S 0481 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIIILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT TING PROG-MBDHANIDAI. S O /) Q 1
tlU1LDINC.PROJECI'IDF.N'1'IFICATION v �r V
BUILDINGADDRFSS: - SANITARY NO. APPLICATION SIIBMITLIJ.DATE
OWNS NAME: PHONE. COMRAC I'OR'S NAM is LIC N(T,
7W1
/
NIC CONT411Lp
G R1. ild ❑
�.AR fI1TEC9'/IiNGINEER: ' LIU NO: ADDRESS: 1
1
CONTAC. PHONE: BIJILDINC PhRMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG , ECT PLUMB Mea
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT •FEE
I hereby different that 1 am licensed under provision,of chapter 9 honsencing 1 I JOB DESCRIPTION
with Second 70(XE of Division 3 oflhe liusinccs uW Profil000ns Cudc,and my license is RESIDENTIAL
'
U10p PF.ItMI'I'ISSUANCI3
ELLE, ora full force and gffjc}/y Al �n Kii� e� y ❑SFDWL ❑KITCHEN REMODEL
�UU Date eC _Y— C• LU Carl JY�—J APPLIANCES-RESIDENTIAL []ADDITION [-1 PLUMBING RH-PIPE
Q a Date Cnntmctor Cn.a
R HIT CT'S DECLARATION ❑MULTI-UNIT El STRUCTURAL
Z~O y Z I undentund my plan.shall be a.ed as public records PANELS MODIFICATION
.L2—0 UP TONYEAMPS ❑INTERIOR [I CHIMNEY REPAIR
1-�L'f"Y] Liecnsad Professional 201-1010AMPS IMPROVEMFNT' F]SWIMMING POOLS
k P; OWNER-BUILDFR DECLARATIONOVER 1000 AMPS ElPATHREM ��L/R Ilt El UIiM ION
et 6'a I barony affmm Thal I nm excerpt loom the Counters's License Law roti the
U following reason.(Section 00315.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 LL F' which requires u permit to cnnstmch alter,improve,demolish,nr rsyair any stmc,.m
0
prior to its issuance.also utilities The applicant for such permit to Bic a signed statement SPECIAL CIRCUI'TMISC.
C Y that he is lloonsml pumnrnno l he provisions of the Com octets license Law Chapter
. df (mmmraining with Section 700(1 of Division Sof the lhoinscss and 11easioas Crld)a, TEM P METER OR POLE INS'C COMMERCIAL.
ti 60 ,bar he is exempt therefrom nod the basis for the allegel exemption.Any violation of ❑NIiW BLDG/ADDITION DEMOLITION
x Section 7031.5 by any applicant for a permit subject.the applicant to u civil Penalty of POWER DEVICES
ly�y ❑TENANT ❑FOOD SERVICE
H Y mmbrc thou Eve hundred Jollem 15500' IMPROVEMENT
d ❑ Luahwneroftep a drucarmyot intended witbwugosas (Set.remissrust..., SWIMMING POOL ELECT'RIC
� will An the wnrA,onJ theswcunre is not inondcdnrnOercJ lawsuit,(Sec.)041.1{usiness ❑O'1'l1ER
and Profession.Code:The Cnntmctor's License Law does not apply to an owner of OUTLETS-SWITCfIFS-FIXTURES
L 3..
property who muds or improves thereon,add who does such end himself or Through
bis own employees,provided th:d such improvements ore nal intended or olliroi for N5W Ii IiSIDENTIAL F,LEC'I R
.ule.lf;however,thebuilding or improvement is sold within one'emorearm miom,the SQ.Fr.FLOOR AREA Vs Q.Fr..
owner-builder will have the burden of proving that he did not build or improve lir,per- PAID D
pass nLsale), W
❑ I,as owner of the property,am exclusively contracting with licensed contructnes In TOTAL:
maruet the project(See,]MY,Business and Professions Code:)'fno Codtoctels I..- OCT
use law does not apply to an owner ofpollwho builds or roundlet,thereon,and QTY. PLUMBING PERMIT' �� FEE 28 Dfpry�
who contracts for such promrf
projects with a comracs)licensed personal o 4 o the Contrac
's REGI
License Law.
❑ Int,exempt under Sec. .B&P C for PLRMII'ISSUANCIi this reason CITY C,JI- Ver
Owner Dam ALTER-DRAIN&VENT-WATER(EA) VA !U!AIOTK N
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE q
I hereby afford under couhy of perjury oda of the following dedamtimsv: F; G'Cr QQ
�❑ I have and will maintain a Cenificateof C'ousenno wiNdmm for Worker's Cnmpen DRAINS-FLOOR.ROOF.AREA.COND. STORIES TYPE.CONSTRUCT ION
satins,as provided far by Section 3701 of the Labor Ede,for the Performance of the
work far which this permit is issued. FIXTURES-PER TRAP
��1 have and will maintain Worker's Compensation Insurance,asrcquirui by Section
eJ]011 of the Labor Code,(I,,the perfarnwnecofthe work l'o,which this pemJl is Issued. GAS-IiA.SYSTEM-1 INC.A OUTLETS OCC.GROUP APN
My Worke, C m nsatiotylnsumncecauierand Policynum1 ro
Comer.be A.
Policy No:
W GAS-IiA.SYSTIiM OV[RYII'v1)
CL'RTIFICATIi •EXEhIPI'LON FROM WORKERS'
COMPENSATION INSURANCE GREASE)INDUST'RI.WASTE NIT H:RCEPIUIi
BUILDING DIVISION FEES
(This section need am be comp Wed if the permit is femme hundred dollars(SIM)
GREAS
orless.) ETRAP
PLANCHECK FEE
I certify That in the performance addle work fnrwhich thl.pennilisissucJ.l shall SEWER-SANITARY-S'FORM BA.21X11,K
nal employ any person in any rearm so an m came besubject to the Workers'Cooper-
ENERGY FEE
O Z .Nation Laws of California.Dune WATER HEATER W/VENT/ELEC7fR
Z Q Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making this Cenifieem of Exemption,you should WATER SYSTEMITItEATING
I• become subject to the Worker.Compensation provisions of the Labor Code,you unit I SOILS FER
dmhwiE oca ly with such proviumv,or thit,pundit shut be demncsl revoked, WATER SERVICE
� ZCONSTRUCTION LENDING AGENCY NEW RP_SIDF.NI'LALPLFIO. SQ.FT. PAID
V Q k for.1i'li rat that iso ted(Sce.30 lending agency for performance of Doc RuciplY
� theworkfor which This permit isolated(See.9fE9J;Civ.C) T
F Lender's Name TOTAL:
W Lender's A verify
t '1(YfAI-
:
I certify thus 1 have teal this application and.are that the elxsve intonation is BUILDING LLE
VV)i cal Iagree to comply with all city and county...E lcesandsmTnlrwsrdatingto Q'py, I MECHANICAL PERMIT FEE
U ,Z building conswclion.and hereby authorirt representatives dflhis city renter upon the SEISMIC FEE
aese-dommuld property for inspection pardoes. / PERMIT ISSUANCE
(We)agree o save,indemnify and keep hmmless The City of Cupertino against ELECTRIC FEE
hard Riess judgments,costsand e......hich may in any way accme ageinsLstill City ALTER OR ADD TO M ECH.
in consequence of The granting of this permit. PLUMBING FEE `
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00)CFM) MECHANICALFEF
SOURCE REGULATIONS.
AIR HANDLING UNIT]'(OVER 10,000 CFM) CONS]RUCTION'I'AX
Signature of ApplicunUContmnnr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardousnntcrial sZ BEAT]NG UNIT(TO 100,00 BTU)
,is difficult by the Capcoad Municipal Code.Chapter 9.12,and the I@rlth and Solely
Code,Section 25532(a)F HEATI NO UNIT(OV ER I00'sm if TO)
E]Yet ❑No PAID
VENTILATION FAN(SINGLE:RILSID) Date Rccrgna
W,II the air comm n on.,a building occupant use equipment m devices cluentell BOILER-COMP 13HI'OR 101,10x1 BTU)
emit b:¢nudons air nmmminnnu as defined by the Bay Arco Air Quality Manngen°Belt TOTAL:
District! BOILER-COMP(OVER 101,00E BTU)
G Yes El No
Iheve mud the bazardnun mrtcriulerc to under Che our L.95 oflhe Cali- ALR C(1NDITIONI3H - ISSUANCE DATE
wremen
bound Health&Safety CWe,Suctions 25505,25533 and 25531,I understand that if the NEW RESIDENTIAL.MI CH. SQ.FT.
building ares not currently have It sort then it is my responsibility to notify the ocsupam
of The reimbursed,which run be met prior to i...all it Cooperate of Ocrapadcy.
t/(l.rr.rd AAw�W«wi Pw 1 -
Ow�bcr'rauthnrirsJtlgent 'I'OTAG ISSUED BY.
OFFICE