S 3042APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELEC'PRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL.
BUILDING PROJECI'IDKNTIF'ICATION
PEtlI No. 3042
BUILDING ADDRESS I f VtN
SANITARY NO.
TA;PPLICAi'ION SUBMIITAL DATE
OWNI3R'S NAME pi PHONE: .
C NTRACfOR'S NAMIi:r LIC NO: M�
NIC
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.ARC411'I'ECT/IiNGINEEI0q
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CONTACT: - PHONE:
'' BUILDING PIERMITINFO
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Hurn 64145 41 -944(e
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑
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LICENSED CONTRACTOR'S DECLARATION
I hereby aRrm that 1 am licensed under provisions of Chapter 9 (commencing
with Semtimn]UoDviaio3ohe usnes ane ppp n nasion.cl6, ylicensc ix
in endeffect.
Limme Class Lic.a
Dam Contractor
Q1'Y EI.ECTRICPI:RMIT FEE
_
JOB DESCRIPTION
KITCHo EN REMODELRESIDENTIAL,
❑SFDWI
❑AUDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT CSTRUCPURAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
PERMUISSUANCE
APPLIANCES - RESIDENTIAL
ARCHOE-CI DECLARATION
mWemmrd my planx shell he usul us public rccnrJ.v
PANELS
UP TO IDl1AMFS
p�yj'FU
a
iOyU
I a.O y
ythat
1 q'po
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yf..r
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IMPROVEMENT [:J SWIMMING POOLS
(_1 BATH REMODEIJREPAIR El DEMOLITION
11 OTHER
IJcrn,ca l'rol'cxslonal
OWNER-BUILDIff DECLARATION
t
1 thereby ifftmt tom I am exempt Pate the Commerce's License Low lou he
following reason (Section 7031.5, Business and Professions Code: Any city or aounly
which teyuitev a Permit to emanot, alter, improve, demolish, or repair any cacmre
prior in its issuance, also requires the applicant for such permit rile a signed statement
be is licensed pursuant to the provisions of the Contracmrs License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Ctdc)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section by any applicant for a Pemnif subjects the applicant to a civil penalty of
intone than five hundred dollars ($5(X0,
❑ Lus owner of the property, nr my ernpinyces with wages as theimnle c044 Business
wlllAmhc work, and thu strucwrc is not imundctl or nRered for vale (SecJ044, Itusine. •I
lad Noc,sionn Calc: The Cm rncmr'e License Low fres am apply to an owner of
woo builds orimpmvav rhmeen, trod who Jaw-vueh work hinwclf or through
2ol-I000AMPS
OVER IgNIAM11PS -
SIGNS ELECTRICAL.
SPECIAL CIRCUIT'/MISC.
TF.MP.MEIER OR POLE INS'IF
COMMERCIAL:
❑ NEW BLDG/ADDITION O DEMOLITION
CTLiNAhT FOOD SERVICE
IMPROVEMENT
❑OTHER—
POWER DEVICES
SWIMMING 4'OOI. EL[CI'RIC
l OUI'LE S-SWI'TCIIiS-PEX'fUR is D
prnpurty
hir own cnrpinyccs, Provided Lot such ioprovanants mu not intended or oll'emd lel
sale. If, hewerer, the building ar impnwamcmisynld within oneyearof cnrnpktien,the
NEW E' 13NHAI, BLEG'I'It SQ Fri.
SQ. F.. FLOOR AREA
$/SQ. FT.
crlamIdcr will have toe moven ol'p,aci., the he did not build or improve for or.
I, av owner of the property, am exclusively commcting with licensed contracmrs m
construct the Project (Sea ]014, Itusinces and Professions Crale) The Contmetoev Li-
-
move Law drasnetzpply loanownerof propeny who huildsm hopmves thereon.and
QTY. UM GPERMIT - FEE
no the Com's
who contracts for such projects with a contmcnn(a) licensed punuanmuor
PERMIT ISSUANCE
License Law.
I am exempt under Sm. ,B& P C for this reason
AMER - DRAIN At VENT'- WATER (FA)
Owner Date
WORKERS COMPIiNSA'I'ION DIFCLARA'GON
VALUATION
y+�`.
'-A—LA
+A!54:5
BACK FLOW I'ROI'1!C'I'. DEVICE
ofthu fallowing dwlanninrrx:
T hereby affirm nmderpemdtcaccol
..,RRR III��� ! a6
Consent
❑Ihavo nndwie lot in,nection icae of he Labor Coxic, xfore for Worker's Ceror do,
aa. us for my Ss 3]W of the Urhnr Crde, for perfomnuncu of the
GRAINS -FLOOR, ItOOIr,ARIiA, CON
ST
'I'YI'IFCONSTRUCTION
k li
work rix which this permit is issued.
Which his as..
PIXI'URES -PER TRAP
C 1 have and will maintain Workers Compensation Insurance, as required IF, Section
39Xluf the LaborCode, for the perfnnnaom of the work far which Nis Permit is issued.
OCC ,• UP
Al
GAS- FA. SYSTEM I INC. 4J(EA)
My WorkerppAA nsatian lnnumnce certicr Nicy mm�Mrare:
Policy
Cnrtier:?�%��2 Policy No.:
GAS -fA.SYSPP.M-OVGR4
GRGSI%INDIISTRI. WASTE
CLRTIIICATE OF BXEMIII'(ON FROM WORKERS'
COMPENSATION INSURANCE
It. ENO DIVISION
FERS
(This section need not lea completed if the prriat is for one hundred dollars (SHalf
mless)
GRIMSETRAP
PLANCF EE
I certify that in the perlbmuumeefthe work fur which this permit is iesuul,Ishall
mq pent any manner Xn us tnooconra snbjuttothe Workerv'Congmn-
min
SHWER-SANITARY- S'T'ORM 1A.20017.noongnlny
1?NER('F /O
WATER HEA'fF?It WIVIiN'I'/I?hf:Cl'H
OR ) PG13 '
O
tiIRD
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Apo.. Lawaof California. Dote
pliant
ICE'10 APPLICANT: If, after making this C'cmificee of Exemption, you should
maid isubjecta, the Worker's Cumpcnationeriod, hal of the Labor Code, you muxt
fnnhwith comply with such provisions or this permit shall he Deemed revoked,
CONSTRUCTION LENDING AGENCY
hereby aHion float is a construction lending agency for the prtionance of
the work for which this Permit is issued (Sm. 3&G. Civ, C.)
Lender's Name
WATER SYSTEMn RIATINO
WATER SERVICE
S 'EE
PAID
Dae 'tat
NEW RESIDIiNT1A1. I'LMB. SQ. FL
TOTAL:
TOTAL:
Lenders Address
IRIILDI
/rsO
SEISM lJJ
1 certify that I have read this application and state that the above information is
correct. I agree no comply with ml city and countyordinances and sate laws nailing It
huileingamstructinn,andherehy callio is represcnlatives of this city to enter upon the
QTY. MECHANICAL PERMIT FLEE
� '
PERMIT ISSUANCE?
nhnm-oartioncal pmpeny for inspection puqune'.
(We) agreems:ne, indemnify and Xcephodnlevs the City of Cupetlnastinfst
EIEC rF: O
PLUMB I EE
linhilitics,judgmenu, costs and expenses which nary in any way acerae against saiA City
In nmscyuencc of the graining of oboe permit.
ACTERORADDTO MSCI.
AIR HANDLING UNE'I'ITO 1EjXXICFM)
hCIfANI LF[E
APPLICANT NDERSTANOS ANO WIL1 O IPLY WITH ALL ON -P NT
SOURCE F LATIONS.
AIR HANDLING IINI'1'IOVLR ID.IXXI CFM)
( .TRU NTAX
n
„ /n t1
/
Signature ofApplicanU un 1)
HAZARDOUS MA'I'TRIAIS DISCLOSURE
EXHAUST HOOD(W/DUCT)
I SING h11T ATION PER
HEATING UNIT (TO 1XIJ000 ll'lot
Will the applicant or future haddingmcupunt.dome or hand haruN smmerial
as defined by the Cupertino Municipal Cole. Chapter 9.12, and the Heath and Safety
Code, Section 25532m)?
HEATING UNIT (GVHR I I1).00I B'TU)
❑Yes ❑Nn
Will the applicant or future building oxcupanl use equipment of deviceN which
coatEantrdnus air contaminants as defined by the Boy Area Air Quality Management
n7
Yrs El No
VHN'1lLA'I'ION FAN (SINGLE ItE51p)
ID
plate 4ic
-
BOILER-COMP(311PORIIX),(XN)II'fllj
I,OFAL.
BOILER - COMP (OVER IIMI,fXX)B'flD
AIR CONDI I'IONER
I have read the hazavous maenuh requirtments under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECIL SQ. FP.
fain Health At Safety Code, Seed.. 25505, 25533 and 255341 unJmwnd that if the
building does no¢urrently have a tenant. that it is my responsibility m notify the oce.fam
7_9?of
the requirement which most he ten poor to iswanee of a Certificate of Occupancy.
C Ao
ISSUED BY: Zl�_Or �•
TOTAL:.
Owner or authorized ogee Date
OFFICE