0331 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-UM BALL POINTPEN ONLY .
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL S 0331
BUILDING PROJECT 11)I:NTIFICATION-
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O N'R'S NA lid 1'HONI?: C ACTOR'S AMC LIC NO'.
NIC CON'fROLN
�ARCHITECf/i?NGINEER: LICNt: AD PSS: ❑
CONTACT: -PHONE: _ BUILDING PERMIT INFO
• ❑ Consultant Fees Paid by Applicant(initial) - BLDG I PLUMB MI?CU
1 UCENsED NTA DECLARATION QTY.' ELECTRIC PERMIT FE
J1 hereby arthro that 1 am licensed under pmvisions of Chapter 9(commencing JOB DESCRIPTION
WOO with
Section
ectrcn7000)em�rvision 3nf Ne Bisinessand Professions Code.andmy licensees PERMIT ISSUANCE41- RESIDENTIAL;
(
WOO in
%UF License Class Lic.N ❑SPDWh ❑KITCHEN REMODELQ$�r, ractor APPLIANCES-RESIDENTIAL ❑AUDIT'ION ❑PLUMBING R .PIPH
rr.1s . ContDECL
p.Orn ARCHITF.C'I"S DECLARATION PANELS ❑MUhT'IANI'I' ❑MODIFI MODIFICATION
Z O v2 Z I understand my plans shall be used as public records MODIFICATION
OZ—O UPTO 21RAMPS - ❑INOERIOR ❑CHIMNEYREPAIR
FN�ad Licensed Professional 201-1000AMPS IMPROVEMENT 0SWIMMINGPOOIS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR DEMOLITION
tY 6 1 hereby affirm that 1 am exempt from the Convector's license Law for the
�yqx(O6U fallowing reason (Section 7031.5,Business and Pmfessiom Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 LL P^ which requires a Permit to conslmnober,improve,demolish.nr sb
repair any ucone
�0 prior to its issuance,also requires the;pplicant for such permit n Blue signed stammew SPECIAL CIRCUI'IIMISC.
�} that he is licensed pursuant in the provisions of the Contractor's lJemue law(Chapter it
cam CC0 (commencing with Seen,,.]000)of Division 3 offs,Business and Professions Cede)nr TEMP.MET ER OR POLE INST. COMMERCIAL,
a a p that he is exempt therefrom end the huffs for the alleged exemption.Any violation of ❑NEW BLDGIADDITION DEMOLITION
W,^�N
Section 703 L5 by any applicant for a writit subjects the applicant to a civil penalty of POWER DEVICES
not mom than five hundred dollars(550(0. El TENANT ❑FOODS RVICP
�9+ IMPROVEMENT!
Q ❑I,as owner of me property.or mynnpluyecs with wages as their sole compensation, SWIMMING POOL ELECTRIC 1'
f.O will do the work.amdthesaumure knotimendedoroRered for snlu(Sce.9(144,Buslness r24)Q0 (71 OTHER
3 and Professions Cole:The Contractor',Li crso I..docs not apply mon iso
er ofOUTLETS-SWI'I'CIIHS-FIXTURES
property who huilds or tropines therein,and who does such work himself or through
his own employees,Provided that such improvements am no intended or offered for NEW RESIDENTIAL ELEC7FR - SQ ET.
sale.If.however,the building or improvement is sold within one year of completion,the a5f1.W AVE FLOOR AREA YSU IT.
owner-builder will have the burden of proving that he did not build or improve for put. ,
Pose ofwle.). _ O
'rOTAL:
Fj 1,as owner of the property,om exclusively contracting with licensed contractors m 11.41,
construct the project(Sea.7044,Business and Professions Cale:)l lie Contractor's Li. - 9Q
cense Law does not up ply m an owner of Property who builds to Improves thereomnnd QTY I PLUMBING PERMIT FEV, X11 /t.
who contracts for such Projects seat u contrumar(s)licensed pursuunuome Connacmrs 1 //.
License Law. PERMITISSUANCE �h yVN P
]am exfmpt der,Sec. .B&P C for this rcasnn �'
- ALTER-DRAIN&VENT-WATER(H U VALUATION
er
1I __ F.R'S CO PENSATION EC f BACK FLOW 1'R(1fLCT.DEVICE
I hereby uRrm nndcr penohy of P.rlury one of the two lin Worker's m.
mg dcalamt
❑I haveand will nmintain a CertlficumufCunsemmself- Compen- DRAINS-FLOOR.ROOF,AREA,CON STORIES 'I'YPI3 CONST'HUCI'ION
whom,as provided lir by Section 37(X1 of the labor Code, a"Ifir mance of On,
wail for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Wmkerx Compensation Insurance,as required by Section
3700o1fhe labor Craft.far the pcifnmuncem'dir work for whichthis permit is i,.cd, GAS-EA.SYSTP:M-I INC.40UTLITS fN:C.GROUP APE
My Worker's Compensmion Insurance cortin and Policy mmober arc:
Carrier: Policy No, GAS-EA.SYSTEM-OVER 4(I?A)
CHRT119CATF.OF EXEMFDON FROM WORKERS'
COMPENSATION INSURANCE GREASIVINOUS1 RL WASTE INT'INCEPI'OR
BUILDING DI VtMON FLITS
(This Eaten naed not be completed lobe permit is Lonna hundred dollars IS1an GREASETRAP
or less.)(This
FIi13
I rnify the mine perform,ncenfthe work for which this Permit is issued,Isba1[ SEWER-SANITARY-STORM EA.200 FT.
nm employ any person in any manner an u m became subject to the Workers'Compen- ENERGY P,
•z ..tion laws of California.Date WATER HEATER W/VENT/ELECTR
7�7 (] Applicant ` GRADING PER
rte- h NOTICE TO APPLICANT:If,after making this Cenificme of Exemption,you should
become
gY5'TIiM/1'RP,ATING
F become gt,hjctl m the Wnrkcr's Campensminm pmvisions of @o labor Coda you most SOILS FEII
UJ forthwith comply with such provisions or t his permit shall be deemed revoked. WATER'SERVICH
Q
7z CONSTRUCTION LItNplNGAG agency NEW RESIDENTIAL PLACE, SQ.FT. PAID pate - kaciplN
Ll O I herebyaffmnhauhere iso found
Shat,
leading agency for the performance of
Le work for which this permit is issuml(Sec.Jm],Civ.CJ '
0 U T'OfAL:
Lender's Name
V Lenders Address �� � TOTAL:
[ -r 1 certify that I have rend this alrplimninn and afro,that the nhnva Infonnminn in BUILD] G FEE
hmmm.l,gree ut cnntply with all'city unA county ordinances and state laws relining to QTY. MF.CHANICALPERMIT FIEF
U huilJing cnmwaion.and hereby amhnrizu represematives of this city minter upon Orn SEI IC FEE
above-mentimad property for impsecfinn purposes. PERMIT ISSUANCE
(We)agree In save,indemnify and keep harmless the City of C.P,ninn against .ECTRIC FEE
liabilu s.judgments,costs and expenses which may in any way acini,.gainsfsaid CityALTER OR ADD'TO MECH.
incnnsequenceufthc gmming of this permit. - PLUMB •FF.F.
APPLICANT INDBRSTANDS AND]l(COY Willi ALL NON-POINT AIR HANDLING UNIT(TO 10.000CF10)
SOU B TAI IONS,
MECHANIC 1.FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONS'TRUC'TI NTAX
Signamreof Applic rilmemr Date EXHAUS'pHOOD W/DUCT) HOUSING MRI ATION FF.F.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or henAl :¢a loos ma¢rial HEATING UNIT CTO 1010,00(1 BTU)
as defined by the Cupertino Municipal Calc.Chapter 912,and the cahh and Safety
Code,Section 25532(,)7 11 EATING UNIT(OVER 100,000 11 FU)
C-]Yes No - PAID
VEN I'l1.AT10N PAN(SINGLE HIiS1ITj pure , ' RceciPtN -
Will the applicant nr future building occupant use equipment or devices which COMP OHP OR I W,(1W BTU)
sun harardous air contaminants as defined by the Bay Area Air Quality Management yUI1.F.R- TOTAL: e
C DiNlcf) ..
❑Yes ❑No ROLLER-COMP(OVER IOQINNI RTU)
I have read the hamard.c itamials requirements under Chuper 6.95 of the Cali- AIR CONDI'1'I ONER ISSUANCE DATE
Lamin Health&Solely Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDIiN'I'IAI.MRCH. SQ.Fr. /
,I the
tins nm cuwi nch have a sunt pit...
it is my of
a Cecil!.,,
il!.,'iifOcc Occupancy.mf the rcyuiremenL.winch mut he met prior m issuance of a Cenilicme of Occupancy.
Owner or nmhorisd a gent - Date TOTAL: ISSUED fly:
OFFICE