornwnccnl
C) F the dark tar w'hlch This Permit is issue) (Sea 3(197. civ. C.)
Q V Lnd, Name
dAddM
T Leender's Address
(.. y 1 cense thus 1 have real (his application county ordinances
That the above information rel, ion is
F-tN c building Construction.
vimmand with all city and eprntativesof and caro lawtr upon the Q'IY.
V z nuise-mentonollion. and hereby authorize representatives of this city mensrupmthe
above-(We)nW pto ave foremnifyi an keeper.
(We) agree to cove, indemnify and keep harmless the City of
rc Cupeninn against
inconsequence of
granting mi
expenseswhichmay in any way a<eme ogainsl said City
consequence of the granting S this permit.
APPLICANT UNDERSTANDS AND WILE. COMPLY WITH ALL NON -POINT
SOURCE',ULATIONS�
SignamreofSlgnu App Vale
HAZARDOUS MATERIALS DISCLOSURE
Wit he applicant or fumre building..... ut sore or handle haeank us nuaenal
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Cn ]I. Scmimn 25532(a) l
D Yes k, rvo
Will the applicanl or fumre building occupant use equipment or devices which
emit haamdeus air contaminants us defined by the Bay Area Air Quality Management
District?
E3 Y., Ly ao
1 hove read the homrdou, naerialy squ ourvil s under Chapter 605 of the Cali-
fomin Heahb & Safcty Cade, Sections 25505. 25533 and 25531. 1 undersand fiat if Tho
builAingda, sol Contend, have v vol, lI ilhmyresponsibddymnnlily the cecnpvm
of atswhich must�i met PnmmixsuanCc Cf aCertifcalc of (kcupancy.
J
-lL-?S
INFO
MECHANICAL PERMIT
FEE
La-
p PERMIT
FEE
JOB DESCRIPTION
RF 11ENTIAL-
PTM' UWL 0KITCI113N REMODEL
)E!ADDI'1'[ON El PLUMBING RE-PIPF.
❑MULTI -UNIT [I STRUCTURAL
MODIFICATION
❑INFERIOR ❑CHIMNEYRFPAiR
IMPROVEMENT[]SWIMMING POOIS
[]BATH REMODF,IJREPAIR El DEMOLITION
tYFHL'R
raz
n�
I'I?RMI'I'ISSUANCE
APPLIANCES_ RESIUF,N'UAL
PANELS
UPT0200AMPS
201-1000AMPS
OVER lap AMPS
SIGNS ELECTRICAL
SI'ECIAI. CIRCUIT/MISC.
T/!1T
A
n. K
'rHoul METER OR NILE, NST
AIR HANDLING ON] T(OVER 10,000 CFM)
/ d %CJ�� I
COMMERCT I EI
❑NEWBLDG/ADDITION ODEMOLITION
O'FIiNANT ❑FOOD SERVICESWIMMING
IMPROVEMENT
❑ OTHER
POWER DEVICES
POOL ELECTRIC
OU'1'LE'IS-SWITCHES-FIXTURES
NEW RESIDEN'FIALELEC'!R SQ Fr.
HOUSING MITIGATION FEE
SQ FT. 11-OOR AREA
/2z.S
S/SQ FT.
2 2-f -K s O 7 `
r�
2 -
PLUMBING
PLUMBING PERMIT FEE
PERMIT ISSUANCE
AI:TER- DRAIN& -WATE\A)
PA)
Receipt#
I VALUATION
F r, D
BACK FLAW PIK iC'F. I CE
DRAINS -FLUOR, RO ARE <.
STORIESU
TYPE CONSTRUCTIOS
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC.SO [SE'S
1li
, /
OCC GROUP
` APN
5J
CAS-EA.SYSFEM-OVERIIEA)
GR1iAS191NDUS'IRI, WAS'T'E INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEE 7n7. 2 to
SEWER -SANITARY - STORM EA. 200 14.
ENERGY FEE
F Q
WATER HEATER W/VIiNT/lil.[CIR
GRAVING FEE
WAIER SYSTEMIrREATING
SOILS FRE
WADER SERVICE
PAID _ _
NEW RESIDENT [Al. PLMIL SQ - FI'.
MECHANICAL PERMIT
FEE
SEISM( TS
/ 2
PERMIT' ISSUANCE
ELECT IC ZE'
/� 2
ACI'13RORADDTOMECH.
PLUM IN P ,
AIR HANDLING UNI'(' (TO HLaM CPM)
MECIIA ]CAL FEE
AEE
AIR HANDLING ON] T(OVER 10,000 CFM)
"IION'1'A%
E%HAUST HOOII (W/UUCO
HOUSING MITIGATION FEE
HEATING UNIT TO HyL001 BTU)
HHA'I INC, UNIT (OVER 100.000 (ITU)
PA)
Receipt#
VENTILATION IrAN(SINGLE BESIDE
BOILER - COMP (3HP OR I0k000 BTU)
LA J
TO
BOILER -COMP (OVER 100,000 B'fU)
1li
, /
ry i7
AIR CONDTHON'ER
NEW BESII3EN'I'IAL MIiClI. SQ.IT.
ISSUED BY:
OFFICE