99100125 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 694 NO.�.5
CI TY OF CUPERTINO BUILDING-ELECTRICAL T PERMIT �
BUILIXING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. Sep
BUILDING PROJECT IDENTIFICATION V
IiGILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAi.DATE
c� 146zl
NE 'S AM1fE: PHONE: CONT ACTOR'S NA MI LIC NO:
NIC CONTROL to
ARCHITECTIENGINECk: LIC NO: )RI?SS: a✓ �� ❑
CONTACT': PHONE, U /1 BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUMB j ME❑CH
I.ICENSEDCON'IRACIOR'SDECI.ARA'f10N QTY ELECTRIC PERMIT FEE
o z z 1 hereby affirm the I are licensed made,prom.Qora of Chimer 9 k,nomeram, JOB DESCRIPTION
xith Section IIXXBnf Division 3ofine Business and Rnfessi x Gale,ani mylicen.ac es RESIDENTIAL
m o O G'� rERf.Hr IssunucP:
C m F in Tota force and t CZV [.+So 3 ❑SFUWI. El KITCHEN REMODEL
ee U License,Class Lica API'LIANCGS-RGSIDENI'IAL ❑ADDITION ❑PLUh1R1 NG RI:PIPE
�Z,Z� Outs Conwcen
F-D c. ARCHITI?CPS"CCI ARATION PANELS []MULTIUNIT ❑STRUCTURAL.
ZOInZ )understand myplan.shall bcmedas public accord, MODIFICATION
O Z 41 C UPT02W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
I=. FW Licensed 1'n,fissional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
y OWNI;R-BUILDER DECLARATION
ad, OVER H")AMPS ❑BAI'll kEM0UEIJR:PAIR ❑DEAIGLI'I'ION
a 1 hereby aft m mat I an exmnpl from the Cnmmcon's Liccnac Law fns he
XO a U following reason.(Section 9031.5.Business and Professions Ceede:Any city or county SIGNS ELEC'1'HICAL []OTHER
W 3 W y which acquires a permit to construct,a1¢r.improve,demolish,or repair any swnure
F-t`'.Oyu prion its i.wanec,ai requires lire applicant for such permit o file a signed statement SPECIAL CIRCUIT/M INC. A VAZ V
ss } the,lea i,licensed pur,ourd in lot provision,of the Contractors License Law(Chapter 9
up0 (commencing whir$e<tion"IgXB o[Divisinn3hf the Rnsinms and lrnfessinns Cude)or lEMP.METER OR POLE INSI'. COMMERCIAi:
a a c x that he is exempt therefrom and the basis for the alleged exemption.Any vada lion of / ❑NEW BLDGIADDITION ❑DEMOLITION
ed Section]031.5 by any applicant for a permit subjttns me applicant to a civil penalty of POWER DEVICES TENANT ❑FOOD SERVICIi
nl mora than Five hundred drift.,(S500).
F Z} IMPROVEMENT
=a p I."'werce of the search,dnny employees with wages as their ink carn,r:tion.
SWIMMING POOR,ELECTRIC
PFC will Jct the veml mdthu,nuch:e is nor imemledoeaRcred fn,sole lSce.700.Havre,, T 'R
W3=e and Professions Cale:The Chnrmmors License Lew docs not apply me an owner of OUTIAH S-SWITCHES-FIXTURES
0. property who build,or improves thermal and who does such work himself m Enough
his own employees,provided that such improvements art not intended or offend for NEW RESIDENTIAL ELECTR SQ Fr.
are,ILI weve,.ihe building or improvanem is sold within mer,cerhr completion,the SQ.FL FLOOR AREA s/SQ.17..
owmar-buildor will have the burden of raving that he did not build or improve for put,
",rill
C a mpecontracting 1,as owner e prony.am exclusively contcting with licensed common moTOTAL:
mafuct the project(Sce.7011.Business and Promote.,Cale:)The Chase....,Ii-
i cense 1-mw deeanotnpply lnaeowner of,rola"who htuld,onapmvesthmeon,and QTY. PLUMBING PERMIT FEE
whommosel.sforsuch projects with a contraction)licensed pti—I.T to the Cmnnctm's
License Law. PERMIT ISSUANCE
❑I am exempt undersea. ,R&P C for this mason
AI.TBR- VI?N'I'-WA'IEH(I' ) VAIAATION
)wncr UIO
WOR ode, coulyof AT10N DfftsAHATION r�
Ie a d will
Iain a C nzlty of of Conwae oft self
-arr mfor dada U
i have and will maintain a Certificate of Conserv nx self-annum for Wad
nation,as provided for by Section 3700 of the Labor Cede,for the Pedo STORIP,$ TYPii CONSTItUCT10N
wark for which Thi,permit is issued,
C I have and will maintain Workers Compensation Insurance,as require tear,
3700ofthe Labor Cede,fordeperfonwnce dithc work for which this permit i i OCC.GROUP
My Worker's Compensation Insurance carrier and Policy number arc: L !!N
Carrier: Policy No.: AS p
CFRI'ILICATE OF EXIiMI'l'ION FROM WORKERS' d G
COMPENSATION INSURANCEGI US HL S' "'R
QTis section need not bit completed ifthe pemiii is-foronc hundred d BUILDING DIVISION PEES
nr less.) PI.ANCHECK FEE
I acridly that in the performance of the work for which this permh is i.
not employ any per conaar,amee,o ac ed become sobject1.the WmIm 1 M .2 ENERGY FEE
i o
ZZ cation lawn of Califnmia.Date 'ATER HEATER WNENf -LECTR
Q Applicant t GRADING FEE
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you.should WATER SYS'I EM(I'REAI[NO
became sub)ecl or the W am,Compensation provisions of the"No Code.you aur SOILS FEE
fahhwitheomply with such provisions a,this peand shall be decamdm,hked. WXMRSERVICE \
Q
UOCONS CI'ION[.ENDING AGENCY NEW RESIDENT'[ALPLMlis SR 14. YI)�
Thereby affirm Him
is
euhere ixeconawmidn lending agency far the peRnrmance of late Receipt
Fthe work for which Bis permit is issued(sec.9097.Civ.C.)
0 v Leaulms Name nr.T , 1G1-4T L:
I<nders AJdacax TOTAL: _
0. I certify that 1 have nail this application and state that We above infimnution in BJ .DING FEE
FA) corrin,l agree to comply with all city and county ordinances and state laws returngm QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby outhorim representativao(thus city theater upon the S IS TLC FEE
ohhvc-necntinncd property for inspection puganes' PERMIT ISSUANCE
(Wm agree n save.indemnify and keep harmless the City of Cupertino against F:
liabilities,judgments.costs and expense.,which may in anyway accede again,said City ALTER OR ADD TO MECH.
in asequence of the granting of this permit. PLUMB]NO FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNII'1'FO I0.000CFM)
sOUkC' r:GU1.A1'10Y5. ` MECHANEE
CONSTRICTIONT
(/�(�(�/(�[iCC-�/ /T � J✓0`� ! 7 AIH HANDLING UNIT(OVER IO.IKKI CFM) CONSTRUCTION TAX
Si,maram of A,Iic..VC.ntrn TG Data EXI LAUST HOOD(W/DUC'1) HOUSING MITIGATION TLE
HAZAR US MATERIALS DISCLOSURE.
Will the:applicant or faun rn
buildingeccupant store or handle haomorranrial HEATING UNIT TIO 100,000 BTU)
asdefined by the Cupertino Municipal Cod,Chapter 9.12 and lie Heahh sad Safety
Code,Section 25532(:0^. HE PING ON]T(OVER I00.000 BTU)
❑Yes EJ No PAID
VENTILATION FAN(SINGLE HESID) Date ReceiPta
Will me applicant or future building by the B use retaliation.Ar or M.a,which BOILER-COMP 13HP OR 100.000 BTU)
emit harunlnus air ttmaminunes:n deemed by the Ray Area Air Qui Management
Distinct? TOTAL:
C Yes [I No BOILF.k-COMP(OVEk 100.000 B'TU)
I have read the mandhus mmmnals requirements under Chapter 6.95 of rhe Cali- AIR CONDI'FIUNER ISSUANCE DATE
fomin Health&Safety Cede,,coolers 25505,25533 and 25531.1 understand that if the NI?W RESIDENTIAL MECH. SQ.FL
building ,not currently h�venrnant.tiro it is my reslamnihiliry to notify the each""
oil
f arms w 'ch nun be mel pie e c of a Ccnibcam of(keupanc.
cr or au hood agcm i Date TOTAU ISSUED BY:
OFFICE