S 2053APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
BUILDING PROJECT IDENTIPICA'UON
PE IT NO -
� 2053
BUILDING ADDRESS: �
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$ANDRY NO.
'A
APPLICA'f10N SUIIMITTAL DRE
S�Z�-4
OWNEIS 71AM1fE: I' PHONE: [��
CONT ACIY)R'$NA t LICNO:
C 410(1
N/C CONTROL If
❑
ARCHi rECT/F:NGINEIiR: LIC NO:
ADDRMS: m
CON TACT.\ 1�, 111A( PHONE:
1 ig%—DSgf
Sat So. 6" co,M
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
RLDQ ELECT PLUMB MECH
� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 Scurfy indium that I am licensed under provisions of Chapter 9 (Simulation, ration,
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANC12
with Section 9(N)(Il of Divisinn7ofthe Business and PodessinnxCWc. wit my li¢nncis
in full force and offer, ,/
-/U LIr 8�
RESIDENTIAL
O SFDWL ❑ KITCHEN REMODEL
AI'PLIANCFS-RPSIUP.N'1'IAL
I.ivenw Cls Lie.0
Date Cnnrrac eymy(y-_
El ADDITION ❑PLUMBINGURAL PITH
MODIF❑MULTI-UNIT ❑STRUCTURAL.
qCHIMN CATION
C) INTERIOR /CHIMNEY REPAIR
IMPROVEMENT C] SWIMMING POOLS
ARCHITECTS DECLARATION
1 understand my plans shall be used us public ree els
PANELS
UP'1'021q AMPS
Licensed Professional
204.1000AMPS
OWNER -BUILDER DECLARATION
1 herchy alrtnn that 1 an exempt from the C'ounselor's License Law for the
following reason. (Section 7031.5; Business and Professions Cale: Any ciry or coumY
❑ BATH REMODEUREPAIR ❑DEMOLITION
El OTHER
OVER 1000AMPS
SIGNS ELECTRICAL
which requirea permit to construct. alter, improve, demolish, m repair any structure
SPECI At. CIRCUS 17M ISC.
prior o its issuance, also requires the applicant for such permit to file a signed stmentent
that he is hicensed pursuant to the provisions of the Contmcmrs License Law (Chapter 9
(commencing with Seaton4XID)of Division Sof the Hmidx,,,md Profession., Code) nr
that he ix exempt therefrmn and the Iasis padre alleged exemption. Any violation of
'I EMP. METER OR POLE IN
COMMERCIAL:
❑NEW SLUG/ADDITION ❑DEMOLITION
' Section 11131.5 by any applicant lin it ornit subjects the applicant to a civil penalty of
PUWGR DEVICES
❑TENANT ❑FOODSERVICE
not mom than five hundred dollars ($500).
01, as owner ofthe properly, or my employees with wages as Their sole compensation,
i will do the work, and the structure us not intended orofferel for Sale (Sec. 9qW, Business
and Po6exuams Cade The Contractor's License Law d.cs not apply Rt an owner of
prolwny who builds or improves thereon, and who Jces such work himself or though
his own employees, provided that such improvements art not intended or offered far
sale. IL however, the building or improvement is sold wiNinone year of completion, the
IMPROVEM13NT (s 1
'�'
OTI{ER-�----
1 ( YO OF -) 1 AI • gr, 0
SWIMMING POO{ ..ECTRIC
OUTLETS -.S 'fCHIS-PIXY -a
NEW RF L FLEC S
O HM
SQ. FL FLUOR AREA
$ISQ, Fr.
mve for pa
nd., will the burden of paving that he did not builder impr
er-haLevu
owner
r c.fsale,.
❑1, as owner of the property, am exclusively contracting with licensed contractors to
.r
may
m6aproject rea the pject (Sec. 9044, B.,Um , ad Professions Code:)'He Contractors
cons, an owner of property%he builds or impmve, thereon and
QTY. PI GING PERMIT FE
who comment for such pin leas with u omaueror(s) licensed pursuant to the Contractors
PERMIT ISSUA
License Law.
❑ 1 am exempt under Sec. . H & P C for this reason
ALTEN -DRAT-WATIiR IP.A)
VALUATION
Owner Date
WORKER :$COMPENSRION DECLARATION
HACK FLOW PROTECT. DEVICE
A
7 �` dV
I lercby nRrm under pcnahy of perjury ane of the following
J
WmIaU,nnr.
❑Ihaveandwill for by Se Cion 37 to ofthe Lalsa Code farthe Worker's Compen-
sai.n, ,provided for by Semon 3900 of TM L bur Cade, for rite performance of She
this issued.
work have
DRAINS -FLOOµ, ROOEARP,A. DDND.
STORIES
TYPE CONSTRUCTION
_ J
PIXTl1Rli5-I'ER TRAP
and maintain
ante of the work hi h requiem by Section
39LY)nf the LtMn Calor for the perfnmmnce of The work for which this permit is issued
37 1 have and will m de. for he rker'sperformance
My Work+q,�f�Co�Qtpensatiopins j ul Policy nytiame:
Carries ! � '#0.sUlecarrie Policy No.: [�U4 -a9 7WV
SOI;
GAS -EA. SYSTEM4 INCA UUT TS
OCC. GROUP
-3
APN Q
Z j
GAS-EA.SVSTIiM-OVERS A)
0 GREASIVINDUSI'RLWA,' tINTERCEMR
Ci;ulrICA#TE EXCMPI'ION FItOM WOI(KIiRS'
COMPENSATION INSURANCE I'1 /
BUILDING DIVISION FEES
(This Section need not be completed ifthe Permit is forone hundred dollms($ISO
or Iesx.)
GREASE'1'RAP
PLANCHECK FEE
SEWER -SANIT -STORM F.A. 200 IT.
ENERGY FETE
I coldly that in the performance nfthc work far which this pram is issuel.I shall
not employ any Person in any manner so as Io Income subject to the Workers' Craton-
WAIERHIiA' . W/VFIJT/ELECTR
GRADING FEE
rIA
' satin. laws of California. Dae
Applicant
NOTICE T'O APPLICANT. IL aper making this Ccnificme of Exemption, You should
become subject to the Worker's Compensation provisions of the Lelwr Cade, you mast
WATER: STEMORBATING
SOIfS PEE
forthwith comply with such pmvisiom or this permitshall be dented revoked.
WpT SERVICIi
CONSTRUCTION LENDING AGENCY
Ifemby offinnthanc.re is a construction lending agency for the arknnancoor
Irework far which this permit is issued (Seo. 30I. Civ. C.)
' Icnders Name
:W RESIDF.NTIALI'LMB. SQ. T.
PAID
I t ReceiptN
TOTAL:
TOIAI.
Ixndces Address
BUILDING I.
I certify that 1 have read This application and state that the above information is
correct. I agree to comply%uh all city and county ordinances and Sato laws relating to
building construction, unit hereby authorize representatives orthisciry ntenteroMir the
QTY. MECHANICAL PERMIT FEE
SEISMICP i
PERMIT ISSUANCE
ELECTRIC C
.bove.menthered property for inspecti.n purposes.
(We) agree to Save, indemnify and keep harmless the City ser Caperton against
PLUMBING FEB
Iiahilities,judgments, costs and expenses which may in any way areae against said City
Sthitp WILL
in consequence offlueUNDERSTAntingNDS
APPLICANT UNDERSTANDS AND \VILE COMPLY WITH ALL NON -POINT
ALTER OR ADD TO Ni
AIR HANDLING UNIT Ob 10,000 CPM)
MECHANICAL FEIi
SOUI(CR REGULATIONS '
AIR HANDLING UNIT (OVER 111.1100 Cr
CONSTRUC'HONTAX
� (�_/ --,_ �/ /��
�(/
Signomte of Afili naionvudor Date
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
UNIT (SO 100,00X) I )as
Will the applicant or future building occupum none or handle hatualms material
defined by the Cupertino Municipal Cock, Chapter 9.12, and The Health and SafetyCade, Scarier 25532(.)!
I'F(OVER (X111 BTU)❑Ycs
N FA SINGLE RESID)
UN.
PAIDIlam RecciptpWIII
the applicant or furore building txcapann use repapmem or Jeviws which
hcromm, air coneirainme, as defined by the Hay Area Air Quality ManagementDistrict^
(3HP OR I.S.000 BTU)emit
MP(UVER IIX),ggI BTU) -
WDITIONER
❑Yes ON'oI
IONER
ISSUANCE DATE.humin
have read the handed,rumored, remormer, under Chapter 695 of the Cali-
Health & Safely Cede, Sections 25505,25533 and 25534. 1 Understand rbc ifthe
NTIAL MECH, SQ. FT.
building does not comedy have a tenant, that it is my responsibility to notify the a'capant
of The requir ms which.mmtbemet or m issuance of. Ccnificme or Ofcll un
ISSUED BY:
TOTAL:
Owner a ugem Date
OFFICE