S 1300 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO INILUIN!-MICHAN1CAL
ECrRICM. ....81T"°. 1300
eun.DINGIIIVIS10N APPLICATIONIPERMIT PLUMBINl\J
BUILDING PROIDWFIITCA'r10N
IIUILDING ADDNCSS: SANITARY NO. APPLICATION SUBMITTAL DATE
OW 'S A E: yH leo ^ C f.j ACT)R' NA _1 :WAO GIC 10 N/C CONTROLIARC�FQI'EN 1 EER: LIC.N1.3 VK �1)IIRM'. •/MI ,1 / CA � ❑
C'�y/V'_
COKTAC1%: PHONE; / BUILDING PERMIT INFO
I� + . _ ,/ O 'D /�//A ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB M[❑CH
AR('1// 1//LICCIENSED CONTRACTOR'S ID)EECCL/LARATION "fV,-1 a QTY. ELECTRIC PERMIT FEE - JOB DESCRIPTION
I hereby ofOrm that 1 am licensed under provisions rf C (m cing
C=Z wish$nnion 7f00)ufDiv'.ion3ofthe Buninexsind Pro 'Ci.le,a licenseis RESIDENTIAL:
�C O 'illosI— in fall face and ellat. PERMIT ISSUANCE ❑SFDWI, El KITCHEN REMODRL
QVU L1A4"re )
APPLIANCES-RHSIDEMI'[AL ❑ADDITION (3 PLUMBING RE-PIPE
H W Date Contractor
m a []MULTI-UNIT ❑STRUCTURAL
HITECTS HA'1'10
FDz .models, Yplunl ahs tic UPIOS - MODIFICATION
Z O— UPTOPAN ' )AMPS
pZ�Q El INTERIOR E]CHIMNEY REPAIR
a�F"J Licc mfe. a r 201.1000A 'S IMPROVEMENT []SWIMMING POOLS
C^.y�
OWNERBUILDERDECLARATION OVER I(XIOA C3 BATH REMODEIIREPAIR DEMOLITION
6' 1 hereby uffinn shat 1 em exempt fourth.Contractor's License Law for the ❑BATHR IQ /R [ DE
U following reamn.(Section]031.5,Business end Pndessiunn Code:Any city or county SIGNS ELECT RICA P A °�-
3 4 Fv's which requires a permit to construct.alter,improve,demolish,or repair any st,eture
primaxi...an..III.requires the upp.icant for Inch pension file to lignedswtemem SPECIAL CIRCUIT/MISQ
`�}J than he is licensed pursuanno no,provisions of the Contractors license Law(Clecolm9
OC (commencing will Section]IXgpof Division]of the easiness and Prof..I'm,Court or TEM 1'.M ETER Olt POLE i NST. 1
a G C that he is exempt therefrom and the basis for the alleged exemption Any.....tion of ❑NCW SLUG/ADDITION ❑DEMOLITION
�m
Section 7031.5 by any applicant for a Permit subjeotsthexpplimm use civil paredlyuf POWER DEVICES WENANICI7Y Ur' Uis,tq pQ'y S1eRVICE
X[N.. not comethor five hundred dialler,($500). PROVFMENT T s�V
XSC ❑I,as owner of the Pmpeny,.o my employees with wages us their side cumpcnsati.n, SWIMMING POOL ELECTRIC
A will do the work.and thenrvcwrei,..,intended or offered formle(Sm.70,o,Business bOTHF:R
C OUTLETS-SWITCHES-FIXTUR1
pl and Professions Coda:The Commends License Law does not apply m an owner.
13� property who builds on improves thereon,and who does such work himmlf a th.. h
his own employees,provided that such Improvements arc net intended or.ffeed for NEW RISIDT:NTIAL F.LF.CTR SQ FT
.sale.It,however,the building or improvement it sold within one ycan.frimPle un.the SQ.17.FLOOR AREA LSQ.FI'.
wne>boilder will have the burden of proving Thal he did not build or improve for per. O
pie.)sale.).
❑ 1,as owner of the pmpen,,am exclusively contracting with licensed c.ntmeton,to
instruct the pmjat(Sec.700,Imorr,ss and P..fes.i.ns Cadep'I he Contin oat,Li-
seLaw does not apply to rn owner of property who builds or improves memon,and QTY. PLUMBINGPERMIT FEE
who contracts for such projeco with a conmicual x).Rented pummot In the Contractor's
License Ww. PF:RMI'1ISSUANCE
❑ I am exempt under Sec. .B&P C for Nix reason
AI '.R--DRAIN&VENT- * (EA) VALUATION
Owns Dater
WORKERS COMPENSATION DIfCefollo following
BACK h W PRI]TIiCP.U V
I hereby ndwill nnunderpenallyof of Cononeofthefolluwingdala,Onvs JJJ
[].I have providalnor yS am 3700 of the" eCodinmmfer Workdx Comp the DRAINS-il ft.N001',ARE A,COND. STORIES TYI'F.CONSTRUCTION
mti.n,n pmviJhi Ipso by Section 3]IX)of the LuMr Calc,for the perinnn.nce of the
irk for which this permit is:stoat, ldXl'URES-PF.N P
❑ 1 have and will maimuin Worker's Compensation Insurance,as required by Section
t]W of the laMr for the perlbnnuncc uI the wurifnr wli'hthrspermitisixsued. GAS-EA.SYSTE i '40 OCC.GROUP AI'N
My Wnrk. pynrond Policy lurch
Carrier. ,V �eanie Policy Na:MN'I) 5-BA.SYSTEM-OVER 41 )
CERTIFICAI E OF EXITM17ION THUS RKIiRS' GRF.AS1%INUIJSTRI.WASTE(NTE .CPTOR
COMPIiNSATiON INSURANCE BUIL INIiD ISION FEES
('Roilsection neral not becnmpleted Tithe perht is fou„handled dollars O.(m) GREASP.TRAP
nr lel.) PLANCHECK FIiP. �a
I minty that:"the peummu mofth,work for.lowh this permit is isolated,i shell SIiWF.R-SANITARY-STORM EA.21N)lel;
not employ any person in any manner so as to become subject to the Workers'Cout WGRADING -
z
,Z nn0.n Laws of Califur i.Date WATER HEATER W/VENTTLECB
O Applicant o. NOHCE'IOAPPLICANT:If,.Eern,king this CertificmeofExemption,you shouldWATER SYSTEM?REAI'ING
hear.adjorttothe Went Compensation provisions ofthe I:WMrCak,you moa forthwith,comply with such provisionsor this permltshall be deemed revoked. WATT7R SERVICE
CONSTRUCTION LENDING AGI3NCY NEW NESIUEMfIAI.PLM B. SQ.IT Receipt to
I hereby affirm that there is a anaruction lending agency ninth.Tmomtmnce of
W the work for which this pereat is issued(Sm.3097,Civ,C.) 'TOTAL:
ULenders Name
U.l Lcndds Address 'I OPAL:
>. I cenify that 1 have read this opplicitim ani sm a(hot the above information is BUILDING P F:
4 u7!) correct,1 agree to comply with all city and county ordounims and state laws relining m. QTY. MECHANICAL PERMIT FEE SEISMIC FE
Ll G building consweti.n,and here by authorbe representatives.(this city to enter upon the
above-mentioned propcn or,n,., ion puHxnes' iRMI'f ISSUANCE ELECTRIC FET:
"xiiiii, 73)
(We)agree to. mde o7, and keep ho"mess'he Cil,of Cupeni"o o,eimt
liahilittes,judgmenl:c eand expe"ms which may in anyway accme against said City N. Ok AUUTp MECII. PLUMBING FEC
or onsequenceof a gl ming of this Plinio.
APPLICANT U )E 'TANDS D WILL PLY WITH ALL NON-POINT' AIR HA ING UNIT(TO Io,000 CFM) MECHANICAL FEE
SOURCE
^� AIR HANDL( UNIT(OVER IO.1gN)CPM) CONSTRUCTION TAX
St at c VCo.roc o D, EXHAUST'HOOD( DUCT) HOUSING MITIGATION FE
HAZAR OUS MATER OSURE
Will the applicant or inure building aeuPam Ston,or handle hasmdous material HEATING UNIT CI'O I IN, .)BTU)
as detailed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 255320)? IMAIINC,UNIT(OVER 100) )BTU)
C]yet, F-1 No VEN'IRATION FAN(SINGLE RE D) PAID
Dote RaciptM
Will the mr,o f..on future bolding by the B use equipment or devices which pO11.P.R-COMP(3H1'OR IOO,IN)0 B
emit hvsadoua sir ttmwminanis as JeEn,J by the Bay Area Air Quality Management TOTAL:
Dismm? BOILFR-COMP(OVER 100,000 BTU)
❑Yes FIN.
I have read the havudous materials rMomemme.,ondcr Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE
forma Ileallh&Safety Code,Smlions 25505,25533 unit 25534.1 understand that if the NEW RESIDENTIAL MEER. SQ.
builder,does not currently have a team,,that it is my responsibility to notify the«apo,
.fine requirements which most be mel prim to issuance of a Cli ilicote of Occupancy.
Owner"r euthorized igen) Date TOTAL: ISSUED BY.
`I OFFICE