S 2014 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES,-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL PESIT NO. 20-14
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL t\!
BUILDING PROJECT IDENTIFICATION
BUILDING ADIIRESS: - - SANITARY NO. APPLICATION SUBMITTAL DATE
x03 . CArO%nom Ur. Gw moi- Ca 5'So� �' "l7'Q
OWNER'SNAME PIIQNE: NT$4CT(lR'S AME: LIC NO: NIC CONTROL#
5. or o�, o Q
HITECf/ENG tE,R LIC NO: ADDRESS: E
S/
CONTACT. HONHONE. - BUILDING PERMIT INFO
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II/,rolcl.6ltvo 'loo-g"10-70"17 CpDeu1[aot Fees Paid by Applicant(Initial) B��I.DtOCIIHLEPLUMB
- MB
LJ L?- �V
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing i JOB DESCRIPTION
oz withSenior700ffef Division 3oftho Business and Prof ss ions Code,and my license is PERM]'f ISSUANCE RESIDENTIAL
Fs in full force mrd alien.
G V U License Class Lia# _ ❑SF ❑KITCHEN REMODEL
r ZSa Date Convector APPLIANCES-RESIDENTIAL DDITION ❑PLUMBING RE-PIPE
,D>,I ARCHITECT S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
1 z O q 1 understand my Plans shall be used as blit records - PANELS
y Pu MODIFICATION
02� UP T0200 AMPS
F ,O Licensed Pmfc,,uaal El INTERIOR ❑CHIMNBY REPAIR
�• UO
201-IUAMPS IMPROVEMENT []SWIMMING POOLS
OWNER-BUILDER DECLARATION
I herebyuffirnt the exempt I am exempt CrammIM1d Comrodmr',Lied Law for the OVER If100 AMPS ❑BATH REMODEVRBPAIR El DEMOLITION
as U following reason.(Section 7031.5,Boston,,and Profesriens Code Any airy ercourty SIGNS ELECTRICAL D GTHER _
W W y which regtded,a permit to construct,alter,improve,demolish,or repair any smm
cre
L' �; prior to its issudwea.alaroodlresthe applumot mr,mbinanoit to fileusigned smmmam SPECIAL CIRCUIT/MISE.
p� y that he is licensed pursuantto the prevroors of the Contractors License Low(Chapter9 _
W 0C) (commencing with Section 7000)of Division 3 ofthe Business and Pntl'esnionx Cadd)er TEMP.METER OR POLE INST. 000, F COMMERCIAL
d W o C that he is exempt therefrom and the basis for the alleged exemption.Any violation nl' ❑NEW BLDG/ADDITION El DEMOLITION
m m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT El FOOD SERVICE
Es an roam than Eve hundred dollars S50(d,
xG D I,os owner of the pm cert,ore IMPROVEMENT
C I y yempinyees with wagesmtheir sole cnmpenamio. SWIMMING POpI.ELECTRIC
p., will do the work,and the structure isnot intended or offered forsele(See,9044,Business DOTHER
Izl orad Is..xions Cedo:The Contractors License Law does nm apply m an owner of WTLBTS-SWITCHES-FIXTURES
d'3 prepeny who builds or improves thereon,and who does such work himself or through D
his own employees,provided that such impmvements are not intended or offered for NEW RESIDENTIAL.ELEC'rR SQ PIT
sale.If,however,the building or improvement is sold within one yearefcompletme,the SQ.IT.FLOOR AREA $/SQ.ET
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sawn. i
❑ 1,as owner d the property,ran exclusively contracting with licensed contractors m U VY
compact Chep jwt(Sed.90704,Business and Pm(ensien,Cndc)'1'ha Contradnrs l.i1;7-
seLaw does not apply toanowner ofpropenywho buildsorimproves thereon,and QTY. PLUNG IT FEE
who contracts for such projects with a con adores)licensed pursuant to the Corianders
License Law. PERMIT ISSUAN
D I am exempt under Sec ,B&Y C to,this reason
ALTER-DRAIN&VE -WA (FA)
I Owner ` Date � � _ VALUATION
! WORKER'. OMPENSATION DECLARATION BACK FLOW PROTE .DEVICE / D D O
.�! l hereby a0imt under penalty of perjury one of the fcllowiug dedluratiom: ( a
❑Ihave end wllltmintaina Cenifirnm e[Gmsenno self-insumfor Workers Compen- DRAINS-FLOOR.R , RP---c -
,alio.as 'dad for by Sermon 370X1 of the Labor Code,for the S'1' IES TYPE CONSTRUCTION
prom performance of the
v which this permit is issued. FIXTURES-PERT
El I lea _
haveand will maintain fon Workers performance
work
for which
ashes perm by Section
My of therker Labor Codeforthe
surance career and Policy
for are: permit is issue]. GAS-EA.SYST' .4 LETS OCC.GROUP APN
My Worker's Compemation Insurance carrier old Policy number are: 0
Carrier: Policy No.: GAS-EA.SYSTE VER444,
CER]'1FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUS'f WASTE INTERCEPTOR
or lets.) G VASION FEES
need not be completed if the permit is for one hundred dollima($100) GREASETRAP
FUI acid] thatimhe issued, PLANCHECK
y anymannero as
for which this the Workers
akeCompn-duall SEWER-SANITARY-STORM EA.20
net employ any person in any manner s',as mhecnme subject le the Workers'G,mpen- ENERGY FED
O {Zs ,mien Lnw,ol'Calilnmia.Dam WATER HEATER W/VENVELECTRei
z Applicant s 1% GRADING FE
►t y NOTICE TO APPLICANT.IL after making,his Certificate of Exemption,you should WATER SYSTEMII'REATING
become subject to the Worker's Compensation pmvisers of the Labor Code,you must SOILS FEll
I1J ronhwith comply with such previsions or this permit shot]he deemedrevoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMtl. SQ,PT PAID
V. work
for which
thathere isaco (Sea
len ding agency for the performance of m Receipt#
V. P the work far which this permit is issuer(Sec.3099,Cr,CJ
O U Leadea's Name T'O'AL.
W Lender's Address - 'TOTAL:
11 I certify that 1 have mad this application and sate that the above information is - BUILDING FEEV:LZ7 a
h correct.L agree to comply with all city and county ordinances and sate laws relating ,, QTY. MECHANICAL PERMIT PEe
U 7Z building construction,and hereby authorize represeneativesufthi,s city to enter upon the SEISMIC FEE
above ormai sed property for inspection port n es.
(We)agent lm nave,indemnify and keep hmanlessthe Cltyar Cupertino against It PERMITISSUANCE ELECTRIC FEE
liabilities.judgments,costs and expenses which may in any way Terme againstsaid City ALTER DRAW TO MECH I, PLUMBING FEE
in consequence of the granting othis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM7 MECHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER IQIIIX)CPM) CONSTRUCTION TAX
Signature of ApplieanVContradmr Dale EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE;
Will the applicum ur{umra buildingoeoupantamre mrhandlehazallous material HEATING UNI'I(TO I Oep0)BTU)
as defined by the Cupenim,Municipal Code,Chapter 9.12,and the Health add Safety
Code,Section 25532(x)? If ING UNIT(OVER 100,000 BTU)
DYes [D No VENTILATION FAN(SINGLE RESID) PAID - -
Will the ncontainment,
or Camra building occupant use equipment or devices which BOILER QHP OR 100,000 BTU)
Date Reeaipl#
anil hazardous air,wmaminants as defined by the Bey Area Air Quality Management T
District!
El Yes
_1 No BOILER-COME(OVER 100,0IX)BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
hernia Health&Safety Cite,Sections 255115,25533 and 25534.1 understood Lha fired NEW RESIDENTIAL MECH. SQ.ET
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which must be and prior m issuance of a Cent icam or Occupancy. �1f
Owner or authnneed agent Date TO L: ISSUED BY: sr'
OFFICE