S 2089APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECIRICAL FEly91'1'No. /�OHV/�'.�]
BUILDING DIVISION APPLICATIONA'ERMIT PLUMRING.ME.CHANICAI, t\7 L
OWNERS NAME:
Z
I hereby affirm that I sen licensed under prevision%of Chapter v oc menially
OZO with ticminn]0Xll of Uivisinn Jof the Husinmsand lkofes%ianz Cwle. and mylicense is
WF in fwnnme and effect.
Ur. License Cla%a I.ic.#
F
C
d
NO:
,x.a D
❑ Consultant Fees Paid by Applicant (Initial)
0TY1 ELECTRIC PERMIT I F1917
I I PERMIT ISSUANCE I I
ABUSES 'SIT C'I"S DECLARAHON
I undcrnl;mA my plans sbull he u%al nx punto% recanH
I.icenecd Vint ... ional
OWNER-ERALDER DECIARAI ION
I hereby alum that 1 ant exempt from the Contractor's License I.aw lit the
fallowing reason. (Section 7031.5. Business and Professions Cole: Any city or county
which requires a permit to construct, altar, improve, demolish. o repair any structure
prior at in issuance, also require.%Ihe applicant tar such Sent file a signed stmemetn
that he is licensed Pursuant to the prnvisinnx of the, Contractors License Law (Chapter 9
Ica ing with Seefin. 70a))afDiciguo 3o fine ly,me%%and Profe%: mCutet or
semen%
that
Sec he is 31.5 b zany applicant
p li and the hn%ia far the alleged exemption. Any Violation of
Section7031.5by anydreddnnfor apermh gWjen,the npplicam toocivil penalty of
not more v rte five a property
r pe dulb.r..I coop!
❑ I, ref the pmpcnr.a ury of infyec with wugesm a.( Sc. ule mnmemne,
will Jnd work. and the le C1 are Corlsnn'sLndnl nr ave dood l not
no in own
nal prof c s Code The oyes I oco land w Luo sac, n apply Inn vgh
his ol
o ny who ou0dv or improves thereon, wW who....•%such wnrk himself or through
his awn employees. e provided Inas web iter, is of nw arc not i car
rof or pfmrcd lm
cavi. ILhowo'withebuilding arintprmvcment issoldwithinone yearofm rove for he
a er-M1uilJcr will have the harden of proving that he did not !wild or improve for pur-
pose of role.).
❑ 1, u. ins ma of the pripert, am exclusively cammNng with licensed mnmacntrs w
amwet the project (See. ]UW, Business and Profession Com:) The Contractor's Li -
sense Law docs not apply to an owner of mopeny who builds or imps es thereon, and QTY.
who so act, for such project, with a cn mactngsl l icensed purmact to the Cantraiars
Licence law.
❑ 1 am eg, So ander Sec. . If N V C fur Ilii, re;man
Owner Dam
WORKER'S COMI'17.NSAOON DECLARATION
I hereby affirm under penally of p:rjuty, one of the following declaration,,
E] Ihave and will nmimain a Certificate of Consent n self -insure for Workeh Conq,em
,,wool, as provided hr by Section 3700 of the Ugair Code, ho he perfommnee of the
work for which this permit is issued.
I have and will maintain Worker% Compensation Insurance. To, required by Section
3700 of the Labor Cure, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance curler and Policy number arc:
Caricl:�ptlicyym d/.ted ECo 1'19
CE 119Gt1EOFF LNIVEIONIBOMWORKI!RS'
CUMPENSATIONINSURANCE
('Ilii%sn'tion need nal M1e cnrnplcmJ it the Per nil ig for enc hmtdred dollars ($ IIX1)
or lcv,00
) certify he, in the any i nnanca of the work Gtr which lits theroid, ers Co.l fer-
tart
nm employ any parv,n in any manner wa as to bunrnc subject to the Workers Cnrnpcn-
,mion laws of Cuhfomia. Date
Applicant
NOTICIT'ID APPLICANT: II aver ranking this Certificate of Exemption. you gonad
Mconm subject Ise he Workers% Compcnvtion provisions of he Labor Code. You na%I
forthwith comply with such provisions or this petnil shall be deemed rooked.
CONSTRUC`HON LENDING AGENCY
1 hereby:dfirm that there is a emnwcri es leading agency fm the lterfmm:mae of
he work for which his pcomil is I,,act (Soo. 3097. Cie C.)
Caroler, Name
Linda's AJdre„
1 cenHy that 1 have reed thin ap,,f,mian and %tare he, he above iofoun elon is
ren. 1 agree at enam, with all pity and county mrdm:mee, and swat Inws algin, to
building comtmvalon, and hereby aahnriee octaro native%nrmis city minter upon the
above-mentioned prupeny for inspection purryne,.
(0.'c) agree to save, indemnify and keep haul the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in conuyuence of Ibe granting of mi%Permit.
APPIJCAN'IUNDERSTANDS AND WILT, COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Slgnaturc of Appfcant/Cnmrannr Date
HAZARDOUS MAE FRIM S DISCLOSURE
W01 the r"heanl nr!venue huddiog aeCupml store or handle haeardnu%ntmoriul
u, defined by the Cup,mma Mmticipal Cole, Chapter, 0.12, and the Health ;old Safety
Code, Section 25532(,)?
CYes 0 N
Will the applicant or future building vocalism use eq 'I
nr device, which
,elnit haeardnu% air comaoinanu as defeed by he Bay Arta Air Quality Mgngermcnt
Db11110
❑Yc% El No
I have real the haeardnm mneri:J, regnnclacc s under Chapter 6,95 To the Culi-
immin uenln, � carat axle. senimt, zssus, 2x533 ;sed zss3y. 1 andacwml m;rt it Ine
hniJirag Ansa not alMyOy havca Icn:un, Pew t ix toy mepunihiiry et amity Ihcmiarpmn
APPLIANCES - RES I DEN 'I'I AL
PANELS
UPTO 200 AMPS
IDI-HXXIAMPS
SIGNS FLI CI'RICAI.
SPECIAL CIRCUITIMISC.
TEMP. METITR R 1`01-H INST.
POWER DEVICES
SWIMMING INl(11. 17.I.ECI'RIC
OUTLETS -SWI I CUES - FIX 'I'UIt ES
NEW RESIDENTIAL ITI,ECTR SQ IT.
PLUMBING PERMIT
PERMIT ISSUANCE:
AL11:14 - DRAIN k VENT- WATER (EA)
BACK FLOW PROEEC'K DEVICE
DRAINS - FLOOR. ROOF, AREA. COND,
FIXTURES - PER 'I'RA['
GAS - EA. SYST EM -I INC. q OUTLETS
GAS - EA. SYS'I HM -OVER q (EA)
GREASEINDU S'I I. WAS 11: IMFERC121TOR
GRLASITTRAP
SF.W ER - SANITARY - S'I ORM EA. 21X1 FI.
WATER HHA'I ITR W/VENTRiI.ECIR
WATER SYSTEM/I'RHAT ING
WATER SERVICE
REW RIISIDENTIAI. Phbt11. SQ. FI'.
T(yl'AL
QTY. MECI IANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECI.
AIR HANDLING UNIT(TO I0,000CPM)
AIR HANDLING UNIT (OVER PLIXp CFM)
EXHAUST HOOD (W/DUCT)
HEATING ONIT (I() EX),Bdo RTU)
HEATING LIN III (OVER 100,000 BTU)
VENTILATION INN (SINGLE BESIDE
BOILER -CORN' DEEP OR 100.000 BTU)
BOILER - COMP(OVER HXk(X)113 SO)
AIR CONDI'DUNER
NI7W RESIDENT EAI, MECH. SQ�E9'.
OFFI
LTJ
PERMIT INFO
P�B
JOB DESCRIPTION
RESIDENTIAL:
❑ SIT DWI,
❑ KITCHEN REMODEL
❑ADDITION
❑ PLUMBING RE -PIPE
0MULTbUNI'1'
❑STRUCTURAL
MODIFICATION
(_1 INTERIOR
❑CHIMNEY REPAIR
IMPROVI.MI:N"1'
SWIMMING POOLS
❑ BATH REMODEUREPAIR
El DEMOLITION
❑ OTHER
4/ _
COMMERCIAL:
❑ NEW BLDG/ADDITION
❑ DEMOLITION
El TENANT
❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. PP. FLOOR AREA
BUILDING DIVISION FRES
PLANCHECK TH
ENERGY 11:17
GRADING ITIT
SOILS FEF: t
PAID
Dae ece, a
ro'rAl,:
BUILDING 1T "
FEE SEISMIC FEE
C
ELECTRIC) i
PLUMBING PE
MECHANICAL ITIT
CONSTRUCI'[ON 'SAN
HOUSING ME I'IGNI]ON Il?E
PAID
Date Receipt a
T
ISSUANCE DATE.
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1"SUEDi 0Y: