S 0267 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CLPERTINO - IIUILDLNG-ELECTRICAL. 1'IiRMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMIIING.MBIGHANICAL.
BUILDING PROJECT IDENT'IF'ICATION
SANITARY NO, APPLICATION SUBMITTAL DATE.
BUILDING ADDRESS:
111-51
O NER'S NAME: PHO 8: OR' NA E'. 1 NIC CONTROL
s�SRCHITECT GLN dot: LIC NO: �N])gp$S ()�„_ j_a �lr- ❑
CONTACT': PRUNE: �•�sYS •,xi\ BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLnG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY GLECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I am licensed under provisions of Chupmr 9(commencing
moo th Sectlon 71X10)ofDrvixiunJ ofthe Busincsso d eszdons Ctsd a mylic uls RFRF 1
00 wi PERMIT ISSUANCE ❑ADDIT ❑PCBMB;N RFPIEI.
y F- to full force and effect. a
O Licen. leis Lia.M APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING NE•PIPE
yGZ Date Cnnllacmr
A CHITECTS DECLARAT ON PANELS [I MULTI-UNIT ❑MODIFICATION
~r2 z L understand my plans shall be used ex public re.Ns MODIFICATION
ZO UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
OZ�Q
{B Licensed Professional 201 IIXXIAMPS IMPROVEMENT 0DEMOLSWIMMING
TION S
aj
OWNER-BUILDERexculDECLARATION OVER 1011)AMPS ❑HATH RHMODEIJREPAIR ODEMOLITION
1 hereby affirm that I L exempt from the f snions Crude:
Any cicensety O for Ne
O y V following roma aroad 1 703 S,Business and Professions Cola My city or roomy SIGNS 13LECI'RICAL ❑OTHER
3 LL�Xt which requires a permit m ronctrvcn,then Improve.Jem,,lish,or repair any structure
ppppppyyhhI prior to its issuance.also requires the applicant for such permit file a si,aedsmement SPECIAL CIRCUIT/MISC.
;!{Q� that he is licensed pvrmatn m the provisions of the Comractuls Linnen Law(Ch�apter9 COMMERCIAL
Wm1
..CO (eumcncing with Section X00101 Division ,,role Business and Profession,CoP.de)or TEMP.M F'f- POLE R OR INST. NEW BLIKIAUUITION E3 DEMOLITION
Q.p, 2 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
i< 4, Section 1031.5 by any applicom for o peound vi bjects the applicant to acivil pCS penally of POWER DEVICTENANT CI FOOD SERVICE
til not more than five hundred dollars(S500). IMPROVEMENT'
SQp ❑I,as owner of the pmpcny.or myempinyrea wiNwagesus their soleasmpenmtiun, SWIMMING POOL ELECTRIC ❑OTHFR
wJl do the work,and the structure is not intended ormlee cd forsole(Sec.10aBusiness a,Busies--
�� and Professions Gyle:The Contractors License Law does not apply of,an owner of OUTLETS—SWITCHES—FI%TURFS
6'3^ property,who builds or,improves thereon and no chat,such work himself or through NEW RESIDENTIAL CLF.Cfll SQ per
his awn employes,provtdN that such imps vOments are not Intended or offered for SQ.FT.FLOOR AREA $/SQ.Ff.
,ale.If,however,the building or improvement is sold within one year of completion,the
her-builder will have the burden of proving that he did not build or improve for Pur-
pave of sada). TOTAL:
I,as owner of the property,our exclusively connecting with licensed contmemm to
comaurt the project(Sec.7044,Business.ad Professions Code:)The Contractors Li-
censeLawduranotapplytoonownerofpropenywhobuild,ofimprovesthereon,and QTY, PLUMBING PERMIT FEB p A It)
who cnnttacts forsucn projects with u ccnbaeer(x)ticensed pursuant m the Cunuacer's w
License Law. MDRAIN&
ANCE
l am exempt under Sec. ,B&P C forthis rtasonY
IN&VENT—WATER(13A) L
Owner Date CIT" �iWORKER'S COMPENSATION DECLARATION PROTECT'.DEVICE /T hereby afrmt under IKfully of Perjury oneof the following declarations:
UOR ROOF,AREA.COND. STORIES YPE CONSTRUCTED
cation,as provided for by Section 3TM of the Labor Code,for the Performance of the
work lot which Nis permit is issued. PER TRAPI have and will maintain Workers Compensation Insurance,as required by Section311 of the Labor Cale,for the performance of the work for which Nis permit is issued. STL3M.I INC.O OUTLETS OCC. UP APN
My Workers CmrNm ,hu Ensomace carrier and Policy number arc: GAS—HA.SYSTEM-OVER J(CA)
Court,, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASIYINDUSTRL WASTE!INTERCEPTOR
COMPENSATION INSURANCE 111 LNG I3IVISION FEES
(Thissaction need not be campdeedif the pemrit is Throne hundred dollar%is 1110) GREA5ETRAP PLANCH pl
or less.)
I certify Natio Ne performunceofthe work for which thispermit is issued.l shall SEWER—SANITARY—STORM CA 20(1 FT, ENERC EE
not employ any Person in any matyeW as+ty Iwrm`\hi+cN•�Ar Workers'Compen-
C) cation Laws ufC'1BFrtxa.lSv (TY `_l f`,�Y� WATER HEATER WNENT/ELECTR GRADE rFLF
O Applicant �VYA 1
y NOTICE.T—CANT.If,atter inakingthas Cemficate of Exemption,you should WATER SYSTEM/TREATENG SOILS FEE
(, '^ become subject to the Worker,Compensation provisions of the labor Cole,you must
a forthwith comply with such provisions m this permit shut?be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
Dene in
Thereby eltirm that them is aeongrvctinn lending agency for the pertimmance at
W 0 the work for which this permit is issued(Sec.3091,Co.C.) TOTAL:
Q U I<ndels Name TOTAL:
W 1<ndels Address BUILDING FF'
I cenify that I have read this application and slate Nat the above Information is
.. E comet.l agree to comply wbhaEl city and county Ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMICFE
-
U z building construction,and hereby comedic representatives of this city to enter Olson the
above-mentioned Property for inspection pmlssses PERMIT ISSUANCE ELECfRI
(We)agree to save,indemnify and keep hath,,the C'ny of Cupertino against
liabilities,judgments,costs and expenses which may in any way access,against said City ALTER OR ADD TO MECH. PLUMB G FEE
in consequence of the granting of this Pandit.
APPLICANT UNDERSTANDS AND WPIILLL CCOMPLY\� WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,lX1U CPM) MECFlANE 'E
SDC' 11L TIONS. l "• 18— F/T�
1\i(`\/K6•J'`l ' -TV. ` AIR HANDLING UNIT(OVER IOJIOOCFM) CONSTRUCTI NTAX
Signature ofApploanVContmctor One EXHAUST HOOD(W/UUCT) HOUSING IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant onfuum buildinguscupant storcur handle bazallous material HEATING UNIT(10 100,00)BTU)
as defined by the CaKnino Municipal Code,Chapter 9.12,and the Health and Safety GLATING UNIT(OVER Bought B'FU)
Code,Station 25532(x)" PAID
0 Yea, 0 N VENTILAUON FAN(SINGLE RESID) Receipna
I Will be applicant orfsmre buildinguesupam use equipment ordeviccs which BOILER—COMP(3HPOR 100.MOBTU7
:mit b ozardaus air coomminums as,defined by the Buy Arca Air Quality Management 'TOTAL:
L
BOILER—COMP(OVER I(IQ000 BTU)
❑NoAIR CONDITIONER ISSUANCE read the ho7andous materials reuiremscros under Chapter 6.95 of the CWi- -
&Safety Code.Sections 25505,25533 ae125530.1 undctsmnd that if the NEW RESIDENTIAL MECH, SQ.FT.oat cutren0y have.tenant,that h is my respnnsgulay m naify the Wet earlments which mst he met plaa issuance of a Certificate ofOccupancyommd.gent
Date TOTAL: ISSUED BY:
OFFICE