S 1076 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT'NO.
[CITY
DIVISION APPLICATION/PERMIT PLIIMItINf:-MP:CIIANICAI. S 1076
BUILDING PROJECT 1DEISTIFIC1TiON
BUILDING ADDRESS SANI'FARYNO. APPLICATION SUBMITTAL DAT
O1gA17SN ME: NIC CONTROL#
PHONE: CONTRACfOR'S NAME: LIC NO:
• ARCHITECFIENGINEER: IAC NO ADDRESS ❑
CONTACT: PHONE: HUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) u)G EIjTCf PLUMB MUCH
LICENSED COM'RACTOR:S DECLARATION QTY ELECTRIC PERMIT I'EB
1 hereby trillion but m 1 ala licensed trader provisions of chapter 9(cammcneing JOB DESCRIPTION
ZO with Secrion](XX))of Division 3 of the business and Professions Code,and my license is PERMIT ISSUANCE. 1 TI I
ce W� m full force and crtecr. ❑KITCHEN REMODEL
1UF Licenu Class Licp
<—U APPLIANCES-HESID[N'I'IAI. ADDITION ❑PLUMBING RF:-NINE
m 61 MUL'1l"UNIT ❑MOD[F[STRU�URALATIO
ARCHITECTS DECLARATION
PANELS hIODIFlCATION
ZOyZ lundecuund at,plans ehallMused as publbe records UP TO 200 AMPS
INTERIOR ❑SWIMMING FOOL
[. ul accused Pmfcssianal 20LI0fNInMYS IMPROVF.MF.NT SWIMMING POOLS
sj OWNER-❑UILUF.R Df:CLAHAI'ION OVER 1000 AMPS ❑BATH REMOUEUREPAIR ❑DEMOLITION
I4. Q I bemby affirm than I em exempt from the Commences License Law for the
d3IL FUF- following reason.(Section]IU E.5.Business and Professions Code:Any city of county SIGNS ELECTRICAL []OTHER
U.N which requires a permit to com anal alma improve,demolish,or repair any slmnnrc
OQ prior to itsissuance,also reFumes the applicantf inch permit File a signed statement SPECIAL CIRCUIT/MISC.
Et2y'` hot he I :#pars' n d 1 fin C I vn' 1 Ia.(Chapter) all
114.Qo (commencing with Secl 7") fD �isi 1 ftheH sines dP f .ions Coda)or TEMP.MFI'IiR OR POLE COMMERCIAL: ��//''�s
d 6 001' shut he Is exempt herelrom and the basis far the alleged exemption.Any violation of ❑NEW'RLRR,GsSs/A�DDITIO /LdyHMOLII'[ON
X Section 7031S by any applicam for a peonit subjects the applicant oa civil pcnvhy of POWER DEVICES ❑TIiNAN' vs ❑1:001)SERVICE
W..h not more than Five hundred dollars 1550th. IMPROV' Vf
L i] Las ownernfthe propeny.of my employees with wages as lheirsole,ort,amtion, SWIMMING POOL ELECT RIC
2Fo will do the work.and the%fracture is nor intended ornrtmW hostile iSec.J0ml.Business ��'aJfg ,,11
L 3 and Professions Code:I'he Corr enar',License Law docs not apply ,,an roan,,of OUTLEI:S-SWITCHES-FIXTURES � �Lx
propeny who builds or impmvm three I,and who doses such walk himself or Though �� t
his awn employees,provided that such impmvcmenty are not intended or offered for NEW ISIUENTIAL IiLECfR SOFT. -
side,If.however,the nunnm
ildingor improvncnl is within one yeof completion.'be SO.FI'.FLOOR AREA NS0.FT
owner- i der will have the burden of proving that he did not build or improve for pur-
Is r sale.l
KiI,ns ow r of he pa'penY•oro exclusively mmtmning with licensed nmtramors m TOTAL
Ihcxpnljem(Sec.7(ki.Business and Professions Cove:)To,ConeriUm's Li-
censeLawdons not apply to mtowncrofpmpeny who builds,,,improves thmcnl.and QTY MEIN PERMIT FEE IJ/7ho
sutra amrrams far such projects with acomrxwr(s)IiccnsW Puruanuorhe Comrnnrs Ll�f
License Law, PERMIT IS UAN -
Ej Iamexcmptunder Sec. .B&I'Cforlhisrceson
Owner Dale RAIV
ALTER-D -WATERER) VALUATION
WORKER'SCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE t8
have
and will lionmai under Certifit!icate
of Coneneoltheimsereor devWorkers
Co
❑Ihaveardidedfarby Seclion3Waftm La1nosnxR-furcfor Workers Gnmpcn- DRAINS-EIAOR,ROOM AftIM,CUND, STORIES TYPE CONSTRUCfIO'.
smion,as protide#far by Section 3]IXI of the tabor Code,for the fwrfammnee of the
work farwhich thisperms is orker, Il%TURCS-PER'IAAI'
1 have and or m Code,
Workers Cnme of the n Insurance,h i%perd h4.Section
�
37N)of the laMa Code,far the Performance of Nc wad for which dix permit is issued, GAS-EA.SYSTEM-I INC.,,OUTLETS OCG GROUP APN
My Workers ,eInsurance carrier and policy n m jtr
Cumcr: v Policy No.: f� MX GAS-EA.SYSTEM-OVER J(EA)
CERI'IFICATI;OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE? GREASFJINDUSI'RL WASTE INTERCF,ITOR A ~VISION FEES
(This section need not be completed if the purl is for one hundred dollars IS 100) GREASETRAP
or less) FLANCHEC&EY1
I ttnify that in the Mrfmmantt offhe worA forwhich this permit isi%sueJ.I shall SEWER-SANITARY-STORM F.A.2W IT.
not employ any person in any manner so as to becunm subject to the Wndcrd Cumpcn- ENERGY f'EL3 512
OZ smion Laws of Culdnmia.Date , WATIiR 111iAT1iR W/VIiNI'/ELIiCfR GRADE I
Z O Apphcam FEE
y NOTICE TO APPLICANT:If,after making this Cenificme of Iixempii You ah rld WATER SYS"1'UNM REA'1'ING
F ; become subject m rhe Worker's Compensation provi,ina,of the labor Code,you must SOILS FEE
{atl forthwith comply with such provisions or this permit shall he detained revoked. WATER SERVICE.
0.
� Z CONSreisa concur LENDING AGENCY NEN'RESIDENTIAL PCMB. SQ,Ff. PAID Dm Reaeito
V l far which
rlhauati isnum(See3lundmg agency for the of p
the work for which this permit is issued ISec.IPA],Civ.C.7
0 F Lender's Name TOTAL:
a lsndcrs Address MAI. BUILDING 31i
I certify that I have trust this applicmian and state that the above information is
correct.l agree to comply with all dry and county ordinances and stale laws relators m QTY. MECHANICAL PERMIT FEE O
U Z building constiuctiun.and hereby amhonze represenmovesofrhis city menlerapon the SEISMIC FE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to sore,indemnify and keep harmless the City of Cupmino againu ELECTRIC FEE
labolitic.judgmems,cousand expenses which may in any wvyaceme againsrmid Cay ALTER OR ADD TO MECH.
in asequence of the granting of this peril. PLUMBING MIT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IFIXX)CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT OVER 100M CFM) CONSTRUCTION TAX
Signamreuf Applicl Con mor 'J lJDvm 000 13AHAUST 110(ID(W/UI1Cf) HOUSING MITIGATION .F.
HAZARDOUS MA'TF:RIALS DISCLOSURE
Will aPPliam nr(attire building oeatpum bare nr handle hn'eallous nm¢rial I HAHNC UNI'F(TO 100.000BIU)
as defined by the Cupertino Municipal Code,Chapter 9.12 and the Health and Safety
Code.Section 25332(,,)° HEATING UNIT(OVER IOf1.000 BTU)
❑Yas []No VENTILATION FAN(SINGLE RF'_SID) PAID Dam Rnelpla
Will the applicant or faun hulling oectrpanr use equipmenl or devices which
emir heardous aircnnmminams as defined by the Bay Arco Air Quality Management BOILER-COMP(JHP OR 101L)10 BTU) IOTA.
•
District? BOILER-COMP(OVER IN),M)BTU)
❑Yes C]No
I have road the haraulm,vened,requirements umkr Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 255(15.25533 and 25534.1 understand thus if lbe NEW RESIDENTIAL MECH. SQ.FF.
building does not currently have a lenanl,that if is my responsibility to notify the receptor
of the ,rare, oras which antro be metprinnn Lsumerof a Canlfimre of Orcvpancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE