S 0736 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUnaHNG-ELECTRICAL PF IT No,
BIALDINC DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 0736
BUILDING PROJECT IDENTIFICATION
UILUING ADORES$: n SANITARYNO. APPLICATION SUBMITTAL DA'Z'E
- OSL Z Loma e7. -4 i� /
PHONE: ON IRACOR'S NA"' LIC N(3; NIC CONTROLp
ARCHITECT/ GINEER: LIC NO: DRE&&j ear ` j)y
CONTACT: PHONE: .- 9-F-1 1G• BUILDING PER MIT INFO
❑ Consultant Fees Paid by Applicant(Initial) x G F.LEC'1' PLUMB MEECrH
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT Ffa: IdLQI` JLI� IL]I
I hereby affirm that I am Iicemw under provisions of Chapter 9 mnmtmenoing ]OB DESCRIPTION
{D{yygeZ with Section Division Sof the Businessand Pmfensions Cole.andmylicemse is RESIDENTIAL
FSB in full force and PERMIT ISSUANCE ❑SPDWI. CHF;N REMODEL
�Z{01� License Chis a ' APPLIANCES—RESIDENTIAL ❑ADDITION OPLUMHING RE-PIPE
�<� Doe ContraDELL
p.Osn ARhallk eDECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O�Z I understand my plans shall he used as public records MODIFICATION
O Z UP TO 2(X1 AMPS
❑INTIiRIOR El CHIMNEY REPAIR
FWef-
-U4 Licensed Professional 201-1000AMPS IMPROVEMENT
Q�ds j OWNER-BUILDER DECLARATION C]SWIMMING POOLS
fE W Q I hereby affirm that 1 ten exempt from the Contractors License Low for the OVER 1000AMPS El BATH REMODEL/RI!PAIR DEMOLITION
06F. milowingreason,(Section]03 L5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
F ya which requites a permit m contact,alms improve,demolish,or repair any sm come
y.] prior In its trio.ace,afso realities the applicant Itamth penninm file.signed statement SPECIAL CIRCUIT/MISC.
�} that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
IYpO (commencing with Section]n0a)of Division 3nfthe Bnuressand Professions Curcio, TEMP.METER OR POLEINST.
a that he is exempt therefrom and the hasis for thea allege]exemption Any violation of -DG/AD ITION ❑DEMOLITION
Section]03L5 hyany applicant for.pmmi mb,cetstheapplicmd,o.civil penaltyof I'OWF!N DEVICE-
but
I ..y TE ❑FOODSERVICE
t more than five hundred dollars($5W). It
Po
SPR
p ❑1,es owner of the propcny.or my employees with wages as their sole compensation, SWIMMING POOL F.LECIRIC
will do the work,and the sam etre is not intended mroffered forsale(Sec.7044,Ruxiness [3OTHER
and Professions Code.The Commens's License Law does not apply to an owner of L0
OUTLETS—SWI TCHES—VENTURES
.. progeny who builds or improves thenar,snit who does such work himself or through
hon own employees,provided that such improvements arc not intended or offered fort NEW RESIDENTIAL ELECfR SQ IT.
sole.IL however the building or improvement is sold within one year of completion,the SQ.FT.FLUOR AREA $/SQ.PI'.
owner-builder will have the burden of proving that he did not(wild or improve for pun
pose of sale.).
1]1,as owner of the property,am exclusively contracting with licensed contmaon to TOTAL:
comtruct the project(Sce.]BM,Business and Professions Cureq'Ibe Convectors Li- A ! D
cense Law does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who cnnmmts fim,arh project with a emantra tO foamed pusmannn the Commmot's
01mc cleo PERMIT ISSUANCE. DEC 1 5
Iamcxcmpt unJcr&m ,R&PCfonhismeson RWI
ALTER—DRAIN&VENT—WA'I'ER(EiGys'Iv, 1r l VALUATION
C
Owner Date 1 V ^,�
ddhLL WORKERS COMP12NSATION DECLARATION BACK FLAW PR�TTECT,DEVICE C�1'i
I hereby affirm under penalty of perjury one of the following declarations:
'l have and will maintain a Certificate of Cars.,I.,clf-i nsure far Worker's Co.,.. DRAINS—FLOOR,ROOK AREA.COND.
tion,as provided for by Section 3700 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES—PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,us acquired by Section
3700of the Lose,Code.for the performance of the work far which this permit is issued. GAS—EA.SYSTEM-1 INC.4 OUT LETS OCC.GROUP APN
My Work rs pc tin c unsound Policy yn
Currier: 4 2 � Policy Na:.j"1;� OAS—EA.SYSTFM-0VHR4(EA)
CMTIFICATE OF EXEMPTION FROM WORKER
COMPENSATION INSURANCE. GREASrANOUSTRL WASTE INTIENCEPTOR RUILDING nMS10N PEES
(This.section..it not he completed if the permit is Intone hundred dollars($100) GREASEMAP
or less.) PIANCHI!CK PEE
I cenifymat man,perfanrmneeof the work for whichlhis permit is issued,[shall SEWER—SANITARY—STORM EA.200 PT.
not employ any person in any man a -n t =nme"'N I to the Wmkers'Compete ENERGY ITE
Applies.
Laws of C.Idon ia.❑ntc
Z O Applicant �a�F./',t KA 1 L WATER HEATER W/VENT/[LECTR GRADING imin
y NOTICE.TO APPLICANT:IL a ter mekmg Nis C r lcc of Exemptmn,you should WATER SYSTENF TREATING
aIe:cnmc sv iv.to the Workers Compensation provisions or the Labor Code,you num,, PEI!
w forthwith comply with such mvisions or this permit shall he deemed resolved. WATER SERVICE
aQ
z CONSTRUCTION LENDINGAGENCY NI!W RGSIDEM'IAI.PLMII. SQ.PT. PAID
(.) p If whihuhi that them isanwswetion lendinge.agency for the performance of Date - tM
IL U the work for which this permit is ixsaeA(Sec,l(N],Civ.CJ
Q U Lenders Name IV TDI'Al.:
W Lender Address TOTAL
I :
y cctiry that I have aced this application end store ohm the atswe information is BUILDING PEE s�
A coned.Ias.to comply with ail city and comyordin...as and smle laws rehougm QTY. MECHANICAL PERMIT FEE
V huddingemnsuaction,.ad hereby authnri¢reprcxenmtivcs of this citym c.Nrupanthe SEISMICF 3
above-mentioned prnpeny for inspection purposes. PERMIT ISSUANCE
(We)ogres to save.indemnify and keep harmless the City of Cupenino against ELECTRIC FTE
I inhilities,judgments,costs and expenses which may in any way accrue against said City ALTER Olt ADD10 MECI I. PLUMBING FEE
in asequence of thegranting of Nis per
APPLICANT UNDERSTANDS \N II COMPLY WITH ALL NON-POINT AI R HANDLING UNIT(TO 10.000 CFM)
CE K :U
SOURLATIONS. MECHANICAL FHIi
AIR HANDLING UNI.1'(OVER 10.0%01 CPM) CONSTRUCTIONTAX
S
/ nawreo pplice oaf c me EXHAUST HOOUIWR)UCT) HOUSING MITIGATION FEE
HA c(US MATI3RIAL5 DISCLOSURE.
Will the applicant orfum building occupant store or handle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cure,Section 25532(1)? HEATING UNIT'HOVER 100,000 BTU)
C]Yes ❑No VENTILATION PAN(SINGLE RLSIIp PAID
Date R7eipt
Will the applicantorfuture building occupant use equipmentordanwhich BOILER—COMP(311P OR 100,00[BTL)
it hmsNnus air mnsaminanks us de0ned by the Bay Area Air Quality Management TOTAL
a?
❑Yes ❑No BOILER—COMP(OVER IIXLUOp RTU)
I have read the haziedous materials requirement under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Foods Health&Safety Code,Sections 25505.8533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building docs not currently have a tenant,that it is my amponsihility m unify be occupant
of the r ammsmt which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Dam TOTAL: I ISSUED BY: •.
OFFICE
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