S 0676 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
IIUII,DING DIVISION APPLICNTION/PERMIT
PLUMBING PROJECT
T IDENTIFICATION
S 0676
BUILDING PROIHQC IDEMI'IfICATIIIN
BUILDING ADDRESS: C k' (�'ow SANITARY NU. N/I'�LI,C.A,I'ION ti/U�RMITI'AL DAL
UJ
\
OWNE ' NAMp: PH( :: CRA IO
O R'S NAMI>: LIC NO:
O1q� NIC CON"(HOLM
ARCHITECiENGINEER. LIC NO. .5.: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) R},pQ ELECT PLUMB h1ECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under previsions of chapter 9(commencing JOB DESCRIPTION
wi�
OW�'C with Senion]1NNpof Division3efnhe Busirw—rl Prolssions Cade,and my license is RESIDENTIAL:
1+10 PIiRMIT ISSl1ANCE
CWF in full fore.and effcn ❑SFDWL ❑KITCHEN REMODEL
QUU Liccnu Cluxs Lick AI'I'LIANC[5-RISIDENTIAL []ADDITION El PLUMBING RI PIPE
F Z U Dice Controctor99y
Vi6a.w ITECTS DEC ❑MULTIUNIT El STRUCTURAL
ZCyZ Iunderstand myp:msshall he nrcdaxpahfc records PANELS MODIFICATION
OZ�� ❑
UP10200AMPS INTERIOR El CHIMNEY REPAIR
P72tw Licensed Pmlcssionel 25b POWAMPS IMPROVEMENT SWIMMING POOLS
�Y7; OWNER-BUILDER DECLARATION pyER AMPS
❑BATH R17M DEIIRFPAIR ❑D17MOLITION
C C Q I hereby affirm Inn 1 am.xentpt from the Cnmmmors License Law for the ��y �
3 d U fallowing rcaum.(Section]RJLS,Business and Yndcssionx Calc:Any city or county SIONS ELECTRICAL ❑(YCHER
W LL vFi which requires a permit to construct.alter,improv.,demolish,or repair any strvclutt
F"40 prior to its issuance,also requires the applicant for such permiuo file a signed statement SPECIAL CIRCUITIMISC.
that he is licensed pursuant a the provisions of the Contractor'.Li¢nse Law(Chaprer9
ul aQ (commwcingwim Seeti, 700(hof Division 3 ofnheBusinexsand Prnfc..iuns Code)or TEM P.MET HR OR POLE I COMMERCIAL'
Q.L e C Ina,he is cxcmpt mercRom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑D17MOLI FION
�y Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
of mere than rise hundred dollars(5510). IMPROVEMENT
F-1 us owner oaths pmpeny,or my mnpinycex with wages us their sets annpensminn, SWIMMING P(l(lLE iCTRiC
�p=.,� will Jn the work,and thrownure isnm intended nr nli'cred for sale(SaA14W,Business ❑OTHE;R
i 3 w and Professions Cade:The ContmntMs License law does not opply to an owner of OUTLETS-S W ITCHES-FI
property who builds or improves thereon,and who docs such work himself or through
his awn vmployces,providul that such improvcmmirs are not intended or ntlbred for NEW BESIDEMI'IAI.ELECTR SQ
sale.If.however,the building m improvement is sold within one year of completion,'he
SQ.1'1',FLOOR ARBA $ISQ.Ff.
o ncr-builder will have the burden aaproving that he did not build or improve fur per-
prseofsale.). p
TOTAL"
I] 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(See,](144.Business and Professions Codu)The CnaloiCams I.I. It
cense law does nm apply to an owner of property who build.or improves manor.and QTY. PLUMBING PERMIT FEE O
who contracts for such projects with a commilors)licensed prsan0
uuo the Contractors
License Law, PERMIT ISSUANCE I ? %'f v I,
I am cxcmpt ander Sic. ,it&P C ser this rca.on v -1NST
ALTER-DRAIN&VENT-WATER(EA) V' U
Owuc Date
WORKER'S COMPENSATION DECLARATION HACK FLOW I'R(1fECi'.DEVICE
1hereby affirm tain a penaltyor te ofCoyencofthefolbwing declarations:
In,as provided
foimaineCenilkers of ConsenttoCoo, urda, Workersce of he URAINS-Iq.00R,RIR)P.AREA,CON D.
on,az provided fw by S¢tion 3700 of the labor Cade for the performance of the tiIUR1E$ '1'YI'li CONS'1'ItUCT1O1
work far which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section '
3700 afine lalxaGidc,rnrd-N,tonnmer of lbe work fforr'r which his pc,00,,issued. GAS-EA.SYSTEM-1 INC.4 OUTLEis (ICC.GROUP APN
ence
C,�orkcr CeniERTTs�'u�� k JE F EXEMPTIOiNYF110M W(McvF_ GAS-EA.SYSTEM-OVIeRA1EA)
CO PI7NSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIV '10 PP
(This section need not bemniplcled if lhepertnil ixfnnma hundred dulhtm(SI(Np GREASETRAP
in IessJ PLANCHECK Il?Lt OV L4
I certify mat moms fierfmcamad cfthe work for whichthis permit is l...ed.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as ns he(nme,.bjem to she Workers'Compere ENERGY FEE
O z. smi.d[cwv dC.Ido hi Dmc W/O ER M17AI'ER WIVCNT/ELECI'R GRADING IIiE
Z o Applicant
ti NOTICE TO APPLICANT:If,eater making this Certificate of Exemption,you should WATER SYSTF,MO71REATING
a , become subject m the Worker v Compensation provisions of the Labe Code,you must SOILS FEE
forthwith comply with wch pmisimm—rthis permit shall he decmed«vokvd, WATER SERVICE
a0
= z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM). SQ.FL. LAID Dam Receipts
U 0 1 hcrcny affirm mat mere is sued(Sec.3B Immog agency far the perlormancc or
HInc work for which this Inrmii is issued(Sec.31M)],Civ.C.)
Lender's Name
U lender's AJdrcs 'TOTAL:
I eagree the 1 have toad this application and sura than the show information relating is BUILDING PF.H
LF. y bunting 1 ogres c crouplyand with all city and nmnty ordinances trod smo: ant relatingbe QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby uutherize representatives elicit coy wcnerupm rbc SEISMIC F1:13
abnve-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree ns.save,indemnify and keep harmlos the City of Cupertino against ELECTRIC hili
liabilities,judgments,costs and expenses which may in any way accme against said City ALTER OR A DO TO MFCIL
in comequrnceofthe grantingol his pcmu. PLUMBING Ilia
APPLICANT UNDERSTANDS A WILL COMPLY WITH ALL NON-POINTAIR HANDLING ON]'p OPO 10,INNI CFM)
SOURCP 1 TIONS,
MECHANICALITE
' 'v'�/ AIR HANDLING UNI r(OVER 10.000 CFM) CONSTRUCTION TAX
Sigo man Appl1cmIC Rica) 1/RIALS DISCL(tiU � 1°%HAUST {pOD(WIDUCI} IfOU51NC Ml'TICA'I'IONI 3Lt
Will the applicant or future building occupant store or handl hazardous material HEATING UN IT(TO 100.000 BILL)
an defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255321u/'I fil',ATING UNIT(OVER 110,1001 RTI)
dyes Fl No PAID
•c VEYTILATION FAN(SINGLE RPSIU) Date A t
Will the applicant or antra bidding h,,hc Rt use equipment or devices which
mil hararJous air contaminants as defined by the llaY Area Air Quality Managemmat BOILER-COMP(3HI'OR IW.(NX)B'1'U)
1,1 AL:
Diatricn] IiO1LER-COMP(OVER 100.0W)BTU)
L
❑No
read the moinous hiledulx rt N under Chvter 695 of the Coli AIRCONDITIONERISSUANCE DATE
Salbty Gore.Sections 255115,25533 and 25534.1 understmm that if the NI2W RESIDFi IAL MIiCH. SQ.I-L
ot cornntly hae atenant,mm it is my responsibility to notify the occupant
eone which must be men prior tri issuance of a Certificate of Occupancy.
octice agent Use T(YI'N,: ISSUED BY:
OFFICE