S 0636 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PESAITNO. 0636
BUILDING DIVISION APPLICATION/IaERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDEN'UFICA'FION
IhDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
I'H11 P' CONTRACTOR'S NAME: LIC NO:
NIC CONTRROOL##
'"WoARCHI F.Cf 'NGI .F.R: LIC NO: ADDRESS: ❑ 1
ONTAC'E PHONE: BUILDING PERMIT INFO ✓
❑ Consultant Fees Paid by Applicant(Initial) BI. ELECT PLUMI MECH
LIC SED CONTRACTOR'S ECLARATI IN TY, ELECTRIC PERMIT FEE
mmen
I hereby affirm Ebel 1 am licensed under provisions of Chapter 9(cocing JOB DESCRIPTION
DMZ with Section 70M)of Division 3 of the Business and Professions Cade,and my liceihc is RESIDENTIAL:
00 in full force unit effect. PERMIT ISSUANCE
aWF License Class—1.1s.On ❑SIUWL ❑KITCHEN REMODEL
APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Nay Date Contractor
F"� ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑MODIFNRAL
z c vv2 4j l urdery rd my plans shot[be usul as public reenrds MODIIICATION
Oz=i, UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
rs,,F',J Licensed Profesinwl 20l-INMAMPS IMPROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION
C 6 1 hereby union that 1 am exempt from the Comrvctor's License Law fm the OVER IOIIf1AMPS ❑HATH RIiMODE1JRF.PAIR ❑DEMOLITION
x�x O
is.U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OfI10R
W 3 LL y¢ which requires a permit m Cons mer.alter,improve,demolish,or repair any structure
�y0J prior to its issuance,al-requires the applicant far such permiuo file a signed statement SPECIAL CIRCUITIMISC.
f. } that he is licensed pursuant to the provision of the Contractor's License Law(Chapter 9
W p0 (commencing with Secti.n900nl.f Dlvision3ofine Businessand Professions Crxlc)nr TEMP.MITI'ER OR POLE INS'T. COMMERCIAL:
a y tY that he is exempt therefu m and the basis for the alleged exemption.Any violation of ❑ -W BLDGIADDIUON ❑DEMOLITION
LLX7 4•
Section]o31.5 by any applicant for a permit suhjcas the applicant to a civil Penalty of POWER DEVICES NT ❑FOOD SERVICE
z y not more than five hundred dollars(55(0). OFIM OVEMENT
�a ❑I,as owner ofthe pmpeny,or myemployees with wages us their sole compensation. SWIMMINGPOOLFLECTRIC
O will do the work,and the strunure is not intended or offered fnrsale(Sec.7044,Business ❑OTHER pp
L a and Professions Code:The Contractor's License Law does not apply m P an owner of OfIT1.ET5-SWITCHCN-FIXTURES A
properly who builds or improves thereon,and who does such work himself of though
his own employees,provided that such impmvemems are not intended or offered for NEW RF.SIDENI'IAL ELECTS ,,"Q
sale.If,however.the building or improvement is sold within one varofrourpletion.the S iAgas.. 5/SQ,Ff.
saner-builder will have the burden of pmving that he did not huild or improve for Fur- NF1 D
wiener of the proper,am exclusively contracting with licensed eumrectin to TOTAL. a•WW('
F.,
tthe project(Seed(114,Business amt Professions CsMc:)Th<Conwcvds Li- � Gh111N(1aw dove not apply man ownerofpmpeny who builds or improves thereon.and QTY. PLUMBING PERMITwocontract,lis such projects with o conwctons)licensed pamaa t m the Contractor's
L'ocasa Law. I PER M IT ISSUANCE
❑l all,este ptvs er Sec. ,B&PC fmthis mason
saner I betel ALTIiR-DRAIN&VIiNT-WATER IIiA) A VALUATION
\ ORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ,� 1 '
Ihereh u rte under pemtlty of Penury one of the following Jcelnrvtions: li
❑ Ihave and maintain a CenifcatenfCansennoself-insure fir Worker's Cmnpen- DRAINS-FLOOR,ROD[',AREA,CONE). STORIES TYPECONSTRUCr10N
sution,as provided for by Section 37M of the labor Code,for the Performance o1 the
work for which this Permit is issued. FIXTURES-PER TRAP
❑1 have end will maintain Worker's Cmeten.mtion lemomer,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.40UTLELS - OCC.GROH AI'N
My Worker's Compensation Insurance carrier and Policy number are:
Currie, Policy No.: GAS-EA,SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRRASEIINDUSTRL WASTE INTER FFTOR NG DIVIMO PEES
(Thisseetinn neat not he completedlfthe permit is furore bundled dollars(Mato GR
I?ASIi TRAP
it less.) PE ANCHE F
Icenifytha in the perksompecof the work fur which this permit is issued,[shall SEWER-SANITARY-STORM EA.2110 FT
not employ any person in any manner so as to become subject to the Workers'ComFcn- ENERGY FEE
Zz scion Laws of Common.Date WATER HEATER WIVENTMI ECTR
� Applicant \ GRADING FEE
Lel NOTICE TO APPLICANT:If,after making this Cenificae if Exemption,you.should WATER SYSTEMOTREATING
a ' become subject to the Worker's Compensation previsions of the lath Code,you inum SOII S FEE
foMwith comply with wch provisiom it this penninhall he deemed revoked. WATER SERVICE
0
7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. FAIU Dam Receipt#
V O I herebyaftirm that there is.concoction lending agency for the perfurmwee of
the work for which this permit is issued(Sec.309.C'tv.CJ
Lender's Name TOTAL:
WLcndcr's Address T(1I'AL: BUII.111 GF p�
I cri that 1 have and this application and state tha the above infor n tion tris -
N nlor,Iagmen.comply with all city andify coumy oNinunces and stare laws relating In QTY. MECHANICAL PERMIT FEE -
U building concoction,and hereby suthorire representatives ofthis city to enter upon the SEES F.
abovo-memioned property for inspection purposes. PERMIT ISSUANCIS
(We)agree m save,indemnify and keep hmmless the City of C.,moi against ELECT PEE
labilities.judgmen¢,costs and expenses which may in coy way accrue against said City ALTER OR ADD TO MECIL
in conseqtuence of the granting of this Permit.
PLUM INE FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT ITO 10,0IX1 CFM)
SOUR�QULATIONS. 1 MECHAN AI.FEE
/]wI VW -L_ 'I II®'C� AIR HANDLING UNIT(OVEN IO,INNI CFM) CONSTRUE O TAX
pherro/Comra<mr I Date l EXHAUST HOOD 1WIDUCq HOUSING MI' ATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the situicum nr future baddingoeeu..a,storern handle hmuNous maenel HEATING UNIT(TO 100.000 BTU)
us depned by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Coda Section 25532hn? IMAT INC,It NIT(OVER 100,001)BTU)
Yes ❑No❑ VENTILATION FAN(SINGLE R131D) PAID Done Rxreipt#
Will the applicant or future huilding occupant use equipment or devices which
)emit haranlius air emanni inunn as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 1(10,100 BTU) TOTAL:
District? BOILER-COMP(OVER HXBXXU BTU)
❑Yes ON.
Ihave real the huzanlous materials requimmenu under Cha 695 of the Cvli AIR CONDITIONER ISSUANCE DATE
Ms'r
formic gHealth does&Safety currently
have
e a itons,.dual 25505,25533 and 25534.1 understand that if the NEW RISIUENTIAL MECH. SQ.Fr.
building does not ewhicyhave am mop EMI.is ua ce of. esti cirofifythe
tion,
of the r�duiretmnts which must be met Pnnr m issuance of a Cenitienm if(kcupanry.
Owner or authorized agent Dom TOTAL ISSUED BY:
OFFICE