31117 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING RLECTRICAL PF.RMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLumnINc.MECHANICAL. ^ �,F ,F
BUILDING PROJECT 111ENTIF'ICATION 3 11
BUILDING ADDRESS:
0 U
SANITARY NO. APPLICATION SUBMI'ITAL DAX7 'I
� q 0
O B A PEON CON RAM OR E: LIC NU:
0Ij e_ N 1o" CONtON
'RITE NI INEER: LIC NO: ADDRESS:
/M d • ❑
CONTV / lACT: PHONE:
BUILDING PERMIT INFO
r '�1 �n ❑ Consultant Fees Paid by Appli...I(Initial) B G ELECT PLUMB MECH
I`sV 1 LICENSED CONTRACTORS DECLARATION �J (/ QT ELECTRIC PERMIT FEE ❑
Z 1 hereby aRnn that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION with Smtiun](KKl)oTUivision30fthc Business and Professions Cal m 'cense is
Uin full f es a and cff PERMIT ISSUANCE RESIDENTIAL
`•j Lima. Clas Lic.b 3 ❑SF'DWL
F'yyW ODEL
Date Commem, PPLIANCES-RESIDENTIAL ❑PLUMBIN RE-PIE
FtiF.Qa ❑ADDITION ID PLUMBING RE-PIPE
Zp�ZON
nrstand my plans shellbeused LCb`Rrealyy({r, PANELS ❑MULTIUNIT 11 STRUCTURAL
oz-- u 12rO� UPT02W AMPS MODIFICATION
1-4It ac hssianl ❑INTERIOR 11 CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
y3W I hereby affirm that I ma exempt from the ComracmrWs License Law for the OVER IOAMPS ElRATHH�^RyE D.1'il1/IttiPAIR C DEMOLITION
6
pgV following teasom(Section]031S,Business nd Pretensions Code:Any city or county SIGNS ELECTRICAL DOTHrap
{trrJJ W O which acquires a permit to construct,alter,improve,demolish,or repair any much"
tn prionuit issunce,uLw aryuircsthe appiicam for such pemiun fileesigned n me,, SPECIAL CIRCUIT/ C.
�Gf that he is licensed pursunno the provisions ofthe Contractor's license Law(Chapter 9
RV, (commencing with Section](NIO)ofDivisinn3ufthe Business unJ Pro1'cssions Cude)or TEMP.METER OR I' 'IN C01
a a that he is exempt there0um end the basis fur the alleged exemption,Any violation of C•W BLDG/AUD(T{Q �7 DEMOLITION
�te Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES T�QFty} �T
C'Z} not more than five hundred dollars($51q). IiIAB71' yVYtl'l1jN 1=1 x000 SIiftVICIi
=CI CI E]1,to owner office Property.or my employees with wages as tbeirsole compensation, SWIMMING POOL ELECTRIC PROVEMENT
RN will do the work,and the struchre isnot iatended.omered for sale(See 704y Business ❑OTHER
iand Professions Code:The Connector'a License Law does not apply to an owner of - OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvement are not intended or ol7<red for NEW RESIDENTIAL ELECR SQ FT.
sale.If,however the building or impruvcmcat is sold within onoyinamenmpletion,the SQ.FT FLOOR AREA $/SQ,FR
mariver-builder will have the burden of proving that he did not
build or impm n,for per,
Pa. fa
e-
poseOfsate—
❑1,as owner of the properly,am exclusively contracting with licensed contractors TO
ate—
construct are project(Sm.]044,Business and Professions Cede:)The Cont arian's Li.
mars"Low does not apply to an owner of p"peny who builds or improves thereon,:and QTY. PLUMBING PERMIT FEL'
who contracts for such projects with a cuntrechr(s)licensed Paramount 1.the Cmmrecmrk
License Law.
❑ I an exempt nor,Sm. ,H&P C for thisreason PERMIT ISSUANCE
Owner Date ALTER-DRAINA,VI -WATER( VALUATION
WORKERS COMPENSA]'ION DECLARATION BACK FLOW PROTECT.DEVICE
affirm �1DIo fllY
I hereby arm under penalty of pcprecursiorecursions:ury one of the fallowing rations: "l 6
'I]Ihavc ndwill maintain aCenificmanf Consent to self-imure for Waders Compere DRAINS-FLOOR,ROOF,AREA,GOND,
ommr,as provided for by Section 37f0 of the Labor Crude,far the perlumaner of the STORIES ]'YPE CONSTRUCTION
work for which W s permit is issued. FIXTURES-PER CRAP
C 1 have and will maintain Workers Compensation Insurance,as required by Section
37110(if the Latour Cade,for fire ionfommnce of the work for which this permit is issued GAS-EA.SYSTEM.I INC.4 OUTLEIS
/ My Wu Insurer dPlicy number Ne OCC.GROUP APN
Carrier. s ASI/t�w tttiny No.:tJ! '4 YYIgef �_EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMP�[ON FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
or
(This section need not he completed if the peorat is for one hundred dollars($IWGREASE TRAY
) UI NO DIVISION FEES
lens.)
I modify that in the performance of the work for which this PLANCREC
Permit SANITARY-,
not .,toyany perforin any mannerso asmbecame subjmnO'he Wnrkcav'Compri- SEWhR- STORM G.2W FT. ENERGY
11414
zZ Applilasysof California.Data
z O APplicnt WATER HEATER WNENTB:LELTR
NOTICE IT)APPLICANT:IL after staking this Certificate uT Exemption,you shuulA GRAD G E
1•-a y become sub'mt m the Workers Com WATER SYSTEMINHiATING
f Compensation provisions of the Labor Code,you must
a Sol_ F.
fM
owhis comply with such previsions or this permit shall be deemed rc,.kcd.
S Q - WATER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB, SQ,FT. PAID
U Ihcrehy om that there is a construction lendingagency for the annumance of late RaceiptN
the work fb
for which thin permit is issued(Sm.3097,Civ.C.)
U Lenders Name
1 Lenders Address TOTAL. TOTAL:
I certify that I have read this application and sum that the above information is BUILDIN FEE, t)
N correct.l agrm to comply with all city and county ordiwntts and state laws relating to QTY. MECHANICAL PERMIT
U 7a
building con.struction,and hereby authorizerepresentionesufthiscity mentorupon the FEE SEISMIC I .0
above-mentioned Propony for inspection purposes.
(We)agree to save,indemnify ad keep hmless the City of Cu nnth gaturnat PERMIT ISSUANCE
ELECTRI PEE
Habil'mics,judgment,fornd espeoseswhich may irony way accrne against sail City ALTER UR ADD TO MECH.
consequence of the grunting of this Permit. PLUMBIN.FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,(W CPM)
SOU REGULATIONS. MF,CHANI'AL FEE
03 AIR HANDLING UNIT(OVER 10,01U CFAD CONSTR ION TAX
Signaturmef ApplicaimcnR do, Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING ATTIGATIONFEV,
/ Will the applicant or future building occupant store or handle harurdous material HEATING UNIT(TO IW,OIX)BTU)
as dclined by the Cupertino Municipal Code,Chapter 9.12,and the lieulth and Safety
Cade,Sexam.8532007 HEATING UNIT(OVER]IRM)BTU)
E]Yes ❑Nu
VEN ELATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which to Receipt p
roil haeardous air contaminant as defined by the Be,Area Air Quality Management BOILER-COMPORPOR 100,0001ITU)
D'smict7
[I Yes C]No BOIL17H-COMP(OVER I00.000 BTU)
I have mad die hnsrdom materials AIR CONDE'IONER
re,25533 an underC I and 695 of Cilie ISSD CE DATE
fomite Health&Scurry Code,ea fuse 25505.SS33aced8534.1 understand thatifthe NEW RESIDENTIAL MECH. SQ,M.
building aures nut currently hweatenam,thm his my resryC.Ceirytv nshe fythe vpunt
f th n"nt which must be met prior to is ce of o which must met prim is of a Cenif¢ate f��
iuvt� R.�.I
o eufhonud ageufhonud a6'mt to TOTAL:
ISSUED BY:
OFFICE