S 0700 AIPPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUD DBI G-ELECTRICAL PE51TNO 0700
BUILDING DIVISION APPI.ICKPION/PF.RMIT PLIIAuuNf:-MF.CHANiC,fl.
BUILDING PkOJECT IDENTIFICATION
Bl11LDINGAI313R1iSS: SAM IAKY NO. APPI.ICATIO SUB '-IALDNIE
IR
WNEH'SNAMF.: -`� PHONE: CONTHAQIT)R'S NA ' z LIC NO:
)x\J Q .N11Y1 N/IV/rN! NIC -INTR My
ARCHI'T,CI'nINGINEER: LIC NO: ADDRI' S: ❑
2 4�`� ST. AA<0
_ CO CI: PHONE: - BUILDING PERMITINTO -
N^,� /A/� y� �go 60 9 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECI{
IV V r/II % ❑ ❑ ❑
1.11 ENSEII CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 herebydri'm mat lam hcensedunderptoskimsof chapter 9("'1 nearing JOB DFSCRIPTION
Owith Section]IMMB of Division 3 0l the Business and Pndeexions Cade...0 my licence is RESIDENTIAL•
p PERMIT'ISSUANC13.
is full force and effect. SFDWL
�yl n ❑ADDITI [I KITCHEN REMODEL
U�j License ChFla/s/l_L�_-,1_GIa_LI1�-Lit.p plgq,IpNCFS-RPSIDIiNf1A1. []ADDITION [I PLUMBING REd'IPE
i Dare Contmetnr _
Fly ARCHITECTS DECLARATION PANEIS CMULTLUNIT CSTRULTURAI.
zOgZ I understand my plans shall he,used as public records MODIFICATION
Oz p UPTO200AMPS El INTERIOR [I CHIMNEY REPAIR
Licensed Professional 201-10(y)AMPS IMPROVEMENT C]SWIMMING POLLS
�t� J OWNER-BUILDER DECLARAI'[ON OVER I(Nl(IAMPS [I BATH RIiMODEUREPAIR ❑DF OLI'I'ION
C 6 1 hereby affirm that 1 am exempt from the Contractor's License Low for the S I(G �f
Oy Uk. following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL, hR
30N which requires a permit m Construct,after,improve,demolish,or repair any structure
prior to its issuance.also requites the applicant for such Permit o file a signed statement SPECIAL CIRCUI'1'IMISC.
fy'y!yj. that heis licemsedpursuannothe pmsisinns of the Cnnwmnrs l-icense Law(Chapmr9
L+1'a`00 (eommencingwim Section Al(I(gol Divisinn3n171he NusinesxunJ Pndesxions CnJe)or THMR ME'1'ER OR POIH INST. '
ti that he isexempt therefrom and the hnxis for the alleged exemption.Any violation if C NEW RI.D i/AIDITION ❑DEMOLITION
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES (-1 TENANT ❑FOOD SERVICE
y nor more than five hundred dollars($500L
F Z} IMPROVEMENT
6 Clasowneeof the proPeuXoe mYemployees wimwages mtheir sok compensation, SWIMMING POULIi1.F.CfRIC
W�O will Pr Newons Codec he structure License Law does
of apply to an Business ❑BTEC^R
W � and Pmfcssinnx Code:The Contractors License Law dreg not apply m an owner of OIl'ItFTS-SWITCIIIiS-Fl%TURFC
property who builds or improves mercer,and who docs such work himself or through
his own emPlnyces,pvided thin such Improvements ore not intended m offered for NEW RESIDENTIAL PILEC'I'R SQ[IT
sale.If,however,the building or improiement is sold within one year olcompletion.the SQ,IIK FLOOR AREA DS/SQ.PU
owner-builder will have the burden of proving that he did nm build or improve for on, lin
pose of salc.f 17
C 1.asowner efthe property,am eulusively,interactingwim licensed comrmeors to TOTAL OCT U 6R�rT
comwn the project ESee.70,14,Business and Profession.Crde:l The Commcmr's RMI)
rinse Lw does not apply to an owner of prnpes m
ny who builds or improveenton,and QTY, PLUMBING PERMIT � FEE /s
woe cemneete fmsac1,pousnswim 0
a roomer )licensed panum ant the Connecters - - CIUr
License Law. PERMIT ISSUANCEVUf -H17N0
C-1 am exempt under Sec. .B&P C for this reason
ALTHR-DRAIN&VENT-WATER 0II ) VAL TION
Owner Date Q�/q
x WORKER'S COMPENSATION DECLARATION RACK PLOW PROTECT.DEVICE / O n+
I hereby affirm under penalty of perjury one of the following declarations: C/
❑l have and will maintain a Cemilicom ofConsem m self-insure for Workers Cnmpen- DRAINS-FLOOR,ROOF,AREA,GOND' STORIES TYPE CONSTRUCTION
cation,as pmvidal for by Suction 3700 of the Labor Cale,for the performance of the _
work for which this permit is issued. FIXTURES-PCR'I'RAP /
C 1 have and will maintain Workers Compensation Insurance,as required by Section
My
Wof aelnMtrCoderofthework(or which( GAS-FA.SYSTEM-I INC.4OUTLETS OCC.GROUP APN
My Wmkefs Com coca Ins mom carriersaidyNo no
Carrier: Policy Nn: GAS-[A.SYSTIIM-OVIER 41EA)
CER I9CATE OIr EXEMPTION FROM WOR .RS'
��,,,, COMPENSATION INSURANCE flREASIVINDUS'I'III,WASTE ENTERCEPIUµ
(ThR'`tion need not he annpkteJ if the permit is Innme hundred Jailors 1$103) BUILDING DIVISION PEES
or less. GRIiASETRAP
PLANCHIiCK PF.E
I cenifythmt a perfomwnceof the words for which this Permit is issued,l shall SEWER-SANITARY-STORM EA.200 IT.
not employ any person in-any manna so os to become suhjecuo the Workers'Compete ENERGY Fiji
Z, smion Laws of Cinforra bine WATER HEATER WIVIINI'/ELECfR
O O Applicant 1 t _ GRADING FET.
G Vl N(yl'ICF:'1'0 APPLICANT:If,alio making this Cenilicale of Exemption,you.should Wpl'jiR SYS'IHh1/I RIiA'I'INC,
5 heeome xobject m the Worker's Crion,o odors provisions.I'the Labor Code,you amt SOILS PER
III
fonhwithcnmply with such provisions or this permit shall be deemed revoked. WAE'I7R SERVICE
6
CONSTRUCDONLENDING AGI?NCY NEN'RESIDENTIAL PL.MI3. $Q.Pf. PAID
V Q kfor shich thi the, iso ed Scvionlendin,agency for the Pertonumme of a¢ Ree
t--t mewnrk for which this permit is isweJ ISec.3lNll,Civ.C.
O LJLender's Nome t TOTAL: -
{LI Lender's AddrCsO'I'AL:
C 1 certify that I have d this vpdisefma and stam that the obese infommtinn is
reaBUILDING FEE
Ln correct.l agree to comply with all city and county mdinovaesvndstam laws elatingm QTY. MECHANICAL PERMIT FEE
(.) Z building construction,and herchy,authorize representatives ofthis city to enter uptm the SEISMIC Fit.
alwve-mentioned property for inspection purposes. PERMU'ISSUANCH
(We)agree to save,indemnify and keep hmmlcss the City of Cupertino against ELECTRI PEG
I iahilities,jedgmetns,costs and expenses which may in any way seems,against said City ALfHR OR ADD'10 MECH.
I n conewuence of the granting of this permit. PLUM131 'FIIfI
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT A I N HANDLING UNIT 001fast CFM)
SOURCE REGULATIONS. A MECHANICAL 'E
'Id AIR HANDLING UNrrQVEH 10.011(1 CEAU CONSTRUCTION T,
namrcof APPllevnVConwcmr D Date EXI IAUST HOOD OVIDUCT)
HAZARDOUS MATERIALS DISCLOS F HOUSING MFGGAT10•FEE
Will @e undicam or faros bttddmit ec,,ant xmrc or handle hozarlon nu lerlal 1117AI INC,UNI'P('I0l100,00I BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Sulcly
Code,Section 25532(a)? ry{ 1113ATING UNIT(OVER 100,000 BTU) /
CYes 'KN. VIiNT11ATION FAN(SWOLERFSLDI PAID -
Will the applicant or future building occupant use equipment or devices which ^' Dam Receipt M
emit hazurdoa it contaminants us defined by the Bay Area Air Quality Management BOILER-COMP(311PORtl(10,t1(MI BTU)-
TO'I'AL:
DIs01m4 Yes No
BOILER-COMP fOVI:R IMAX)BTU)
�
I have real the hamNous materials requirements umkr Chapter 6.93 of the Cali- AIR CONDITIONER ISSUANCE,DATE
(anis Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL.MECH. SQ.FT.
building mss and currently have a tenant.that it is my responsibility to notify the occupant
ofthe r•^ ,rants whichmost he and prior to issuance C ifca of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED I3Y:
OFFICE