S0001 B0606 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY3F CUPERTINO BUILDING-ELECTRICALPERMIT N0
Hl11LDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SQ��1 16 PERMIT
BUILDING PROJECT IDENTIFICATION �O
RUILUINGADDRESS: SAN]FARY NO. APPLICATION SUBMITTAL DATE
E 'S AMH: WM) j CONTRACTOR'S NAME: LIC NO:
wigs �Y / NIC CONTROL4
\ ECf/ENGINEER: LIC NO: ADDRESS: 3 7
`r J /
CONI 'T: PH-OIC: BUILDING PERMIT INFO
4Di �lir. F.4&6?
,r I-/ _O ❑ Coneultaut Peea Paid by Applicant(Initial) BLr ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLA TION QTY ELECTRIC PERMIT FEE �' LI
I hereby from that 1 am licenced under provisions of Chapter 9(commencing JOB DESCRIPTION
WpZ with Section 9000).[Division 3ofthe Business.ad Professions Cade,and my license is PERMIT ISSUANCE R ENTIAL-
g-
I L•
F,- in full force and effect. '�� SFDWL ❑KITCHEN REMODEL
�Uz License Class Contractor
APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
NQ Date Cammemr
F 7 m ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z p hZ 1 understand my plans shall be used as public records MODIFICATION
Oz.. UP102WAMPS
� EPAIR
,4 Licensed Professional El INTERIOR ❑SWIMMINGNEY POOL
9 � 2fVER1000AM IMPROVEMENT �SWIMMINGPOOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEURE IR El DEMOLITION
C W d 1 hereby affirm that 1 am exempt front the Contractor's License Law for the
t1 O ,allowing meson.(Section 90315,Business and Professions Coda:Any city or county SIGNS ELECTRICAL ❑OTHER
F O N which requires a pudidi m eariond,allow lot pr..r,demoiish,or repair......stard
rt
q d� priooits i.smance,also requires the applicant for such permadISC.
it t.file si,restatement SPECIAL CIRCUITIM
that he is licensed p...mmrto the,noisions of the Complains license Law(Chapter 9
faCl p0 (commencing with Section 7001)of Disbar.3oDho Bminass and Pmfx,i...Code)., 'TEMP METER OR PULE INST. COMMERCIAL:
d y M y that he is exempt therefrom and the basis for the alleged exemption.Any violation of DEC ❑NEW BLDGIADDITION ❑DEMOLITION
Wmay Section 9031.5 by any rMlicaut for a Form,subjects the applierm to.civil parr,of POWER DEVICES ❑TENANT ❑FOOD SERVICE
t ore an five Imbe rel dol lar.($500).
F mthIMPROVEMENT
6 (] SWIMMING POOLELECTRIC
willdothewark.and theocratic is nm intimated o...Papal foraole G9ec.INN,Business ❑OTHER
W m uvd Pmfeseians Gale:The Conmasmr's License Law duan mat apply to an owner of OUTLETS—SWITCHES—FIX'I'ORES
property who builds or imprm'es thereon,and who does such work himself or through IF
his own employees,presided that such improvemems are not intended or offered for NEW RESIDENTIAL ELEMR 'Opt
sale.If,however,the building or improvement is sold within one yearofoomplation.the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for par- 0 ��
p.a of susm
❑ 1,as owner of the property,am exclusively contracting with licensedThCamm Cambodia's
d1.- OTAL,
instruct the es jet(See.o an wner of
and Professions Core:)The es thereon,
Li- Ld�l K 373 o S
cense Law d.esnoapply r man with
a cofpmpery who builds.,improves thereon,and QTY. PLUMBING PERMIT FEE /
who concocts for such projects with a contmanr(s)licensed gumu.m m the Camrvamre �
License Law.
❑I am exempt r Sec. ,R&P C for this rearm PERMIT ISSUANCE
ALTER-DRAIN&VENT-WA ER(EA) VALUATION
ter Dae '�
ORKEk' OM .NSATI NDECLARATION BACK FLOW PROTECT.DEVICE VVYVeI
I hereby affirm under pens of perjury one of the following dwlamtlons: J
have and will maintain a Condcao ofConsem to self-insure for Workers CemNa- DRAINS-FLOOR.EDGE,A CONU' Its STORIES TYPE CONSTRUCTION
wkI,as phmcvtried for b Sectioh this Permit v, n e3700 of the Labor Code,for performance of the d. FIXTURES-PER TRAP
mr
I have trod will maintain Worker's Compensation Insurance.as required by Section 2
37M ofthe Labor Code,for the performance of the walk for which this permit is issued. OAS-F.A.SYSTEM-IINC40UTLFTS OCC GROUP APN
My Worker's Compensation Insurance carer and Policy number are:
Cores PolwyNot GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed if lhepennil ix fnnmehundred dollars(VNE CRBASH'TRAP ��
ar Ie vJ PLANCHECK FEE
Ioyany that inperson
0m anyperformance o theus
become
ark for which ubject to permiti.+iss'Cmperl SEWER-SANITARY-STORM EA.200 FI'.
not employ any Person in any manner so as m become subject m the Workers'Gtmgeo- ENERGY FEE Ss 0
z ,z, anion Laws of Califmmio.Date WATER HEATER W/VENT/FUFcTR
Applicata t GRADING FEE
ti NOTICE TO APPLICANT:If,after making this Cenificme of Exemption,you should WATER SYSTEM?REATING
abecome subjem to the Worker's Compensation previsions of the Labor Code,you must SOILS FEE
{>a forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
UO CONSTRUCTIONis aa0Nrainn cGAGENCY NEW RESIDENTIAL PLMH. SQ,Ff. PAID Date Recci IF
1 hamby affirm that there i.a connmaian lending agency for the perfarmanw of P
ti
the work for which this perndt is Issued(See.3097,Civ.C.)
�' ULender's Name T F Q
Lender's Address TOTAL
1 nify that plia
I have revel this nption m but stethe cleave informmion is BUILDING FEE
paa
l correct.l agree to comply with all city and county oninaaces and state laws relating to QTY. MECHANICAL PERMIT FEE ,y
Vbuilding coast...demand hereby amhoize representativesof this dry m color upon the SEISMIC PER V
above-mentioned pmgerry for inspectiot purposes. t
(We)agree to save,indemnify and keep homeless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE `q n 4, y
lialuthues,judgmm�ts,cons and expenses which may in anyway acemeagainst said City ALTER OR ADD TO MECH.
in .sequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOURCE RF.GULATIO 4/, O_ZMECHANICAL FEE
T� AIR HANDLING UNIT(OVER BLOW CFM) CONSTRUCUON TAX
ignvturc of Applr I tractor Dole EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE/
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building omepanl store or handle hteanlous material HEATING UNIT(TO 100.00)BTU)
as dehned by the Cupertino Municip Code,Chapter 9.12,and the Health and Safety
Core,Section 25532(a)'I HEATING UNIT(OVER 100,000 BTU)
I Yes VENTILATION FAN(SINGLE RESID) PAID AO -
199 ceiptM
Will the ti,liam.r future b tilt occupant use equipatctn or devices which BOILER-COMP(3HP OR I W.IXq BTU)it hmommun air commainams as do d by the Bay Ana Air Quality Management TOTAL:
asoma?
[]Yes BOILER-COMP(OVER I OO.000 BTU) OV it
I have read the hazardous materials requirements made,Chapter s95.f Ne Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cade,Sections 25505,25533 add 25534.1 unde..nd Nat d the NEW RESIDENTIAL MECH. SQ.FT.
building docs not currently have at.lhm it is my resrymeibility m notify the mcoNat
of the requirememe st M+me nor m issuance of a Cerlf,Cae of Occupancy.
^/0
cone(tar autharieed.gem Dace TOTAL: ISSUED BY:
OFFICE