B0608APPucANTTO FILL W INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDEN IFIFICAfR N
PERMIT NO
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ItUI DING ADDRESS:
745 Fo Rh Pe--
SANITARY NO.
APPLICATION SUBMITTAL DAT
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RXEY NIiR'S NAME: ''HONE: S7. 0.13
CONTR IOR'S NAh LIC NO.
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CON'fROLn
ARCHTECf/L'NGINEER: LIC NO:
ADDRESS:
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❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MIiCH
❑ ❑ ❑
LIC ENSEDCON1RACnOR'SDECLARATION
y affirm that I am licensed under provisions of Chapter 9 (commencing
Di,nion 3mr,heBninss and Professions CoJemillig 'dense i.
F�odEcl.
d cl.
LichAPPLIANCES-kES1UEN'1'IALWContractor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL,:
❑SFUWL ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RE -PIPE
OMULTI-UNIT CSTRUCTORAL
MODIFICATION
El INTERIOR ❑SWCHIMNEY
MMING EPAIR
IMPROVEMENT ❑SWIMMING FOOLS
POOL
C BATI I REiMODHUREPAIR CDEiMOLITION
C OTHIiR
r _ _
PERMIT ISSUANCIiH
ARCHI'1liCTS DECLARATION
I nndemmad my Mans shall be nod as public o nada
PANELS
UP 10 200 AMPS
Licen,eJ Pndesaio^°I
OWNER BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's Liceme Law for lite
following lemon. (Section 7031.5. Business and Profevsions Craft: Any city or county
which rcyuires a permit tottanmucl, alter, impnme. demolish, of mild, any structure
prim,,, as ivanea. aHo requimithcnpplicunt forsuah,,rion,, Elco signeJnmcmcm
,hat he is licensed pursuant to the provisions uprise Contmctnh License Law(Chapter 9
Rolimeneingwith Section lW(Bra Division 3ofthe Business and Professions Code) or
that he i,. exempt therefrom and Ne basis fin the alleged exemption. Any violation of
Section 1031.5 by any applicant for a pert subjects the applicant to a civil penalty of
mi
more Nan five hundred dollars ($500F
❑I, as ow net of the penton, or my employees with wages as theirode compensation,
wHl do the work, and the structure is not intended oroffemd fur sale (See. 7(M4. Business
and PrdrWom Code: The Curansi is License law does not apply to an owner of
pmpeny who build. or improves Nefeon, mal who that, such work htmsslf or through
his m re own employees, provided that such improvements enot intended or offered for
sale. If.however, the building or improvement is sold within one year of completion. the
;�mer -builder will have the Iwrden of proving that he did not build of improve for par-
..:f lel.
r of the Propcny, xm exclusively conuucting with licensed c.nvacnor<m
a suuct the project (See .11WG, Businmss and Protestants Codc;),bc Gmmrnaor's Li-
Else, does not apply m an owner of progeny who builds or improves thereon,and
who emaracts for sunt projects with a amtmetons) licensed pursuant to mu Cl ntmcmrs
License law.
❑Ium exempla derStt. ,13&P C fordik reason
201-I(XX)AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUTUMISC.
TEMP.MEITiRORPOLEINST.
COMMERCIAL:
C NEWBhDG/AUDI'PION' ❑ UIiMOi.I'I'ION
❑TENANT ❑FOODSERVICE,
IMPROVEMENT
COT
POWER DEVICIiS
MO
SWIMMINGPOOLELECT
OUTLETS -SWITCHES - FIXTURES
Mc
NEW RESIDENTIAL ELECT SQ IT
.FR FA O
-
MAY 2
1 �QaM1�
Sly
-� �Q. IT.
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN&VEt WA I ER (EA)
Date
WOR'111 S COMPENSADECLA RAF ION
I hereby affirm under penmity of perjury one of Ne following dedications:
❑ I have and will maintain a Certificate of Corrom to,elf-insum for Worker's Carmen-
anou the perforce of the
tler, es provided for by Section 39110 of the [.shot Code, lman
work for which this permit i, issued.
0 1 have and will maintain NFrkerr Compensation Insurance, as required by Section
170() of the Labor Code. for Performance of the work for which this permit is issued.
Wodce% Contpcnsmion Insurance cancer and Policy number are
Courts: Policy No.:
C17KI'IFICAI'E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for late hundred dollars ($ 100)
or Ices)
l cenify thin in the perfofinence.1 the work fill which this .if is issued. l shall
not employ any permm in any incliner sons .m become subject to the Workers' Compen-
w,ioo laws of Calif.mi.. Date
Applicant
BACK FLOW PROTI C'L DEVICE
DRAINS - FLOOR, RO(OI', AREA, COND.
STORIES
OCC GROUP
TYPE CONSTRUCf10
AIN
FIXTURES - PER TRAP
GAS- EA. SYSTEM -[INC. J OUTLETS
GAS -EA. SYSIPM-OVER d (BA)
GREASFIINDUSTRL WASTE INTERCEPTOR
B U ILDING DI VISIO '
GREASETRAP
PLANCHECK PEP,
SEWER -SANITARY- S'IORM EA. 200 FT.
ENERGY IEE
WAFER HL'A1'ER W/VENT/ELECTR
GRADING FEE
NOTICE TO APPLICAN'C IL after making this Cenificme of Exemption, you should
become sobject o the Worker's Com samalion pm,,i.m of the Luber Code, you must
Forthwith comply with such Provisions or this permit shall he deemed revoked.
CONSTRUCTIONLENUING AGENCY
I for by which thi that thereamnai issued(lee inn lending agency firths perhtmm;¢e nr
work for which this Iermit is issue) (Ser. 3097, Ci, CJ
Lender's Name
WATER SYSTEMOTEATING
SOILS FEE
WATER SERVICE
PAID
Dom Rec,ipnN
NEW RESIDENTIAL YLMB. $Q. FT.
'I'OL'AI
Lender's Address
TOTAL:
I rectify that I have read this application end sate Nan the above lotsmtmuon is
correct. l agree tocomply with all city and county onlinancesund sem laws relating to
buildingconstruction, and hereby aalbonve representatives of city to enter open Ne
.lane mentioned Pmpery for impuainn per,"'ms.
rose) agree to save, indemnify and keep harmless tileri
City of Cupemo againq
Iiahilines,judgmenns.costs and expenses which may in ane way accrue agmr,[ said City
ccn,cyucncc ul the mining .1 permit.
APPLICANT'NDF,RS'TANDS A' WII. i( PLV 'I'TIi ,L -NON 1'OIN'f
SOURCE REG'NDE
S�
BUILDING PER
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCEI
ELECTRIC P .
ACT HR OR ADD TOMECH.
PhUMBIN PEE
AIR HANDLING UNIT(TO K.Ba CFF11
MSCI IANICAI. ISI
AIR HANDLING UNIT (OVER HLWB CFM)
CONSTRUCFIO X
Sign Ap ,n tractor Dulc
aHAZA DOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havardoes material
as defined by the Cupertino Municipal Civic. Chapter 9.12, and the Health and Safety
Craft, Section 25532(x)9
❑Yes ON.
Will the sill icam m furore building .,,.Pon, use a Empment of Jevioes which
mit hvnNous air contaminants as defined by the Buy Area Air Quality Munagmncm
District'
❑YIN No
I have feud the hazntdnu, maerialsm uireancrel eck Chirpierfi95 of the Cali.
I'omla Health &Safely Cade Sections 25 ,25533 am1255JJ. 1 understood Nat if the
building Jt acu .1 mi' ny rusponsihility In notify the occupant
,,r Naramus oid t..aana ora Cerulea¢" 0 ap;ie',
EXHAUST HOOD(W/DUCI)
HOUSING MITIGA'I'10 FEE
HEATING UNIT LTO 100,000 BTU)
1[RATING UNIT (OVER IOBWU B'TU)
PAID
Dam Be cipt p
VENTILATION FAN( SINGLE RESID)
BOILER -COMP (3HP OR 100,I0IRTU)
12 11
BUFFER- COM V(OVER I0E.000 BTU)
AIR CONDITIONER
ISSUANCE DA1'li
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ISSUEDBY:
NEW Rp_SIDEN'I'IAL MECH. SQ. IT
U e t Uate
TO
OFFICE