S 1235 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF, IT NO.
CAL
BUILDING DIVISION APPLICATION/PERMIT PING PROJECTB NO IDHANIFICA 1235
BUILDING PROJECT IDEM'IF'll'ATWN
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
gRo� q q�
OW N 'OI P1107,73 COMt A OR'y AMB: / 1 ^X'T L NIC COMtROLp
ARCHITBCTIENGINE LIC NO: A R� S: n
I 44, ,rE:]. _
CONTACT: PHONE: BUILUING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG _F.LECI,, PLUMB MI.
❑ ' ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I Hereby vflimr Nm I..tic.sed under pmvisiuns of Chapter 9(rommencing JO ESCRIPTION
¢O�1ce won section]aaal of Division Sonne Bramcs.and Professions Code.and m.y loom.¢is 135, RESIDENTIAL•
F10p in PERMIT,, J
tyU full havem. T ❑SFUWL C1 KITCHEN REMODEL
C U F hicens Lic.M
yaYi] Dam - Commnor APPLIANCES-RESIUEMlA1. El ADDITION ❑PLUMBING RE-PIPE
F=GN ass ARCHITECTS DEC A ION PANELS []MULTI-UNIT ❑STRUCTURAL.
coZ Iundcmm�d my plans shall be used os pubic roams MODIFICATION
UPT0200AMPS
O Z.`�-C ❑INTERIOR ❑SWIMMING P'OL
,co, ; Licemed Pmfessiansl gal-I00(IAMPS IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDER DE CLARAg30N OVER I000IMIK ❑RATE OFFEREMO lRE' I}0R El UE.
C 6 1 hereby a0i m,Ihw I am exempt Gom the Contrecmrs License Law far Ne J,�.\ ��k
LOLU following reason.(Section]031.5.Business and Professions Carc Any city or county SIGNS(ELECTRICAL El OFFERtelt
3 LL ywhich refutes a permit in construct,alter,improve,demolish,or repair any nrewre 12
prions its....ame,also coca.lncapplimeen for ooh prermiva lileusi,m],wteaem SPECIAL C'RCULUMISC. .
51
E;!Iy that he is licensed pursuant the provisions of the Contractor's License Law(Chaptcr9
�_o0 (commencing with Section 7")ofDivision3ofthe Businessand Prefession,Codc)or TEMP.MET ER OR POLE;IN COMMERCIAL'
L L ey Lha he is exnupl Ihcmliom vnd the basis for the alleged enemptimn.Any violmiom of ❑NEW BLDG/ADDITION ❑DEMOLITION
Xml+• Sttvion7031.5 byany applicant far a perndsuhjens The applicant a civil penalty of POWER DEVICES_..
Way - ❑'fENpNT.� EIFOOD SERVICE
zy nm mare Nun five hundred
perty, r yempl IMPROVEMEI]s'1--�-
W'-'Q (] do unevcfof the pesuracturmycmntendes with wages a.Their ole 04,t.B.satian, SWIMMING POOL ELEC TRIC
will dodiwork,and the swcrrcisnot s Livens Lawdofsamle(Sec..Cor Uout,(If El OTHER
ILi1
property
Professions Cade:The Contractor's License Law docs nut apply s if owner of OUTLCq'S-SWItCHEs-PI%TURES
L 3� propcny who builds or impmvcs thereon,and who does such work himself or through
his own employees,provided that such improveTnmaa am not intended or offered fur NEW RFSIDIEN'TIAL ELEC'R SQ
sale.If,however,the building or impmvarmt is sold whhin one year ofcompletion,The SQ 1^^4.MOOR ARBA SISQ.FT.
owner-builder will have the burden afproving that he did not build or improve for poo- P I1
rine of sale.). ry
E]1,as owner of the progeny,am cadrsively cmnron
eing with licensed cTmcmrs m ' 0
Construct the project(Sec.]MX.Business and Professions Cale:)The Canwcmds Li- f��
c m taw does not apply m an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE n
who contracts for such pmjees with a eammmr(.$)licensed pursuant m the Coutract 19
L
License low. - PERMITISSUANCIE
I am exempt under Sc. ,B&1'C for this reason LtJr
ALTER-DRAIN&VENP-WATER(EA) ATION
Owner Dam
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hemby affirm under penalty of pe jury one of the following declamations:
(](have and will nwimain aCenifr,c of Consent to elf-insurcfur Workers Camper- DRAINS-FLUOR.ROOF,AREA.CONE.
S'FOHIBS TYPO CONS'tRUCfI(IN
.salkni,as provided for by Second 3900 f,he Labor Cade,fon he perfnncome of the
work for which this gem n i.issued. FIXTURES-PER MAP
1 have and will maintain Workers Compensation Insurance,as required by Section
3 of the Labor Cede.for Ne perfonnanee oflha work for which this pemdt is issued GAS-EA.SYSTEM-I INC.J DO TEETS OCC.GROUP APN
My Carie:: T's� `sa�iar)Ins��pp•Vmbrand y No `Ns g_-�1
Came¢ / \ 1-�y�\�Pali< No� 11-S.,L= GAS-EA.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEA/PI'ION(FOM WORKERS'
COMPENSATION INSURANCE GREASE NDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FBFS
(Thisscction acednolhecompletedif Nepermit isforonchumareddollars(SI00) _
orless,) GRBASETRAP PLANCHECK FEE
I artily Nat in the performance ofthe work for which This famous is issued,I.shall SEWER-SANITARY-STORM EA.200 Ft.
not employ any person in my manner so as to became subject Ice The Workers Compcn- ENERGY FETE
Z motion Laws of Cullinane.Date WATERHEATERWNENVELECIt
Q Applicant GRADING FEE
tiNOTICE TO APPLICANT:If,after making this Certificate of Exemption,you mooed WATER SYSTIEM/TRCATING a SOILS FEE become offer,m the Wal pmviaions of The Labor Code,youmost
fonhxith comply wiThsuch pmciTi.m,,a this pcomil shot?M deemed revoked. WATER S17RVICE
n
CONSTRUCTION LENDING AGENCY NEW ft[SIUENTIAL PLMB. SQ FT. PAID
'7 z Ihercby uRrm Nat Nene isaconswclon lending agency fonhe per4mnanee of Date RaeiplM
L)r.r. Ne wort,for which this pronia is issued(See.309],Co,CJ
Um
Lenders Nae AL:
LS1 Lenders Address TOTAL:
1 certify Nal I have mad this application and state that the above information is BUILDING PI
N correct a
I agree to comply with all city and county ordinances and mc laws relating to QTY. MECHANICAL PERMIT FEE
LJz building conswction,and hereby vwamicni'presetatices of this city(I)enter upon the SEISMIC -:IE
.base mentioned property for inspecdan purinnes. PERMIT ISSUANCE
Over agree to save,indemnify and keep harmless Ne City of Cupertino against ELECTRIC ,--
liabilities.juJoacres,costs and expenses which may in any way accrue against mid City ALTERORADDTOMECH.
a.consequence of the gromin,of this pertit. PLUMBING
A PPLICANT UNDERSTANDS A NO W ILL COM PLY WITH ALL NON-POINT A IR HANDLING UNIT G010,000 CFM(
SOL' T EGULATIONS. MECHANICAL MR 1
5 AIR HANDLING UNIT 10,001 CFM) CONSTRUCTION TA
Si na rc of ApplmmVConwct Oa EXt1AU5'T BOOD(WIDUCry 1 HOUSING MITIGATION TEL
Will NcapplHA]ARu�mreard grw upan0i aorcO handlcbaramous nmmriel HEATING UNIT(TO 100,000 BT UI
m defined by the CoNnino Municipal Calc.Chapter 9.12,vad We Health and Safety
COTe.Section 25532(x)? HEATING UNIT(OVER 100.001 egTJ)
Yes Na
E]Yes VI?N'O WTION PAN(SINGLE RESID) PAID pant Rca
. Will the applimn,or flare build,.,ampand use equipment ar devices which BOILER (LHP OR Hl BTU)
Cardharallous air coneco:tats is defined by the Bay Arca Air Quality Management
TOTAL.:
Distrin'1❑Yes ❑No BOILER-COMP(OVER 100,000 BTU)
'have rend m
Nc hammers enials requimmms under Chapter 6.95 of(lie Coli- AIR CONDITIONER ISSUANC
forma Health&Safety Code,Sections 25505.25533 and 25533.1 understand that if the NEW RESIDENTIAL MECII. SQ.FF.
building docs no,currently have a teneat Nat it is my msprnaibilal he mmi theO opera
of Ne aciado m uts which mum he me,prior m issuance of u CeniTicam of Oaupaay.
Owmcroram vaiTedagen Dam TDTnI., O ISSUED NY:
OFFICE