S 0514 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull DING-ELECTRICAL P' NIT NO.
BUILDING DIVISION APPLICATION/PERMITPLOMBING-MECHANICAL 05-14
IIUII.IIING PROJECT 11)4.MI'EFICA'1'ION
BUILT GA U3Sy SANITARY NO, AITLICATION SUIIMITTAL DAT'.
Fi ISM
OW 'S NA P PI N CONTR O ;S N li: .: 1,
TM N/C CON'I'ROLN
I ••qµ ITE NGIN[I?R .1 O: ... ADDRESS:_?_/ /. ❑
ir/ Oro
I CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG lin' e n I IiC
LICENSED CONTRACTOR'S DECLARAHONQTY ELECTRIC PERMIT � PEI?
1 hereby vtprm thin I into licensed under pravi,hrm..f Chapter 9("am
mendin JOB DESCRIPTION
DWZ with Swiion7")nf Divisian3ofthe9usinessend PmfcssimsCWe.attd myltccnm,, RESIDENTIAL:
a10 0 PP.RMIT ISSUANCE
aF"� infall Class dcl7ect. DSFDWL D KITCHEN REMODEL
F._Zu Lv:cnu Class LidN APPLIANCES-RESIDENTIAL ❑ADDITION DPLUMBINGRE-PIPE
N 6 RDam
te Contn
F.Ow or
ARCHITECTS DECIARA'I'[ON. MODIFICATION
❑MULTI-UNIT ❑STRucTURAL
-
Z O Z, 1 understand my plshell be used ms public records PANELS
OZ-O UPT021g1AMP5 El INTERIOR ❑CHIMN17Y REPAiR
:;44 E Mailed Prore"warl 201.1000AMPS IMPROVEMENT E]SWIMMING POOLS
aa .•]] OWNIiR-exempt?R UIiOne Cor em OVER 10OFAMPSi
G" ..1 DEATH REMODIiI 1 DEMO TIO-`
y6, < 1 hereby.(Orin that I am tempt faro Pr CnnOaotar's License law lin the
p(06U following ream..(Section 703L5,easinessand Prof ession.Caic:Arty city orcountySIGNS ELECTRICAL ❑OTHER
W 3 a,Fa which requires n permit re cores the aper,improve,demolish,nr rcpar any Owment
J pdnnrsficerancgakm requires theapplansiefor e such Contrarminofile aicense ned Law
SPECIAL CIRCUIT/AfISC.
ythat he is licensed pursuannoahe provisions of the Cnntmnor's License loaw lChmpter9
WfYpO (commencing withSection 711W)of Division 3nftbe Bvainessand Professions Ctdc)ar TEMP.METER OR POLE INS'lt COMMERCIAL:
that he is exempt therefrom and the look for the al leged exemption.Any violation of D NEW BLDG/A DDITIoN ❑DEMOLITION
iLLC7 W Section 9031.5 by any applicant for a permit.subject,s the applicant too civil penalty of POWER DEVICES DTENANT ElFOOD SERVICE
'Z m
out more than rive hundred dollars 65W} IMPROVEMEN9'
0 ❑ 1,as owner of Ncpmperty,nr my empinyewwithwv'es ns thcirsnlevontpcnsntion, SWIMMING POOL
HLIiCTRIC
will do the walk,and the s0ucam is oat intended oraRe¢d fnr .sole(Sec.70,14,HusinessD OTHER
and Professions Code 'Me Contractors LicenseLaw does not apply man owner of OUTMTS-SWITCHES-FlXTURG'
d 3 property who builds or improves thereon,and who does such work hin velf or through
his own employees,posided that such improvements am not intended or offered for NEW BESIDE NTIAL ELECIR SQ
- sale.ILhousem,the building or improvement issold within,;..,, ai'.e.'eninn,the SQ.PII FhDQRARI3A S/SQ.FT.
owner-builder will have the l mden of paving that he did oat build m improve for pur- P I
'so,t ale).
❑ 1,as owner of the prnpeny,are exclusively rundown,with IicenaaJ mmmnors to f - C �[paI�
.intact the project(Sec.71,4,Business ad Pral'r1da,o Code:,
oem 'fhe Cnnuuebn"e I:- AUG
nu law ds napply to on owner of property who hre
ui Ids or improves theon,and QTY: PLUMBING PERMIT EE �/ IE{/U
who contracts for such projects with a contmcmrt.$)licemed pur.uanun the Contano's
License
exeLaws & PERMIT ISSUANCE: CITY Ur CurtHUNU
❑1 am exempt under S . .B P C Inr this an
xo
ALTER-DRAIN is VENT-WATER(EA) VALUATION
Owner Date
WOR KER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following decimations:
I have and will maintain aCertifcateufCaneenuo,euf-lmurcfar Worker's Campem DRAINS-17AOILROOP,AREA,COND. STORIES 'TYPE CONS'I'IOJCTION
,anion,as provided far by Section 77(10 of the Lahr Coxle,for the perounnuaec of the -
walk for which this peur n is issued. FIXTURES-PER TRAP
1 have and will com ain Workers Cima,m Its,Insurance,as required by.Section '
37W of Ne Labor CoMe,for Ne perfonmaace of a he work for which Nis ani s d. GAS-EA.SYSTEM.I INC.4 OUTI.Lrhs OCC.CROUP APN
My Workers�mpy gy ILIttgC--9ag{nl cY lacy num
a 'ee IJ�/ !"fY.7LI GAS
-EA.SYSTEAI-OVF.R4(F:A)
m Z CERTIFICATE OF EXEMPTION No; WORKERS', J/ GRIiASPJINDUSTRL WASTE INTERCIiPfOR
COMPENSATION INSURANCE w BUILDING DIVISION FEES
(This actio nccl not he urmplcted due wnut is foram hundred duh,o,5100) GRISASIFIRAP
it,less.)(This
PE13
I certify that in the performance of Ne work forwhich this permit is iourd.l shall SEWHR-SANITARY-STORM P.A.2W Pµ
not employ any person in any manner so a to berg ne subject m the WnrkerC Carmse. ENERGY FEET
0 sonar hwsof Cehfnmiu Dam WATER HEATER W/VENIVELECIR GRADING FEE
Z 0 Applicant
ti NOTICE TO APPLICANT:IL inner making thin Certificate of Exemption,you should WATER SYSTEM/TREATING
abecome object the Worker's Compensation pmvisiuns of the Labor Code,you must SOUS HE
mil forthwith comply with such pmvisiuns or this permit skull he deemed revoked. WATIiR SERVICE.
P Q
CONSTRUCTION, lo. .coulLENDINGAGENCV NIiW Itlitil Ul?N'IIA
LPLM. SQ,4T, PAID
VQ I for
r�t Nernalri isacrnume..30leading agency for the perOnnnnnm of Dura Receipt is -
� I-^ the work for which this permit is issued(Sec.31W7,Civ.CJ T
1-' Lenders Name
Lenders Address TOTAL: BUILDING FEE
{{.. I certify that 1 have read this applienion and state then the above infnnnation is
L ((AA comet.I agree to comply with all city and county oainanccs and state laws relating ro QTY. ML'CIIANICAL PERMrr '1 FEE
'U Z building construction,and hereby nuthonze representatives ofthis city mender upon the SEISMIC FEE
alawe-menomial property for inspection purpmu.
1 We)agree b Once,indemnify and keep harmless the City of Cupertino ngonst PP.RMI'T ISSUANCE ELECTRIC F H
liabilidcgjudgtnend,c...taund c.,cmcs whichnay many way accmc against laud City ACfER OR ADD TO MECH.
in amsequencc of the'noting of permit PLUMPING
APPLICANT UNDERSTANDS A D.WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE FrU 10 S. MECHANICAL I'IiP.
AIR HANDLING UNIT(OVER 0,000CPM) CONSTRUCf10N AX
SignaareofAppliunUComacmr ate EXHAUSTHOOD(W/DUC) HOUSING MIT iATION FEE
HA7ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous underial HEAI'INC UN1'1'(TO 100,000 BTID
as defined by the Cupertino Municlp6l Coule,Chapter 0.12,and the Health and 9dBny
Cock,Section 25532m)? IIEXI'ING UNI'I'(OVER Iopium 13 TO)
❑Yes ❑No VENTILATION PAN(SIN GLI:RE.SID) PAID -
Oas Ns it,g
Will the applicant or furore Molding occupant use t,Air Qu or devices which ,
- mit hazardous air mmuninantx as Jefine4 by the coy Area Air Quality Management BOILER-COME I3HP OR IW.ggl lf1'U) tL.
Di cal
❑Yes L)N. ,IXBOILER-COME(OVER 1000 BTU)
-
I have rend he hmzardoue come is regnircmenas under Chapter 6.95of the CaliA I R CONDI I'IONER ISSUANCE DATE
litmus Health Ac Safety Cala,Sections 25505,25533 and 25534.1 understand that If the n NBW RBST DIdSUAL MECI1, - SQ.IT.
building Nes not currently u anam,Nan it is my rc,Emsihility to noail'y Nmecupam
of the mgeircmems which mustse,he men pnonoissuance nfa Cenificme of Ocvupanry. '
Owner or authonzed agent Date TOTAL° ISSUED BY:
OFFICE