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CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT rLumxwG-ml=.cxnrvlcnl.
ItUILDIUMBING-M CHANIFICATION
PERMIT NO.
RUll,ING ADDRESS:
Z52-5-25-7ONE
SANITARY NO,
APPLICATION SUBMITTAL DATE
�C0NfR0
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A\ R'S NAME: / 3 LICNO:
NIC
❑
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ARCHITECT/ENGINEER: L'ICNO:
p�
ADIIREoSS�30 C2�r N,tL T� C,
CONTACT PHONE: -
D (Z 0 / j�+ ^�
[:]Consultant FCCS Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG 13LECT PLDMR MECII
El 0
QTY ELECTRIC PERMIT FEE
_.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
liness ard f scudo, andn+ylicnmsels
of the
Dusid
with Soadcm IDlloLdtr`2Arm JH
in full force and effec S' ! [+-
JOB DESCRIPTION
Kybm
11SFDW NTIAL:
❑SPDWL El KITCHEN REMODEL.
err-
PF.RMI'f ISSUANCE / J O
APPLIANCES - RESIDENTIAL.
License Class Lie # e --k0
Dale Cnnw
❑ADDITION [I PLUMBING RE -PIPE
❑MI11,T1-UNIT [I STRUCTURAL
MODIFICATION
❑INTERIOR ❑ Cl HNINEY REPAIR
IMPROVEMENT C]SWIMMING POOLS
CL ION
TELTIS DF,CLAR
I urdemand my plans shall he used es public records
PANCLg � -
UP'1'0200AMPS
I LicensW Professional
201-1000AMPS
OWNERBUILDERDECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for that
m following reason. (Section ]031.5, Business mp Professions Code: Any city ao cnowo
which s permit construe, apes improve, demolish, ore any strdure
❑ BATH REMODhLIRPRAIIi El DEMOLITION
OTIILR-
OVER I000AMPS
SIGNS F.LECIRICAL
a sig
prinnnims issuance. also acquires the applicant for each pem+iuo filcusigneJ statement
itsiso n a
SPECIAL CIRCUIT/MISC.
bQ'rrr
I hal he is licensed pmsuam m the pI....i na of the CI hurcuaI License Law (Chapter 9
9/-q-\Jr/♦US'
(commencing with Section70of, of Division J of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects (be applicant seivilpenahyof
TEMP. MET ER OR POLEINST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
El TENANT ❑ FOOD SERVICE
POWER DEVICES
not more than rive hundred dollars Dfult .
I, us owner til the propeny, nr my employees with wages us their sole compcnsution,
will do due work, and the structure is not intended wondered for sale (Sec. 70crl. Business
and Professions Code: The Contractors License Law does not apply to an owner of
IMPROVEMENT
❑ O'fIIER
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - RXTURES
NEW RES IDENI IAL ELEC'IA SQ tri'.
• propeny, who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not Intended or offered for
sale. If, the building or improvement is sold within one year of completion the
Low
owns-builder will have the burden of reason, that he did not build or improve for par -
SQ. ET. FLOOR AREA
95Q. FT.
pose of
❑ L az owner of he property, um axcluMsti, contracting with licensed rommotom tea
QTY.P BING PERMIT FEE
construct the pmject (Sec. 7004. Business and Professions Code:) The Commences Li-
mas Law data mol apply Io an owner of propeny who builds or improves thereon, and
who emarooz for such projects with a emmuctads) licensed Panama m the Commaoes
'PERMIT ISSUAN
License Law.
1 um exempt under Sec. . B & P C for this reason
ALTER - DRAIN&VG ATER EEA)
VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION
BACK PLOW PROTECT DEVICE
1 hereby all inn under penalty ate lof Con one of the follow, LelarroWorkers
DNAINS- FLOOR. NODE AREA, COND.
STORIE-S
TYPE CONSTRUCTION
Ca
those and will maimainx Certificate of Consent mzdhinsure for Workers Campeau.
ration, es prvidhi for Section 3]00 of the Inbar C,de, for the perfnrmunce of the
work for which this permit is issued.
FIXTURES -PER TRAP
❑ 1 have and will rote, far he para s Carse of me w rkfirr m, as ns per by Section
P(Xl of the Laba Crede, for the perfwirnance of the work lar which this permit is issued,
GAS -L'A. SYSTEM -1 INCA 0f1TLET5
OCC.GROUP
APN
My Worker's Compensation Insurance carrier and Policy number am:
Carrico Policy No.:
GAS -EA. SYSTEM -OVER 4 (EA)
GREAS 171 N DOS'IIII. WASTE IN'fERCEPIUR
CERTIFICA]'E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(This section need not be, completed if the permit is for one hundred dollars (&1 fir)
unless.)
GREASETRAP
PLANCHECK FEE
SEWI?R- SANITARY -STORM PA. 2fgl tori.
ENERGY FEE
certify Than in the performance of The work for which this permit is issued, I shall
and employ any person m tiny reamer e<myv-v(Ig�o7e6ubia?io the Workers Counce-
WATER HEATER W/VENT/ELECTR
GRADING FF.F.
colon laws afl?elih+mi#. lav¢ / Z f
1 Applicant //��✓f
j NOTICE TD APPLICANT: IL after making this Certificate of Exemption, you should
I become subject to the Wnrker'a Compensation provisions of the Lubar Code, you n u,c
WAI IN SYSTENIO BEATING
SOILS Il ?E
fonhwith comply with such provisions or this permit shut[ be deemed revoked.
WATER SERVICE
- CONSTRUCTION LENDING AGENCY
mebynrm that them is o coniruction lendingngency for the performunm oil
I I hffi
NEW RESIDENTIAL FILMS . SQ. Fri.
PND
Dam Reccipm#
TOTAL:
{ the work far Is this pcnui, is issued (Sec. 3097. Civ. CJ
Lender's Name
TOfAI.:
Address
Lenders
is
BUILDING FEE
1 ceni(y that l have read this application and state that the above imformnhon
and creta lewxr cram to
1 corrccn.lagrm mtcntupld withynothoW representatives
building ronoroeiun, and heathy authorize repreumatives of this city to emeruµothe
- .
QTY' MECHANIGAI. PARMIT' FEB
SEISMIC FEB
PERMIT' ISSUANCE
1RTCI'RI
above-mentioned property for inspection purposes.
(We) agree to save, forwardly and keep harmless the cry of Cupertino against
ALTER OR ADD 10 MECIL
PLUMBING 'EE
1'mhilities,jud,ments,costs and expenses wbidt may irnmy wayvamo against suit] City
this per mit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
A PUCAence of the UNDERSTANDS
AIR HANDLING UNIT (TO 10.(Rp CFAO
MIiC11ANICn J31i
SOLmvrn vLGULATIONS.
AIR HANDLING UNIT (OVER000 CPM)
CONS '1'RI1CT N'TAX
�}'y�fnf%-•--�-� S'/26�AG
T
/
/
Situation, offAAppliierruCourancr Dute
EXHAUST HOLD(WNUCq
HOUSING MRI 'ATION FEE
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building oecupanm store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
Code, Section 25532(a)"
HEATING UNIT (OVER 100.00) BTU)
VENTILATION PAN (SINGLE RESID)
❑Yes ON.
PAID
Date Bete' I#
Will the applicant or future building Occup tin rose equipmmd or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
BOILER 100.000 BTU)
: O
BOILER - COME (OVER IIXLgNfBTU)
District?
❑Yes ❑No
AIR CONDITIONHR
I have read the roommates materials requirements under Chapter 6.95 of the Cali-
fools Health & Safety Cade. Sections 25505. 25533 and 8534.1 understand mho if the
ISSUANCE DATE /yJ
S 2-6`
NEW RESIDENTIAL. MECIL SQ. FC
es not curntly ha atenam,throuisary responsibilirymmnifythcsccupow
building dore
eM [O���P y.
f a- i me .hich . I Iso mo prong issuanceofa !MM
ISSUED BY:
TOTAL:
C rr�im�r or umhori aBe / �—
OFFICE