S 1006 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY g/��
CITY OF CUPERTINO BUILDING.ELECTRICAL. PI$MIT NO. 1006 1 O O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL `kJ
BUILDING PROJECT IDEN'TIF'ICATION
LDING ADDRESS: SANITARY NO. APPLICA'f10N SUI3MITTAI.DATE
223 C o
NER'S NAME: Luff NONE: COM ACTOR'S NAME: LIC NO'.
NIC CONTROL#
ARCHI .NGINEER: LIC N4, ADDRSS: ❑ y�
COWA CNG: BUILDING PERMIT INFO
T1I. ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
ii
LICENSED CONTRACTORS DECLARATION QTY, ELECTRIC PERMIT PEE JOB DESCRIPTION
I herehy ulBrm Net I um licensed undo pmvisinns of Chap,cr 9(commencing
O�Z th Sa,ton]IX1)ofDivision Sof the tlusinesx and ProfessionsCNe,and mylicenu is RESIDENTIAL;
ENTLIL
1,10c) wm PERMIT ISSUANCE
P� n full force a al.nocc ❑SFDWL ❑KITCHEN REMODEL
�V�kJ Liccnw Class Lic.# APPLIANCES-RESIDENTIAL ❑ADDITION []PLUMBING NE-PIPE
FFZLLI Ilam Conlmc[or
to<6 ❑MULTI-UNIT ❑STRUCTURAL
!•7m ARCHITECTS DECLARATION PANELS MODIFICATION
Z O O Z 1 undersmnd my plans shall he used as public records
OZ4o UPT02MAMPS ❑INTERIOR El CHIMNEY REPAIR
I.,ye l' Licensed Professional 201-1100AMPS IMPROVEME WIMMING POOLS
9iR<< OWNER-BUILDER DECLARATION X)
OVER load [3 BATH REMODEUREPAI F.MOLITION
C I hertby, em
off.,has 1 am exempt from the Contmmnfs License Law for the
°'O a V following r (Section 7031.5,Business end Professions Colic;Any city or county SIGNS ELECTRICAL 00,
O y reason.which requires.permit m construct.alter,improve,Jemmieh,or repair any swcmre
IIF... <, prio,to is issuanecaH,requims the applicant forsuchpermittu fin.,igned valorem SPECIAL CIRCUIT/MISC.
yQ� [hot he is licensed pursuant to the pmvio.m.fdo Comaccam,License U.(Chapter 9 COMMERCIAL
m�p0 Icommeneingwith Seciion]IKKBofDivj,mm3 ofthe Busimessand PmfccsimsCrdgm TEMP.MECR OR POLE INST.
2, c�' Nal he is exempt Iherefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
.`rto Section 7031.5 by any applicant for a permit subjects the applies.,to a civil penalty of POWER DEVICES [:1 TENANT C]FOODSERVICE .
LF.. not more than five hundred outlets($500). IMPROVEMENT
❑1,asownerofthe property,army employees with wugesaslhenvolecompemation, SWIMMING POOL ELECTRIC
0022CC c'1, will do the work.and be stmcmre is not intended oroffeard for,sale(Sec.70,14.Business [I OTHER
S 3 se and Professions CM,:The Contractors License law Jens not apply to an owner of OUTLETS-SWIICOBS-FIXTURES
property who builds or improves Neman,and who does such work himself or through
his own employees,provided that such improsxmmr are not intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
sale.If,however.the building or improvement is sold within one year of completion.if' SQ.IT.FLOOR AREA $/SQ.FT.
nerbuilder will have the burden of proving that he did not build or improve for put
pose of a led. TOTAL:
❑h es awm,of the Senn ,oro exclusively contracting with licensed cmmem,a [m
ansa Lo the project apply
to on %ter os and Profession ds or improves vesntmmon, nd
came Law Joesnmapplr lots itha omaract ny who sed purst LothNercogoeJ QTY. PIA INC PERMIT FEE yep A 0
who contracts for such projects withaammrac[nr(,)licensed pursuant to the Comrac[nrs tP' ri7 'V
License Lew. PERMIT ISSUAN -
❑ Itmexemptunde,Sm. .B&PCftnthis reason
ALTER-DRAIN&VE -WATER(EA) Off .0
1 Ownu - Dotc
WORKER'S COMPENSATION DECLARATION BACK FLDN'PROTEGE UEVI
I hereby affirm under penalty of perjury one of the following declarations: FPAID
El Lhavee.dwilmaintainuCenifteateofConunttnself-insumforWorker'#ComNn- DRAINS-FLOOR,ROOFAREA,CO S-- ECONSTRUCTIONsalon,as provided 1'or by Section 3]00 of the Labor Code,for the performance of thewrk far which this permit is award. FIXTURES-PERTRAP
1 hove and will mainmi.Worker's Coopertion Ina mace.nrequiredby Sectionssued. GAS-EA.SYSfEM-IINC.40UTLEfS UP .+ APNMy Warkees Compensation Insurace cane er end Policy numberam:
Carrier: Policy Na: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASUINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE NG D :ION FEES(This sectionneed nut be cotplered if,he permit is faronehund[edddlarx($100) GREASETRAPor less)I cenfy that in the performance of the workfor which this pcsmit is issued.)shall SEWER-SANITARY-STORM EA.200 F1'.not employ any person in any manner so as o become mbject to the WorkedCompen-,Z ,upon Laws ofCalifornia.Dau WATER HEATER WNGNT/ELECfRz ApplicantNOTICE TO APPLICANT:If,tuna,nuking this Cerfifir a of Exemption,you should WATER SYSTEMOREATING become subjectto the Workers Compensation provi s mthe LM)r Crede.you mint
fonhwi[h comply with suchpmvisionsnnhi.v permit shnllhc JttmW revoked. WATER SERVICECONSTRUCTION LENDING AC.FNCY NEW RESIDENTIAL PhMR, SQ.PT.V0I herehyalTnn that there isosxmsmsoon lending agency for the performance of Raeipm#
the work for which this permit is issued(Sec.3017,Civ.C.) WSEISMICFEE
OTAL:
VLenders Name
{$7 Lenders Address TOTAL
1 certify that I have read this application and atm that the above information is
((AA cored.l agree m comply with all city and county ordinances and state laws relwing m QTY, MECHANICAL PERMIT FEF.V 2building conmumion,and hereby authorize repmsentatives of Nis city to enter upmnhe
above-rumioned prpsny for.inspection purposes. PERMITISSUANCE(We)agree m save,indemnify and keep harmless the City of Cupenlno against EEliabilities.judgments,costs and expenses which may in any way accme against said City ALTER OR ADDI0 MECH. ELin consequence of the gaining of Nis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CPM) AL FF.SOURCE REGULATIONS. AIR HANIl1.ING UNIT(OVER 10,10X1 CFM) ION TAignatum ofApplicauXon[mctor Date F.XHAUSTHOOD(W/DUCT) HRIATE FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.,future building occupant some.,handle hamrdous material HMTING UNIT(TO 100.0110 BTU)
as defined by the Cupertino Municipal Cnde,Chapter 9.12,and the Health and Safety
Code.Section 15532(a)'1 HHA'FING UNIT(OVER 1100,(01)BTU)
❑Yes No VENTILATION PANS INGLE RESID) PAID
Dme Receipt If
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HPOR 111. 8 BTUI
mu fin
011
emit htmrdnus air conminanas deed by the Bay Area Air Quality Management TOTAL:
District? BOILER-COMP(OVER 1(1.0118 BTU)
❑Yes El N.
I have read the haamdous raterials rcquiremenm under Chapter 6.9561'the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cede,Sections 25505,25533 and 25534 I undersmnd Nm if the NEW RESIDENTIAL MECH. SQ.f4.
bndbutidas not contend,have a anent,that i[is my resp n,ibility,,ratify the acupant
mthe a IousuouH which mus[be out Her m issuance of a Cerifmcnte of Mi,apancy.
Owner or auNmiuJ agent Dau
TOTAL: ISSUED BY:
OFFICE