S 0434 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PESIFFNO. O4,k ,t
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. J 3 4
,AUILOINGTROJECT IDENTIFICATION
BUILDINGAD E SANITARY NO. APPLICATION SUBMITTAL DATI
NLR'S NAMEPHONE: T'O
RACk'S NAME: O'
N/G ONTROL
2CHITECUENGINEER: - LIC NO: - ADDRESS: ❑
ME ONTACT PHONE: ( BUILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
gj�JA-r O 4 A-rJ 250qCQ 400
.�
LICENSED CONTRACTORS DECLARATION I
QTY •ELRCTRIC•PERMIT
I h reby affrm m I'cooed d p Chapterr9¢ c ng - .. JOB DESCRIPTION
Da1L with un p 3 Rhe Bus dPi f ouse Code,and my licnae is - RESIDENTIAL:'
��]]p0 w PERMIT ISSUANCE
Fa W r in fell f d c ❑SFDWL ❑KITCHEN REMODEL.
6 V Llce ed Cl.s Lic h '
>>>V APPLIANCES-RESIDENTIAL DDEHON ❑PLUMBING RF.PIPE
F, D'ule - Contractor _
RCHITECse DECLARATION MULTI-OUNIT ❑MODIFI STRUCTURAL
MODIFICATION F�`� - PANELS
zprn'ZF Iunderamnd my plans shall he used as Public records MODIFICATION
py4, UPI
110000AMPS ❑INTERIOR El CHIMNEY REPAIR
�I Licensed Professional 2M-I(N10AMP5- IMPROVEMENT
Ise!
❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODE4REPAIR ❑DGMOI,ITION
I hereby informal 1 nm exempt from the Contfns Cm License Law for the
p F U following reason(Section 903 L5.Business and Professions Code:Any oily or county SIGNS ELECTRICAL ❑OTHER
F O on which requires a permit to construct,alter,improve,demolish,or repair any structure '
prior to it iszmanaa also requires the applicant for such permit to file a signed statement SPI3CIAL CI RCUIT/MISC.
that he is licensed purseenl m the provisions of the Conlmemrs License Law(Chapter 9
Q�a (commencing with Section 70(foof Division 3ofma Bueine,fod Pmfesions Code) TEMP.METBROR POLE INST. COMIlIERCIAI:
4 c W shot he Is exempt IM1evefrom and me basis foe the alleged exemplion.Any vi conjuror ❑NEW BLDG/AUUrrl0N ❑DEMOLITION
'^
Section 7031.5 by any applicant fee.permit subjects the applicant it)a civil penally of POWE pVICHS
w []TENANT El FOOD SERVICE
b
not more than five thpm,,Holl.rs(empl' PROVEMENT
= C ❑ Lo thework,the properly,ormyemntended wages as compensation,
ess SWI GPOOL ELECTRIC
willa and dothewons and the The Contractor's
License Lawc does of apply 9044,Business OTHER
a and property
%hie N Code:The C es funded,
License Law saes not apply m if owner of OUTLET C —FIXTURES
propeny who builds or improves thereon,roti who does such work himself or through
his own employee,provided that such improvements am oat intended or offered for NEW RESIDEN .LECTR SQ ll.
sale.If,however,the building or improvement ieeald within one yearor completion.lheSQ.FT.FLOOR AREA S/SQ.FT.
racracclumilderl ro l have the burden of pg that he did not build ormp for put _
Forename.).
❑ 1 fprproperty,am exclusivelycontracting with:)licensed contractors i-
t
eon t theproject rt(Sec 7044,Business and P .fe. n.Code:)no Contractor.s Li-
cousin
.
Law does not apply to an owner of properly who hudds or improves thereon and QTy, , PLUMBING-PERMIT FEE P AD
who contmen'for such projects with u conmutons)licensed pursuant m the Conlmelors
License Law. PERMIT ISSUANCE
❑I am exempt under Sec.' ,B&P C for this mason
ALTER-DRAIN&VE.NT-WATER(EA) - VALUA'T'ION
Owner Date
WORKER'S COMPENSATION DECLARATION, BACK FLOW PROTECT.DEVICE 'yA.,) ` /
I hereby affirm under penally of perjury one of the following deduralione - f ,UP
I have a ad will maintain a Certificate of Consent m elf-insum for Worker's Cnnrpeo- DRAINS—FLOOR,ROOF,AREA,COND. - STORMS 'r PB CONSTRUCTION
tion,as provided for by Section 39W of the Leh...Gude,Far the performance of the
work for which this permit is issued. FIXTURES—PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
370(of the labor Code,for the performance of the work For which this permit is issued GAS—EA.SYSTEM-I INC.4 OUTO
OCC.GROUP/ - APN
My Work^"� —pep,5prio red Policy a GAS—EA.SYSTEM-OVER 4(EA)
�1TT//1��I ffii ler an
Cartier:„ I �Policy No,: bt
CERTIFICATE.OF EXEMPTION FROM WORK�kS'
COMPENSATION INSURANCE GkEASE/INDUSTRL WASTE.INTERCF.
(This section need not he completed iflhe permit is Futuna hundred dollars X100) x 's; s «^BU ) 'DIVISION TV
m leas) ORBASE'1'kAP PLANCHECK PEE
I cenify that in the performance ofthe work Forwhich this permit is issued,l shall SEWEk—SANITARY—STORM EA,200 FT.
not employ any penton in any manner so as m become subject to the Workers'Creation- ENERGY FFEss
Z nation Laws of Califomia.Dam
O Appliesm ) WATER HEATER W/VENT/ELECTR GRADING FEE
N NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should Wq'I'Ek SYS'fEMITREATING
L~ s"t become subject to the Workers Compensation provisions of the Labor Coda you must SOILS FEE
W-� forthwith comply-with such provisions or this permit shall he deemed revokes. WAFER SERVICE '
O CONSTRUCTION LENDING AGENCY 0 NEW RESIDENTIAL.PLMB. SQ EL PAID
I hereby of tour that them is.construction lending agency for the performance of Dmo #
wiMthe work for which this permit is issued(See3097.Civ.C.) '
Q U Lender's Name
OTAL:
Ili
Losell Address Toil
�y I certify that I have read this application and slate that the abovet 1 n is - - BUEDIN r .H
F. lA carted I agree to comply withal]city and county ordinances and tate Imc,micang to `QTY MECHANICAL PERMIT- 7 FEE
O
Ua7building consumption.and hereby amtharzercpresentamm
vsofth'scityenleruponlhe SEISMIC E
above-mentioned property for inapparent purposes. PERMIT ISSUANCE
(We)agree m'save.indemnify and keep harmless the Cityof CuNnino against ELECTRIC FH
liabililies,judgmenls,costs and expenses which may in anyway seer against said City ALTER OR ADD TO MECII.
pool PLUMBING FEE
in c ue ranting t 1. \
A L 'r UNDER N D WILL COMPLY WET ALL NON-POINT AIR HANDLING UNIT LTO IO.OW CPM)' HANICALFE9 `\
5 U .1
AIR HANDLING UNIT(OVEk 10,00()CFM) MEC
- CONSTRUCTION'I'AX
ignatre of ApplivmVCommcmf Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
HE rheapplicantor future buildr,cceupirtan eor handle hamrdous motorial HEATING UNIT LTO ion,acto BTU) -
aa deli d by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Code,Section 25532(a)?- HEATING UNIT(OVER 1 W.0a)(I BTU)
❑Yes EJNm PAID
VENTILATION FAN(SINGLE RESID) Doe preempt
Will the appliceman fnturc defined or cup amu Sem Air eutof Management
BOILER—COMPLIPOR IW,000B'I'U)
nil hazoAass.Ir
man ants as defined by the Boy Area Air Quality M.nagement
restrict?
11 Yes F]NaBOILER—COMP(OVER 100,000 BTU)
m ..
I have readfichavadous namisl.v requirements under Chapter 6.95 of the Cali- AIR CONDI'L'IONER ISSUANCE DATE
fomia Health&Safety Code,Scalars 255115,25533 and 25534.1 understand that fide NEW RESIDENTIAL MECH. SQ.PT. -
building does nmcumnllyhave atenant,that it is my responsibility m onefy the occupant _
of the requirements which must be mel prior to issuance oft Certificate of Occupancy.
. Owner or ra tharized agent Date ISSUHD BY:
OFFICE