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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINTIPEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDEN'I'IFICA1 ON
PERMH7 Nn.
S 2441
BUILDING ADDRP_SS:
os E CS reel
SANITARY N(l.
APPLICATION SUBMI ITAL DAM?
OWNERS NAME: PHI NE:
CO "IRACTOR'S AA :: I LIC NO:
S 0.
NIC
E]CON'I'AC'1':
ON'fRO1.N
ARCIRI'I!CI'/IiNfiINF,fiR: LIC NO:
At) It SSS Il- ��
,/'sN
PHONE:
Nem 3t?y $733
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MI
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby Aft in tent I am licensed under prav'uums ol'Chapter 9 h'mmmendmg
with Seaimn 70(hol )isision3ofthe Business and Prote.,lun, CWa,amny license is
in Hol fore, an l dboo. �/
Limnse Cl... SIT'—Lion.
Mule— CtmlmCntr
QTY. ELECTRIC PERMIT ITE
JOB DESCRIPTION
RF. N IA
'
FOWL ❑KI'ICHIiN HIiMODF.h
❑ADDITION [I PLUMBING RE -PIPE
❑MUhTI-UNIT []STRUCTURAL
MODIFICATION
[I INTERIOR C3 CHIMNEY REPAIR
IMPROVEMENT [DSWIMMINGPOOLS
❑HATH REMODIiI/ItIiPA1R (]DEMOLITION
❑ OTHER
Q
PI?RMI'f ISSUANCE
APPLIANCES -RESIDBNPIAL
fd /"//pl AR%hallb use DECLARATION
I understand ,nY plane shall lw used a, public records
PANELS
UPTO 200 AMPS
Licensed Profeavo'ta1
OWNER -BUILDER DECLARA9JOIJ
I hereby affirm that I am exempt from the Contractor's License Law for the
following lira..... (Scctian 70315. Humes and Profession, Code: AnY city or county
wprihich teyuires a period m emamet, alter, improve, demolish, or repair any structure
pem GlcusigneJswanw7u
�rte lin issuance.also retryircx 'he applicant fur web nne
,but he is licensed punuanno the powi,ions of the Committee, License la. (CIm nr 9
fconnnene'mg with Seeslon 901(11of Division3 of the nu,inew:md Pnofcsions C'fde)ot
that he is cscmpl therefrom and be basis for the alleged exemption. Any viwlaion of
Suction 911.115 by any applicant finnpernutmhj1v,, the applieantma civil punultyof
not onan d an live hundred dollars ($500).
iQ1, ucnwnernf Chep operry,or mycmpinyeex with wages artheirnnle countertenor..
C]
will du the work and the nmmme is not intended orof4ved for sale (Sec. 91134,....aincrs
and Protcsdons Cadc 9e,, Comordon's lJormu Law does not apply in an owner of
his o nY who builds lir hopers thereon, improvements and won docs snob watk d d orf of Irrdogb
his own employeehe provided Ihit such ormioldw an not intended or , cliod for
.role,,-1mdwc, will have the
gnTertof pmncn iBoblh did can build uimprove fomdou
p ncer-builder will have the burden of proving Bob he did not buil) nr improve bar pur-
uf.akJ.
❑ h ac rsvner of the pm,,ny, am exclusively contracting with licensed commnors to
mm the project (See 7G44, Buslnecs,mA P fex,iomc Calc:) She Contractor's I.,
cenw law does not apply to an owner of propeny who builds or improves thereon. and
whoa onocw lin such pr„ject, win a ronnaean(s) licensed pursuant to the Comrscon s
Licensc law.
❑ I nn cscmpl rods, So. . It & 1' C lin This reason
201-1000AMYS
OVER IIXM)AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
7
TEMP. METER OR POLI! INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION El DEMOLITION
❑TENANT 11
IMPROVEMENT
❑ OTHER
POWER DEVICES
04
SWIh1MING MMOL ELE
OUTLETS -SWITCHES -FIXTURES
NEW RE.SIDWTIAI. ELEC!'N S
SQ FC FLOOR AREA
S/SQ. I'1'.
TOTAL:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
AL'I'HR - DRAIN & VENT'- WAI 17R (EA)
Owner [)are
VALUATION
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Ccnibcalcol Consent o sclbimsure lin Welcr'xCotten-
whore, as provided for by Section 39(X1 of the labor Code fonhe performance of Ie
r
wod, for which thin permit is issued
❑ 1 have and will maintain Worker's Compensation Insurance. as "cited by Section
i9(Nlofthc`'aMCENsI1FICATEe. fit IU HEXEus I'TION oil. hicb,his pcnni(is'nsucJ.'
My Wr Com Inaua sma��_cejjjjjjlllvrier inkyod NcypayRlK�yS���Aya�
Cmric ,p/V ION No Na��ee�rRKE'
�F M11 WORKERS'
COMPENSATION INSURANCP.
(This section need not lernmpleted if the permit is formic hundred dollars OEM
or Ices)
I cenifylhal inlhe putfnrmarecof the work for which this perni t is mew ed, Is hall
not employ any person in any manner so as to become subject m the Wicker%' Compen-
,won Lawes of Cahfomia. Dole
Applicant
BACK FLOW PROI'EC K DEVICE
DRAINS_ FLOOR, ROOF. AREA. COND
STORIES
TYPE CONSTRUCTION
PIATURES-I'I:R'I'RAP
GAS -13A.SYS THM-OVFR4 DTLE'I;S
fICC GROUP
APN
_
GAS-EA.SYSTGb1-OVGRd(EA)
GRI?/xSI'IINUUS'IRI, WASTE INTERCEPTOR
BUILDING DIVISION PEES
GRHASE'fRAP
PLANCHECK TEF,
SEWER -SANITARY- STORM EA. 2(X1 FT.
ENERGY FEE
WATIill HFAT ER W'IVEN'T/EI.ECI'R
GRADING ITE
NU11CB'10 APPLICANT: If, after making his Ceniticmc of lNeriplion, you should
become subject to the Worker, Compensation provisions of the Labor Cale, you mu
fmnhwiat,mmply wilt each pro—irm lir Ibis prnor..ball be detenterevoked.
CONSTRUC, ION LENDING AGI!NCY
I herebyaflimuhn there isacnrowction lendingugency for Ne pertummocof
,he work lin which dr, enrmil Is ..surd (See. 309], Civ, C.)
Lender's Name
MAT 13R SVSTElvin REX) 'INC
SOILS EFIi
WA99iR SERVICE
PAID
NEW R” i!N'IIAL PLMB. SQ. FT.
Date Receipt
I IL'I OPAL:
Lcudcf's Addtesv
1 certify that 1 have mad this applieaion and state Ihm Ibe .Mrve information is
pear l agree m comply with all city and county ordinance. and state laws relating set
building construction, and hereby authorize mpoesentati.es of this city it) enterugm the
abmve mentioned propeny for inspection purposes.
(We) agree m.muse indemnify and keep hamdess the Ci y of Cnpenino again,,
Iiabilides.jnJgmmtils, coos and expenses which may in any way accrue against said City
mnsrqumcc of nhc griming of thou permiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
0 L:
BUILDING FE
Q'fY. { MECHA it PERMIT FEE
!,,(// r t rt n
SEISMIC F'
�f
P'RMIT IASUANCI? V
BLEC'I'
IC PEf
1,' )WRADDTOMECH.
11I_UM13
VEE.
AIR IIAND III,IXXI CFM)
MECH ICAL FEE
AIR HANDLING UNIT (OVER IO,f
CONS'TRL :TION TAX
Signature of ApplicaHAZARcmr ])air
fI6ZARits, building IAI-SDISCLOSURE
Will theeCa,aallir future Ipal ode. haptrarelir handle Health
sd Safety
the Cupertino Munlciphl Cade, Chapter 9.12, and the Ileahh and tinlety
w defined Section
Coda Scctian 2551$v0'!
❑Yes Nr
Will the upplicanl lir future building oceupum rhe equipment or devices which
can, haurJnuc air uomaminamso , defined by the Buy Area Air Qr:tllty M: agcmm�t
District)
F2
Ib.vc recad'he h 'I `I , L' d CMI rou I'thcfth
homi g he,&1f YCod S I :25505255Jt J2553d.1 d t Jabal Tobe
build 61 nlyl t I than it: my :q b'I'gt unity the occupant
of me tela e ' ,
with most the me pmor m i..rana ofs most In o cycy.
EXHAUST HOOD(W/DUCT')
I IOUSINGMITIGATIONFEE
HEATING 11NIT(TO lll,lHID Is'TG)
IIHATING UNIT (OVER 100,0y) B9i])
PAID
VENT I LAI ION EAN(SINGLE REST D)
Doe Recoipt N
11OILIiR-COMP (311P OR T00,0008 'lV)
T) L'.
BOTER- COMP(OVER M.0n)13'1 U)
AIRCONDI'TIONER
ISSUANCED E
!s
ISSUED BY:
NIiW RI;MDEM'IAi,MF;CII. SQ PC
Owner nr zmhoneed agent I la¢
TOTAL
OFFICE