S 2139 —APPLICANT-TO'FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. PESIT N0. 2139
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTi FICATION
BUILDING ADDRESS: _ SANITARY NO. APPLICATION SUBMITTAL DATE
- -a
OWNfk'S NAME: PHONE: CONTRACTORS NAME: LIC NO: 36q
�_ NIC CONTROL It
10 ARCHITECTIENGIN F.R: LIC NO: Alli ESS: ❑
C�
CONTACT: PHONE: BUILDING PERMIT INFO
Q D ❑ Consultant Fees Paid by Applicant(Initial) Bu{G ELECT PLUMB i MOH
LICENSED CONTRACTOR'S DECLARATION (`� QTY. ELECTRIC PERMIT FEE � 16-61/
1 herehy affirm mat I am licensed ander pmonomm of Chapter 9(commencing JOB DESCRIPTION
F�WOO with Section 9000)of Division 3 of the Business and Pr it and mY liciamet,
� in fall forcca def PERMIT ISSUANCE RESIDENTIAL
luV License Clam `�p Lic,p�( o I ❑SFDWI. ❑KITCHEN REMODEL
yGL Dam Contractor APPLIANCES-RESIDENTIAL []ADDITION Cl PLUMBING RE-PIPE
ypyon ARCHITEC'PS DECLARA9'ION PANELS [I MULTI-UNIT El STRUCTURAL
PZS lundershnsdar,dansshall be used as publierecords MODIFICATION
O'Z.2 q UP TO 2M AMPS
r✓4 W Lammed Prolesvanal ❑INl'ERICK El CHIMNEY REPAIR
Q 201-I WO AMPS IMPROVEMENT
W OWNER-BUILDER m Ce Coure0N ❑DEMOLITION POOLS
a¢C¢1 I hereby aflirm that 1 atm exempt from the Contractor's hiceasc Law for rhe OVER Unit AMPS El BATH RF.MODEVREPAIR �Uh:MOLITION
WF U following reason.(Section 9031.5,Business and Profceions Cor:Any city or county SIGNS ELECTRICAL, [-]OTHER
O y which termini a permit to construct,alter,improve,demoli o,or repair any s m turc
prion,,its issuance,also requires the applicant for such permit to file a-signed statement SPECIALCIRCUIT/MISC - r
IhatheislieemWpursuenuatheprovisioncnflhe Commemrs License Luw(Chapter9 /I✓/I'� W O&✓
W Qp (commencing with Section 900th of Division 3 ofthe Business and Pridessloa,Code)or TEMP.METER OR POLE INST. COMMERCIAL:
tL y,C that he is exempt dmrefmm and the basic for the allesod exempflan.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W Section 7031.5 by any applicount for a permit subjects the applicant to v civil penalty of POWER DEVICES
1- N not mon,than Live Imndred dellers(5500). ❑TENANT ❑FOOD SERVICE
ydn ❑ Las ownerafthe propertyarmypmd,,c,with wrgec vs theiraole compemmion, SWIMMING POOL ELECT RIC IMPROVEMENT
will doWowods,andthest...me rap,intended-roBernd mrsale(Sce.7044,Reece, _ ❑OTHER
m uad Professions Code,The Contractors License[.so does not apply to an owner of 13TLH'IS-
SWITCHES-FIXTURES
property who bolds or improves therum,and who does such work himself rn'thmugh
his own employees,provided that such improvements are not intended or offered for NEW ESIDHN UAL ELF.CTR SQ Ff.
sale.If,however,the boiningorimpmvementissold witherme,onurfeamplatim,the SQ.FT,FLOOR AREA $/SQ,14.
nrchailder will have the burden of proving that he did ort build or Improve for pur-
pose of sole.).
❑I,as owner of the progeny,ant exclusively conmmting with licensed contractors to TOTAL.
mewm the project(Sec.70,14.Business and Professions Cade:)Tine Conoaaods Li-
whse Law does not apply to an owner of property who bn11Jx or improves thereon,and QTY, MIT FEE
o contracts for such projects with a contrcontentions)mons)licensed pursuant m the Canhecmrs pL C P ,
License Law. PERMIT ISSUANCE (,
❑ lam exempt under Sec. B&P C for this reason
OwnerALTER-DRAIN&VENT-WATER(EA)Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT..DEVICE hereby affirm under penalty of perjury one of the following declarations:
❑ Ihave and will maintain a Condi as of Consent to self-insure for Worker's Crup,am DRAINS-FLOOR,ROOF,AREA.GOND.
anice.as provided far by Section 37N of the Lather Code,to,the performance of the STORIES TYPE CONSTRUCTION
O
work far which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Workers Compensation Insurance,as required by Section
3700 orthe Labor Code,for the Performance ofthe work for which this petrels is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Comparecho r Insurance cannot and Policy number vin:
Cancer: Policy Nd.. GAS-FLA.SYSTEM OVER 4 HoO
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPINDOSTRL WASTE INTERCEPTOR
(This section need not 1,e completed lithe BUILDING UIVISION_FF.ES_
p permit is(or one dollars(SIfXI) GREASE TRAP
or less.) PLANCHECK NEG
I,anythat:.the lopfulmarce Ne kfar whblodto the W.se",C.l shall
notomploy any person in any mnnnersr c-soh ed to Workers:Cam SEWER-SANITARY-STORM EA.200 F1'.
=�•n^corn j pen- ENERGY FEE
z cation 'Californiaso .Dy���
0 WATER HEATER WIVENT/ELF.CTR NG
z 0 Applir //1 � �l
Iti Ul NOTICE TO APPLICANT 1 a ter ma ing this Comficae of Exemption,you should WATER SYSTEMn REATING
become subject to the Workers Compensation providnns of the Labor Code,you muss S 1 S FEEL
LkI forthwith comply with xrich pravisi0ns ,,his permit shall be dcemW revoked. WAFER SERVICE.
Q
z CONS'RUCTONLENDING AGENCY NEW RESIDENTIAL FILMS.IhcrehY afFlnn that there is lendingagc Gsrthe performance of R
pU Q SEPl
fA a the work for which this permit is issue)(Sec.3057,Or.C) to
LF" Lender's Name TOTAL:
.I Lender's L
fr-1 y cenify tendrils I cenify Ihvt 1 have application anJ soup that m� A
the shove information is BUILD
Ir V) correct l agree In comply with all city and county ordinances and state laws relating 10 QTY. MECHANICAL PERMIT B
U Z building combordion,and hereby authorise representatives afthivicety to enterupon the SGISMICF sO
abUve-mentioned properly for inspection putpnccs
(We)agree m cave,indemnify and keep hornless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
Imbili ties,judgments,costs and expenses which may in way vecme against said City ALTER OR ADD'I'O MECH. Q O
at onwconaceofma gronfin,of this permit, PLUMBfNC .E
APPLICANT UNDP,RSTANI S AND WILL COMPLY WITH ALI.NON POINT' AIR HANDLING UNI'T(TO I0,h O CFM)
SOURCE REGULATIONS. MECHANICAL E
�— AIR I IANDLING ONI'f(OVER IO.Om CFM)
CONSTRUCTION'NIX
Sigmurre Ap n atract Date EXHAUST HOOD OODOCT) HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfunne,huildingmcapantstore orhandle hm.ardous material HEATING UNI1(10100,000 B'I'U)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the HenOh and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
F7 W, FIN.
VENTILATION FAN(SINGLE REST D) PAID
-� Date Receipt#
Will the applicant is furore bolding by the B ore e,Air Qu or devices which
antrict) us air ennwminana us defneJ by the Bay Arw Air Quality Management BOILER-COME(3HP OR I01,000 BTU)
District) TA .
❑Yes ❑No BOILER-COMP(OVER I(NI,IMIO LOU) -
I have reedthe hovNous apaccala requircnants under Chapter 6,95 of the Cale- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cade,Sachem,25505,2.5533 and 25534,1 understand that if the NEW RESIDENTIAL MECH. SQ.
building does not currently have a tenant,that it is my respsmsibility to nearby theoccapent FT. ^Q y(
ofthe requirementsm
wushmt be mat oinno issuance afa Cenifcam of Occupancy. 7 o r
Owner or arm iwal agent Date TOTAL: Q� �
ISSUEUBn (��
OFFICE