S 0733 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. (� O
BUILDING PROJECT IDENTIFICATION O
733
BUILDING ADDRESS'. SANITARY NO. APPLICATION SUBMITTAL DATE
O ER', yAME:L -��rHOQN .�_��� ICONTRACfOR NAME: LIC NO N/C CONTROLp
ITECT��..GIINEER: , l LIC�NO: ADDRESS: ❑
J s Wt C� L 0
CONTACT: PHONE: BUILDING PE MIT INFO
j✓K_.�Is� ' /���.��� ❑ Consultant Fac3 Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
vi VR ID
LICENSED CONTRACTOR'S DECLARATIONQTY. ELECTRIC PERMIT PEE
I hereby affirm Thal 1 am licensed under It vii ions of Chapter9(oommencin6 JOB DESCRIPTION
{G{�C4Z thSermon p000pdnivision3ofine Business and Professions Gds,nnJ mylicensm is
F010- infallforce and effect. - PERMIT ISSUANCE RESIDENTIAL:
V U License Class c.k ❑SFDWL ❑KITCHEN REMODEL
F Zm Dote Contrmvor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RHTIPF.
yah A TDECLARAT
ZOrnZ fit' ypl h s PANELS ❑MULTI-UNIT EI STRUCTURAL
MODIFICATION
O E.,0Z UPTO2WAMP5
A ❑INTERIOR ❑SWIMNEY REPAIR
MING POOL
eeeF[3 1'uw ocssionel 201-I(1(OAMPS IMPROVEMENT SWIMMING POOLS
OWNER- ILDER LARATION OVER 1000 AMPS DEATH REMODEL./REPAIR El DEMOLITION
uu11 I he
affirm that 1 R-exempt from the Coofveor'S License Law Inn the
?L$ 6 following reason.(Section]031.5,Business and Professions Gale:Any city or county SIGNS ELECTRICAL ❑OTHER
W 31L F" which require,a permit W construct,alma improve,demolish,or repair ony xtn¢mre
rt
prioo its issuance,also requires the applicant for such Permit it)file v.signed statement SPECIAL CIRCUIT/MISC.
d� that he is licensed pursuant to the provisions of the Contractor License Law(Chapter 9
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. BLDG/A -
L y m a
that he is exempt therefrom and the basis fon the alleged exemption.Any vielmion of PN=L, ❑DEMOLITION
tvXl LL,�, Section 7031.5 by any applicant lora permit srbects the applicant o a civil penalty of POWER DEVICES
not more Nan five hundred dollars($500).
❑TENANT El FOOD SP.RVICE
F Q ❑ 1,as owner of the propeny,or my employees with wages as their.sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not Intended oroRered for sale(Sec.7044,Business ❑OTHP.R
and Professions Code:The Contractor's License Law does not apply to as owner of OUTL S-SWITCHES-FIXTURES
-. titularly who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are nm intended or offered for NEW RE ID IAL ELF.CIR SQ FT
sale.If,heweveglhe building or improvement issold within one y.....I toomenam,the SQ.IT.FLOOR AREA $/SQ.ET
nu-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.). h
❑ 1,as owner of the property,am exclusively contracting with licensed connectors to TOTAL: ii^^'' 1T
construct the pro/ect(Sec.9044,Business and Professions Code:)The Cm loc,aa'e Li- 8Y
come Luw does not apply to an owner of property who builds or Improves thereon,and QTY. PLUMBI PE MIT FEE pp
who comrac¢forsoch projects with a commen of I accused pursuantn the Contractor's • �e
License Law. PERMIT ISSUANCE Cqy ragpll�l
❑lam exempt under Sea -, this ea V
Owner DateALTER-DRAIN&VENT- ER VA) VALUA �KV11(,
'
WORKER'S COMPENSATION DECLARATION ' BACK FLOW PROTECT.D ICE
I hereby affirm under penalty of perjury one of the following declarations: s,J DO O
I have and will maintain a Cenificme of Consent to self-insure for Workers Counter- DRAINS-FLOOR,RO .A.COND. STORI,S TYPE CONSTRUCfION
sation,as provided for by Section 37M of the Labor Code,for the performance or the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 haveand will maintain Worker's Compensation Insurance,as required by Section
37(X1 orCode,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I IN O ,F.TS
OCC.GROUP ` APN
Wer rh and Polioy nA ^ /
Carrie. /w= mlicy No.' e/�'� +/s)5-F.A.SYSTEM-OVER4t� ' V
CERTIFICATE OE EXEMPTION FROM WO KERS'
COMPENSATION INSURANCE. GREASE/INDUSTRL WASTE INT. C T B NG DIVISION FEES
0 his sominowed not be completed ifthe permit is for one hundred dollars($100) CREASE TRAP
1o".) PLANCHECK 0o
I county that in the performance ofthc work berwhlch this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FF. a
Ir
no[employ any Person in any manner as to become subject to the Workers Common- ENERGY FEE rO V
,`� -m sntion Laws of California Date
O WATER HEATER WNENT/ELECfR
O Applicant I GRADING NE
Z 'NOTICE TO APPLICANT e.after pensat this Cities a of Exemption.you should
�t V] gWATER SYSTEM?BEATING
become subject to a Workers Compensation provisions toe de Labor Code,you mot SOILS FEE
� (othwilh comply with sucM1 provisions.,,his pump shall lm deenneJ revoked: WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PUSH. SQ.Ff. PAR
p thereby affirm that there isaconstmdion lending agency fonhe Pedommnce of me Receipt
O (~-t the work for which this permit is issued(Sea 3097,Civ.C.) r oO
VLender's Name T 1.:
{✓a Lender's Address TOTAL
Cit 1 certify that 1 have read this application and state that the above information is B BILDING .E
V) correct.)agree u,comply with all city and county udireaces andstate lawsrelmingo QTY. MECHANICAL PERMIT FEE
UZ movengconsnedproend hereby uuttionprposes.nwtives ofthisoily toemm�tpnn the SEISMIC FE
move-mentioned property for Inspection purposes.
(We)agree m save,indemnify keep"a so s the Cily nr Cupertino against PERMIT ISSUANCE ELECT IC PER
liabilities,judgments,costsandex hichmayinanywayaceme.agamd said City ALTER OR ADD TO MECH.
in asequence mf the granting hi.w roil. PLU LNG FEE
APPLIC U ERSTA De WILL COMP LTH ALL NON-POINT AIR HANDLING UNIT(TO 10.gf1 CFM) MECH. AL FEE
SOUR .TION
Z AIR HANDLING UNIT(OVER 18000 CFM) CONSTRUE NTAX
S' ore of ApplicanU onnacror Dat EXHAUST HOOD(W/DUCP) HOUSING MIT .TION FEE
HAZARDO MATER DISCLOSURE
Will the applicant or future building option store or handle hasaNs)us material HEATING UNIT(TO 100.000 B'N)
as defined by the Curtains)Municipal Cale,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)7 HEATING UNIT(OVER 100.001 BTU)
❑Yes -1 No VENTILATION PAN(SINGLE RESID) PAID
vtc Rccdpt p
Will the air conn or future building by he nt Ray
equipment or devices Manch
agement
BOILER-COMP GHP OR 100,M)BTU)
mit hazaMons air contaminants as detinet by the Bay Area Air QmJiry Management '1'(YI'AL.
Dian cl7
❑Yes (]Nm BOILER-COMP(OVER I(a),(KKI BTU)
I havinced the hallou
ias materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fornia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Er.
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which must be met prior to Issuance of a Certificate of Occupancy. V err`
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE