S 1781 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL : PE ITNO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1
BUILDING PROJECT IDENTIFICATION 1 178 V
BUILDING ADDRESS: yM��Q-�'I I�f1 SANITARY NO APPLICATION SUBMITTAL DATE
Y G�JtoI i1t5b'f L1k�I� PHV�/P�R1lhfO NA
CONTRACTOR'SN GOtq LIC NO
V
(STIP R UlUF1N0 asr i15 SIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
60
CONTACT: - PHO# -
C4Sr _ U5(?//s B. ELECT_
RLUMBMIT O
�1 /,gyp,�� 7 ❑ Consultant Fees Paid 6 Applicant Inifial
A Zw�.. Qi(v Y PP (Initial) BLDG_ ELECf PLUMB MECH
Cx C1' C� C�
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I herebySection
a(fion that 1,m licensed order provisions of Chapter 9(commencingsis JOB DESCRIPTION
�pZ with Section 7(deffideDivision3ofthe Business unJ Professions Gds and mylicense is - R SID NTIA
FQC infall a Class
eRect. PERMIT ISSUANCE ❑smwL ❑KITCHEN REMODEL
�UO Lianse Class ContiLie# APPLIANCES-RESIDENTIAL
y �i1 Dore TS DECLARATION
DDITION L1 PLUMBING RP,-PIPE
p)nnZ ARCHITECT'S DECLARATION ppNF.LS ❑MUL'rl-UNIT ❑STRUCTURAL
ZOyZ IunJeraand my plans shall he usedmpublic recoNe MODIFICATION
EOZ UP TO 200 AMPS El INTERIOR' El CHIMNEY REPAIR
.ted , Ltansed ProfessionalUP
021AMPS
IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDERexemptDECLARATION OVER 10011AMPS ❑BATH REMODEUREPAIR El DEMOLITION
U 1 hereby,(firm thin 1 am exempt from the Contractors Co License Law for the
Pi O b U fallowing mbaon.(Section 70315;Business and Professions Code:Any city or county [_1 OTHER
3 q F which re 'ecu Faalso mous,ares the ape,int SIGNS ELECTRICAL
'qurt permi improve,demolish,or repair nny swclufe
pFpz WO� 'hat hesor to licenedpursuant to
oithe Previsions
evisionofcant far such Contrarmiuoicele ssigned smrnment SPECIALCIRCUII'IMISC.
MN that bels licensed pursuant pmvisions of the Contractor and
Pime"mr,Chapbe9
W�GO (commencing with Section 7000)of Division 3of the Business and Professions Cade)or 'fEh1P.METER OR POLE(NST, COMMERCIAL
Fy c(� that he is exempt therefrom and the basis for the alleged exemption.Any violation of
w„N Section 7031.5 by any npplicant for u permit.subjects the applicant C a civil penulty of POWER DEVICES E]NEW BLDG/ADDITION El DEMOLITION
LI...�, no arm,than five hundreddollurs(3500f ❑TF,NAN'f ❑FOOD SERVICE
CQEl 1,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
.22willdothe work,and thestmcmm
re is not iatendedoflcrrl forsare(Sce,7044,Business DOTTER
Gni) 'see uad Professions Code:The Contrnctm's License Law does not apply to an owns of OUTLETS-SWITCHES-FIXTURES
L pmpeny who huild,s or improves thereon,and who does such work himself or Nmugh
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ
sale,If,however,the building or improvement is sold within one year of completion the _ �� SQ.Ff.FLOOR AREA $/SQ.FT
oar-builder will have the burden of proving that he did not build or improve for par- 2 1 0 7 3e�L 2
pose of"are).
❑ 1,as owner of the property,am exclusively convening with licensed contractors to T
consrtue( he project(Sec.7044,Business and Pmfessimo Codc)Tim Coamacmr's Li
owLawdtesnmupply10unnwnerofpropertywhobtche,orimprovesmereon,and QTY PLUMBING PERMIT E 22
who contracts for such prowas with a eornractorp)licensed purman(to the Commclnrs JJ
License Law. - PERMITISSUANCE
E] lam exempt it der Sea ,B&P C for his reason
Orvner s D:ne ALTER-DRAIN&VEST-WATER(EAU VALUATION
WORKERS COMPENSATION DECLARATION BACK PLOW PROTECT DEVICE 00
I hereby Zan under penalty tf perjury one of the following dalmatians: J V, 1717 CJ
.� shave and will maintain aCeniOmv(e of Consent to self-ins,rc for Wnrkerc Compen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3700 of the Labor Code,for the performance of the
%ark for which this permit is issued. FIXTURES-PER'IRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance orihe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP APN
My Worker's Cmnpensatlon Insurance carrier and Policy number ora'
Corrie': Policy Na: GAS-EA.SYSTEM-OVER 4(FA)
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GRFASE/1NDUSTRL WASTE INTERCEPTOR
(Loswedime need not be romded if the pcourts(orone hundred dNlors(S 100) BUILDING DIVISION FEGS _
or re"') GREASETRAP PLANCHECK FEE &
I employ
any thin in the perany manner
of s to become
for subject to the Work esued,'Cr mer-shall �o m�0
$EWER-SANITARY-STORM EA.2M FT
Z
not employ nny person in any manner so as m become subject m the Workers Grmpen- ENERGY FEE
.4 Applicant
Laws of Cali from.Data
z O Applicant � � WATER HEATER WNENT/ELF.CTk GRADING �
ti NOTICE TO APPLICANT:If,after making(his Cer ificale of Exemption,you should WATER SYSTEMOREATING
becnme.'object to the Worker's Compensation provisions of the Labor Code,yon mus( SOILS FEE
{ZIti
forthwith comply with such provisions of(his permit shall be deemed resulted. WATER SERVICE
Q
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID q 5'11?0 ���
610 Ihueby a0dnn(hutrhere isaconnmminn lendin6 agency!the performana of Date ceipt#
W u the work far which'his permi(is issued(See 3097,Civ.C.) _
Q U Lender's Name TOTAL
V H Lender',Address TOTAL:04 1 certify that I have read this application and state(hot the above information isB DING FEE 2-
O U
Ln correct.I agree to comply with all city and county ordinances unstable laws relating to QTY. MECHANICAL PERMIT
LI4 building construction,and hereby authorize representatives of this city to enter upon the tl IC FEE
above-mentioned property for inspection purposes. ILI
(We)agree to save,Indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
inliabilities.judgments.staving expenses which may in any way accmu(gains(said City ALTER OR ADD TO MECH.
nsequcncc of the graining of this permit. PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SO CE REGULATIONSAIR HANDLING UNIT(OVER 1010,000 CCA)k 114 o1wMLQ4- � 4J4 CONSTRUCTION E
X
Sga u e ppheanOConmacmr
aC EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE
Will the u,hic rotorfarm..building occupant sore nr handle hazardous material HEATING ON IT TO 100.00d)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ileal(h and Safety
Code,Section 25532(,)? MATING UNIT(OVER I00p00 BTU)
❑Yes
EI VENTILATIONFAN(SINGLERESID) PAID -
Will the applicant or future bei Wing occupant equipment or devices which
Date Receipt k
�onrib bamrdoun air condominiumsM Defined by the Buyy A Arca Air Quality Management BOILER-COMP f3HP OR 11t1,fg0 PTU)
District? T f
` ❑Y,A ElNo - BOILER-COMP(OVER 100,000 BTU)
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
q un ISSUANCE DATE
Inmia Hemhh Yr,Safety Code,Semens 25505,25533 eIv25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Ff.
In ing�Iucc not curtenbly have utenunt,slut iris my( ponabiliry¢mnmify the mcupam
of b re v t en� TZ L yO coif ( r(,0 P T
Owner ar authorized agent J,•`-�T` L� Dam TOTAL: ISSUED BY:� ,)e- ���`•' ,
OFFICE