B 0314A
As ICGNTTn FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMI'FNO /4
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BUILDING ADDRESS:
.;1850 Fe_rnqmdo FW29�
SANITARY NO.
APPLICATION SUBMITTAL DAT If
OWNJ}N-JJEO � I03
C N'NACTCJOS SN ML14 It
O. 721167
N/C
❑
CONTROL #i
RCHITECTIENGINF.ER: LIC NO:_ /��
A DRESS: „ l
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CONTACT. PHONEZ
H1111.DING PERMIT INFO
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❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT- PLUMB MECH
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lj �i �l —J
❑ ❑ 8� ❑
LICENSED CONTRACT OR'S DECLARATION
mfin 1 am licensed under provision of Chapter 9 (atmtmencing
I hereby am th
QTY ELECTRIC PERMIT FEE
_
JOB DESCRIPTION
PERMIT ISSUANCE
iso Section9000)of Division3ofthe Business anJ l'mfessions C.de nd my limns is
in full force and of rct.
R�SIDF.NTIALL
CSFDWL C KITCHEN REMODEL
APPLIANCES - RESIDENTIAL.
License Clues _ Lic.#
Dutc Connac_ —
❑ADDITION [I PLUMBING RE.PIPE
CMULTI-UNIT []STRUCTURAL
MODIFICATION
Ll INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIh1MING POOLS
CHITECTSDECLARAT IA
[understand y plans shall be used as public records
PANELS
UP TO 2001 AMPS
Licensed Pmfessioml
201-1000AMPS
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contrarinea Liecmw Low for me
t following reason. (Section 703 1.5, Business and Professions Gale: Any city or county
C BATI I REMODIi1JREl'All DF.MOLH [ON
❑ OTHER
OVER I"AMPS
SIGNS ELECTRICAL
which require a permit to eondmm, site , imprm e, derefid, m repair any swemre
SPECIAL CIRCUIT/M ISC
prior to its issuance, also requires the applicant for such Permit m file a signed statement
that be is licensed pursuant to the provisions of the Contractors License law (Chapter 9
(commencing with Section 900t1) of Division 3 of the Business and Profeisions Code)Or
TEMP. METER OR POLE INST.
COMMERCIAL:
mm he is exempt thertfmm and the M1asis for the allegaf exemption. Any violation of
C NEW BLOGIADDITION C DEMOLITION
Section 7031.5 by any applicant for a permit subjects the appirmu m u civil penalty of
not more than five hundred dour rx ($500).
C Lina owner nl the progeny, or my employees with wages os their sole drmpensmion,
t will do the work, and she%wcture is not intended oroffered for sic (Sec. 91144, Business
POWER DEVICES
C'FENANT CTOOD SERVICE
IMPROVEMENT
El OTHER
SWIMMING POOL ELECTRIC
and Professions Core: The Contractor's License Low does not apply to an owner of
OUTLETS -SWITCHES - FIXTURE
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such hnpmvdnems are out intended or effemd for
sale. ILb.cvcq the building or improvement is.nld wiminone yrural rnmPletion,me
NEW RESIDENTIAL ELEC'I'R SQ BT
SQ. 171 FLOOR AREA
1/SQ. LT.
towner-0uilder will kava the burden of proving that he did not build or improve for pury
pace of sale).
C I, as .,our of the propeny, an, exclusively Co..ducting with liccmcd cmm'neam ,
TOTAL:
amsuucf the p Ice'[ Xce. 90M4, Itmjnes, and 11 firsouns Cote:) The Cnnmomuds Li.
naeLaw does not apply to an owne,of nropmy who, huilda or improve, mere.,.., and
QTY.' PLUMBING PERMIT FEE
-
who coalmd, furxueh process wish connndo,10 licensed Tomo ,oche Cnnmre.....
Lfcensc law.
PERMIT ISSUANCE
C I son exempt under Sec. . It Ai P C lire this re;
ALrER-TRAIN Ao VENIT-WATER (EA)
Owner D
VALEATION
IO
WORKER'S COM Pl ne,itryoft DECLARATION ItATI(1N
BACK FLOW 1'ROTELT. DEVICE
1 hereby ill under of enc of the fnllnw lay dcalurationu
nit cetion ica¢ef Consent m.celde,Fnrc lin Workers Cnmpen-
mai Certificate of Con
i]Ie, as and for
sation, as provided for by Semina ]]TNI of the lathar Cade, For she fnrlinm:mcc at the
DRAINS - FLOOR, ROOF, ARCA, COND.
1'I(lRIB3
'1'YI'E C(1N5'I'ItUC'I'ION
work for which this Permit is i
FIXTURES - PER TRAP
ork r' as required by Section
C 1 have and will eat fon Worker's Ca , I the w rk tar which
3]W n(me Labor Code, for the perfnmmnc Ithc workad Yf+oar{tw�hfich this p9em/nit is issueA.
My Wo r' tmti 1 Y^Focgrr Policy No.'�L!j(`L
Came lfG W
OCC GROUP
AVN
CAS - EA. SYSTEM. INC. 4OUTLETS
CAS -BA. SYSTP,M-OVRR4(BA)
GREASIDINDUSTRI. WASTE INTERCEPTOR
CF.RTIFICATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(Thissectionneed nm be cvanpletcd if the permit it future hundred dollar.(511X))
or less.)
GREASE TRAP
PLANCHECK FEE
I certify that in the performisme oft he work for which this permit is mind, l shall
not employ any person in any mmnner so as m becmne subject m the Workers Cnmpen-
SEWER -SANITARY -STORM EA. 200 FT
ENERGY FEE
WATER HEATER W/VENTIF.LF.CTR r�
r V
sation Laws of California. Date
Applicant )
GRADING FEE
NOTICE TO APPLICANT: IL sties making this Ce"mccreOf Exemption, no should
emian provisions of the Labor Cale, ynu must
Cepm
hecoe,object m the Workers m
m
WATER SYSTEMOREATING
SOILS FEE
WAT17R SERVICE
forthwith comply with such Pmvi.sions or this Penni[ shall lc deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby allinn that here is a construction lending agency for the peremincemf
NEW RESIDENTIAL ELMS. SQ. FL
PAID
Date Receipt#
the work fur which this parent is issued (Sec. 3097, Civ. C.)
Lender's Name
TOTAL:
L' t
L.erders Address
information is
BUILDING FEE
L eenify that I have read this application and state that the above
.red. l agree to Comply With all city and county ordinances and sate laws mumingm
building reastmction, and hereby umhodu mpresertmives of this city m enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE.
ELECTRIC
emed propeny for inspection purposes.
aMve-mion
(We) agree m save, indemnify and keep harmless me City of Cupertino against
ALTER OR ADD TO MECH.
PLUMBING FEE
liabilities,judgments. costs and expenses which may in any way acerae against said City
in cart cifuenee of the gmming of this permft.
AIR DANDLING, UNIT (TO I(MV) CFMI)
MECHANICAL, iE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH At.]. NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER infant CFM)
CONSTIIUCI'ION NX
Signature of ApplicanisContracmr Date
HAZARDOUS MATERIALS DISCLOSURE.
EXHAUST HOOD(W/DUCT)
HOUSING MITLGATI IEE
I]HATING UNIT (TO I(ML(M it BTU)
Will the mphestat or future building occupant store or handle haeaNnus matarfal
as defined by the CuEemm, Municipal Code. Chapter 9.12, and the Ilnthh all Safety
Code, See ti m 255320)]HEATING
UNIT (OVER 100,000 BTU)
V13NTICATION PAN (SINGLE RESID)
[:1Yes mrd°PAID
-
])at, Receipt at
BOILER - COMP (311P OR 1 W,B00 BTU)
Will the applicant or future building occupant use ximmarm is,devices which
tis hamrdous air contaminants as defined by she Buy Area Air Quality Management
'f0'fN.:
BOILER - COMP (OVER 100,000 BTU)
Istria!
Yet /No
I have read the haze tlnaa mafcriul.rrquirrownfs, it, Chapter 6 95o @e Gdi-
fnmia If , iidaty C'd , Sctlinns 2.5511.5, 2,5591 nnJ 25534. 1 undaamnd that If the
buildingtmpf all i en lcncit,has it is my re,eauhllity o ulyfI uc Ieni
AIR CONDITIONER
ISSUAN Ar11
-( /
NEW RESIDENT Al.TMECH. SQ. ET.
ofshorcQQQQQQuir `` ttss ha rocs prix mieaunncc nfn Cr" meof0
tif
ISSUBD BY: p
TOTAL:
Owen, woo 1311. ... Doc
OFFICE