S 1118 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELECTRICAL PESAIT N° 1118
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
yUL51NG PROJELT IDENTIFICATION il
tU11.DING AUDRISS: SANITARY NO. APPLICATIIIN SUHh11T1'AI.UATI
)W LIC NO:
0 U E: L �^ ,R(A�= h14 i' . 71
NIC CON'TRUE#
•'.A CVIITG:CTIINGINEIiR: EIC NO: Z(R�1 6 n�„k�mla / s
CONTACT: PHONE: (Yl a_ V' `•'L'JA` BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑ ❑ ❑
1 Items (firm that I am licensed under f Chapter 9(a mother; QTY. ELECTRIC PERMIT FEE
Items, pmvdsir.so p s AOR DESCRIPTION
FZ with Section]gp).f Divisirn3afthe Haziness and Nrofessions Cale.and mmy licenis RESIDENTIAL,
OO in full force and "- Q PERMITISSUANCIi ❑
y.ty f, L D 1 SFDWI. ❑KITCHIiN REMODELQUU 1;On, C_I 1.¢.M APPLIANCES-RESIDENTIAL
yGW ale Conlran., GG ❑ADDITION [I PLUMBING RE-PIPE
FO ARCHI'FECPS DECLARATION PANELS ❑MOLT-UNIT ❑STRUCTURAL
ZO Z IundersarW my plans shCllhused az puM1lic mads MODIPICAl ION
OZ4- UP TO 200 AMPS [I INTERIOR E3 CHIMNEY REPAIR
F�f'ul Licence Professional 201-IgN)AMPS IMPROVEMENT
�M OWNER-BUILDER DECLARATION C]SWIMMING POOLS
C 6 I hereby ofEnu that I as exempt from the Contraction,License Law for the OVER 1000 AMPS ❑BATH RBMODEUREPAIR ❑DEMOLITION
X C'a U following recon.IScction]011.5,Business and Rofcuinnz Csrle:Any city or crane,' SIGNS ELECTRICAL [I OTHER
W 4 Nwhich tequtres a permit roumstmct,alter,improve,demolpaistructureish,or repair any structure
OQ prior to its issuance,also«quires the applicant for such Permian rile a signed statement SPECIAL CIRC U IT/M TSC.
that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9
W aMC (commencing with Section]OW)of hvison 3 of the Busiexswd l'ndc.�siom Code)or TLMBME'TERORPOLL'INST. COMMERCIAL-
6 a c 5 that he is exempt memfrom and the basis for We alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�m
See,inr7031.5 by any applicant for apchum,sub)cers the applicant to a civil penally or POWER DEVICES
not mnrttban five hundred dersor($500). TENANT ❑FOODSERVICE
^=Q ❑ 1,as owner ofthe progeny.or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC I MOVEMENT
F will do the work,and the structure is not ealcndcd oroffemJ To-olc(Sce.9(rii Bmimma ❑OTHER
W and Professions GNe:The Contractor's License law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
it..3 progeny who builds or improves thereon,and who does such work himself or through
his awn employers,provided that.tach improvements am me intended or oflched for NEW RESIDENTIAL ELECTR SQ ET.
sole.lf.however the building or improvement is sold within one yea efntmpletion,the SQ,IT FLOOR AREA S/SQ.F1�
own
cr-huildcr will have the burden of proving that he did not build or improve for par.
Insect k.).
IIn L as owner of Ne progeny,um exclusively Protecting with licensed cumene', p N 1 D n, TOTAL
Inasmuch : T p
msthe project I701.]yBusincFs and Professions Codctru
)The C,,ncnti s Li�
cense law does kotapply m an iswocrofptopeny who builds,,,improve themor and Qry. PLUMBING PERMIT FEE
whocum...f,r ,ohpmjcmts whhac dremmp)licensed pusmatto the Comments ��� WIGL¢`nseLaw.
CI I am esempt under Sec. ,Ii B:P C far this reumn PERMIT ISSUANCE
R-DRAIN.F VENT-WATER(EA)
Owner Dat` ALTER TTY Ur tiurcnYlldU1ON
WORKER SCOMPENSATION DECLARATION HACK FLOW PROTECT DEVICE;
I hand w off ai rainunder penalty of petofCon one of the following declarations
inne.
❑lhave and will maintainsioCertificate70ofConvent sure ler Workers Ci,.1 he DRAINS-FLOOR,ROOI.ARfiA.CONT. - S'I'ORIIS "TYPE.CONSTRUCTION
smirk,as prrwldhi for n sermon PW of the Labor CnJe for the peditrmence oT IM1e
wont for which this permit is tamed. IIXTURES-PER TRAP
1 hath and will maintain Worker's appeco fion Insurance, h T is peri by Section
My of t��hgge la�(M'r�pCeWa,for the perfnrm:mce of the word for which nhiepernit is issncd, GAS-F.A.SYSTEM-I INC.gUUTLEI;S OCC.GROUT' APN
CammneYr�Cngpc_nm{it�Nyyance came Policy No.° o' 371 GAS-EA.SYSTEM-OVER S(EA)
ACERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASFIINDUSTRL WASTE INTERCEPTOR
(This action need not he compleed if the,Brod is for me hundred dollarsH I(D) BUILDING DIVISION PEES
or leu.) GREASETRAP PLANCHECK FEE
Iccnifythatin he efounanmofthe wark m,whichhd,pmol is isbued.lchull GEWER-SANITARY-STORM EA.2(p FT.
not employ any perste in any importer so as to l emme subject to the Wrrkcn'Cnmpcn-
satin.Lows rl'Califu..or Dae ENERGY FEE
0 O Applicant t WATER HIiATER W/VENT/EI.FC R
r. GRADING FEIi
Nal h become subject
APPLICANT: ra Coca making this wsmirsaOf of Eacmplio r you should WATER S1'S'1'IiM/IRfiAI'INC
a {�"
become m the Worker's C.nymormmn prem ioas of the labor evoke,you must SOILS FEE
[L) fonhwinM1 comply with such provisions or this permit shallMdeemeJ revoked. WATIiR SERVICE
c. Q
CONhem is a 110N LENDING AGENCY
� 2 NEW RESIDIiNT1AL1'LMB. SQ,FT. PAID
U kbar by which hitbat woup i isaed Sce.ion[ending agency for the performance of Uum Reccipnp
U. e-I Lewnrk bar which lhispennit is issued(Sec.3(N].Civ.C-1
FF--II Uradefs Name
Lenders Address TOTAL; TO
1�•s y I cenify thin 1 have read this applieaiun and amt.that the abrvc irk,mtmion is BUILDING FEE
Z) correct,Iagrte to comply with all city and county ordinances andaam mws relating no QTY. MECHANICAL PERMIT FEE
C.) Z buddtngum.amctiun.and hereby authen,e representatives of thi%eity bender upon the SHISMIC ME
abnve-mentioned progeny for impection purnowe's' PERMIT ISSUANCIi
HMO agree m save,indemnify and keep harmless the City of Cupertino against E1.RCIRIC FEE
Iiabililies,jhd,mcnt,c cows and expenses whichmay i"any way rectum agwit"'aid City ALTER OR ADD TO h11iCH.
in coaseyuence of Inc getting of this penin. PLUMBING
APPLICANT RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111.01(1 CPM)
SOU CE RE IONS. Q�p�/ MECHANICAL
/mss/ // AIR HANDLING UNIT(OVER 1(k0H)CFM) CONSTRUCTONI
Stgwtarcof App came Commaor Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MUDIAI I TEE
Will he nppl i...I nr future mildlkgocch,wd mm or handle h...ackuvnaodal HEATING UNIT(TO 100.00)BTU)
as defined by Ibe Cotentin.Municipal Code,Chapter 9.12,and she Hcalnh and Safety
Code.Section 25512(a)'1 HI?ATING UNIT(OVER 100,0M10 BTID
❑Yes F1 No
VENTILATION PAN(SINGLE RFSID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt d
emit hawmdous air contaminants as dc0ned by the Hay Arca Air Quality Management BOILER-COMP OHP OR 100,000 BTU)
Dollicly TRIAL:
El Yes E]No BOILEIe-COMP(OVER IsMor)BTU)
I have read the haerd,,m macrials tequirenares under Chapter 6,95 of the Cali- Nit CONDITIONER
forma Health&Safety Code.Scions 25505,2551]and 2553].I understand DATE
Thal if she NEW RESIUENTIAL MECH. SQ.ET.
butWingdries ecuwhich hovel Irnetn.Ihalo ismYecof;iiCeiitYm Bmf thetcllpy. t
,,robe rgrirtments which mora he Ines prior m issuance of n CeniOcnm of @cupvncy.
Owner or uvlhoriznf agent Dae TOTAU
ISSUED BY.
OFFICE