S 1311 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL TE ITNO
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL 1311
BUILDING PR(1JEC3T IDF.N'I'IF'ICATION
BUILDINGADDRESS: - SANI'PARY NO. APPLICATION SUBMITTAL DAD
d 2 -�� -76
OWN X NAME: PHONE' CONTRACTOR'S NAMIi: LIC NO:
7Y' NIC CONTROL
ARC T :' - GINEER: OTIC NO: W ADDRE.'� r ❑
61&12
CONTACT: PHONE: BUILDING PERMIT INFO
///.` 'l� -�_^e e q� ❑ Consultant Fees Paid by Applicant(Initial) BUs ELECT 1'LU❑MH MC
N/ I LICENSED CONTRACTORS DECLARATION 'N+ QTY ELECTRIC PERMIT FEE El,"'
1 hereby off. but I atm limov.•d under provision of Chaprer v(commitments JOB DESCRIPTION
OCZ with Sucti�n7lXXH nl Division3of the Husinesaand Prtwouna Cude,and any,license is
I� in full force and effect PERMIT ISSUANCE
❑KITCHEN
License Class ❑ADDrnON ❑PLUMBING RE PIPE
PzkjDac ContrmCln! APPLIANCES-RESIDENTAL
f ❑MULTI-UNIT ❑STRUCTURAL
'Dao ARCHTFECPS DECLARATION PANELS
ZpyZ Iuodenandmyplanssddl beusedaspublic records MODIFICATION
p y,.o UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional3111-111011AMPS IMPROVEMENT SWIMMING POOLS
��dd Sy OWNIiR-BUILIJER DECLARATION OYER IIXX)AMPS D BATA REMODEURF.PAIR ❑DEMOLITION
6s r+ 1 hereby offmt that I um exempt from the Contractor's License Law for the
fLO6V following ream.lSecom 7831.5.Business and Professions Code:Any city m county SIGNS ELECTRICAL ❑OTHE/R�
which raqumrea a permit m rombarl,aIle,Improve;demolish 11,action any mnmaure / 1
prior to its issuance,also requires the appficam for such Permit o file a signed statement SPECIAL CIRCUCUMISC.
} Thal he is licensed punuantmth,previsiunsofthe Contractors License Law(Clai
00 (commencing with Sm,I,m70%ocfDivmslom 3of he Boonessand PmfcssionsCon0or 'TEMP METER OR POLE INST. 41-1
a%�K Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
��rn Section 7031.5 by any applicant for a permit subject the applicant to a civil penalty of POWER DEVICES ❑TTNANT FOOD SERVICE
not more Nun live hundred dollars(551X11.
to 4} IMPROVEMENT
6 0I,as owner ofthe property,or my employees with wagesas Neirsole compensation. SWIMMING POOL ELECTRIC
F'f0 will do the work,and the%wcture is not intended oroffered mosaic Nee.7014,Business ❑OTHER
LL�1 and professions Gdc:The Conlmdoei;License Law dxe mm apply min an owner of OUTLETS-SWI'TCHES-
L Z- ORES
property who builds or impmve.s Bmerem,and who Nma.such work himself or through
his own employees,provided Nat such improvements art not intended or offered for NEW RESIDENTIALE SQ pl'.
sale,ILhowever,the hui lding or improvement is sold withlnonc ycarof cnnmpletian,the SQ.FT.FLOOR AREA StSQ.F1'.
nesbuilder will have the bunlen of proving that he did not build or improve far pur-
pam of sale.).
❑ 1,as owner of me property,an exclusively contracting with licensed contractors mTOTALIs
onstrua Ne project(Sec.7(141,Business and Professions Come:)'Me Contractor's Li-
censelawdmenmapplymanownernfpropertywhoM1uilasorimproveslhercnn,and QTY. PLUMBING PERMIT FEE
who contracts To such projects with a mntractogs)licensed Personal to the Conlmclors
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,H A,P C for this reason
Owner Dam ALTER-DRAINA VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE
I hereby alRmm under pcnahy ofperjuryone of be fallowing deals mtinns:
❑I have and will maintain a Certificate ofConsenno self-insum forwmices Compete DRAINS-FLOOR,ROTOR AREA,COND. STORIES TYPECONSTRUCTIUN
series,as provided for by Section 371X)of the Inbar Code,for the performance of the
work whichthis permit isissued F1XICRES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37M(if the Labor Cole,for the performance of the work for which this labor is issued. GAS-EA.SYS TEM-I INC.4 OUTLETS OCC.GROUP Al'N
My Workers Compensation Insurance carrier and Policy number art:
Carrier: Policy
GAS-CA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKIiRS'
COMPENSATION INSURANCE CRF.ASI%INDUSTRL WASTE.IN'1'ERCEI'roR
BUILDING DIVISION IgiHS
Obis section need not becompined ifthe pcmmit is(trate hundred dollars(§100) -_--------—
orlessJ GRI3ASE'1'RAP I'LANCHIiCK NII
I certify that in the Performance ache work forwhich Nispermit isissaad,l shall SEWER-SANITARY-STORM EA.2(0 19'.
not employ any person in any mmner so as to became object to the Workers Camper- ENERGY NE
Z, ration laws of Californma.Date WATER 1117ATER Wisi DELEC GO
G
Z 2 Applicant A A1
y NOT ICE TO APPLICANT If,after making this Cerificale of Exemption,you should WATER SYSTEM/TREATING
a ; become subject m the Worker's Compensation provisions of the Labor Cale,you ainst II
{il forthwith comply with such provisions or this person shall he deemed revoked WATER SERVICE
a0 - 07
CONSTRUCTION LENDING AGENCY NEW RESIDENT]AL PLMR. SQ.FI', PAID
V C) Ihumbyaffirm that them is.mushroom lending agency forth,p:rforromemd' C r VVr LDat' eiptM
the work for which this permit is issued(Sm.3097,Civ.C.)
W (~ Lender's Name 'ITAL:
WLenders Address TOTAL^
1 cenify that I have read this application and stale that the above information is BUILDING FEE
.r (�/J correct.1.,me to comply with all city mW county ordmunces and aide laws relating in QTY. MECHANICAL PERMIT FEE
L)Z building construction,and hereby amherim representatives ofthix city to enter upon the SEISMIC FEE
alsovomentioned pmpeny far inspection purposes.
(We)agree insist,indemnify and keep harmlcas the City of Catarina against PIINMI'1'ISSUANCE ELECTRIC NE
Iiabilities,judgments.costs and expenses which may in any way active against said City ALTER OR ADDTO MECH.
in n¢qumtt of Ne gaming of Nis persit PLUMBING ME
APPLICANTUNDERS'I'ANI AND WILL COMPLY WIT 1 .NON-POINT AIR HANDLING UNIT(TO I10.000CF1,I)
SOURCE :GUEATIONS. / fe MECHANICAL NE
y6
M . AIR HANDLING UNIT(OVER 10,000CPM) CONSTRUCI'[ON'TAX
tApplicand, Date EXHAUST HOOD(WIDULTT HOUSING MITIGATION Ne
H 7.A
RDOUS MATIiR1ALS DISCLOSURC
WIIlthe applicum nr fame building accupum rarear handle hmardo.,raincoat I IIIAI'INC,UNIT('10 100.000)BTU)
as defncd by the Cupertino Municipal Cock,Chapter 9.12.and the Health and Safety
Cale,secli 255320)7 BEATING UNI T'(OVER I Wood It FU)
No
es VCNTILATION FAN(SINGLE RESIDE PAID Date eeip N
Will the upplicam or future budding occupant use eximpm.•m or devices which BOILER-COMP(3HP OR 1 W,gXI BTU)
emit hurard y,air commitments as defined by the Bay Area Air Quality Manaent gemT(yT
Datnctl /
❑Na BOILER-COMP(OVER Haim)HW)IS�re�
L have read the hazvdem,cromm a1% AIR CONDITIONER
dequirenmrna-under Chapter 695 of the Celi- ISSUANCE DATE
Rome Health X Safety Cale,Sections 25505,25533 and 25534.1 undenNmd that it the NEW RESIDENTIAL MUCH. SQ.FiC
buildingd sum currently havcu Rnant.that it is my spmsihiliy to ratify[be upon
of ani whit he met pile, isst a of a C ifieate pane
e a m nosed ags By TOTAL: ISSUED BY: l
OFFICE