S 3049 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PER IT NO /1
BUILDING DIVISIONif
BUILDING rI.UMRING-MECunNWAL 3049
RUILDING PROJECT IDENTIF'1CATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
t2 jp' ZI
OWNER'S NAME CONTRACTOR'S CONTRACTOR'S NAME: LIC NO:
NJ NIC CONTROL
/,PC
`
ARCHITECDETKIINEER: LIC NO: ADDR S: 0
D S 11
CONTA T: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG Is ELECT PLUMB MECH
b b ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY , ELECTRIC PERMIT FEE
I hereby.Ilirm thin 1 am[leered under pmvixers, ...9(commencing JOB DESCRIPTION
i00 with Secli.n]0)(Bid Dismain 3mfthe Bminmsted ProfessioreCede,mndmybeinme is RESIDENTIAL:
%W;: PENMI'I'ISSUANCE
F m full force era efface(2 C] [-1SPUWL KITCHEN REMODEL
aUUU Lsenx le J.J Lic.N 1. APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE
W Date Co..,.,
RCHITECT'S DECLARATION ❑MULTI-0NIT Cl MODIFICATION
ZFpvURAL
Z I understand my plansshall be Coedutsm1heme.ons PANIil.S
OZ4- UP'T0200AMP5 El INTERIOR El CHIMNEY REPAIR
F. Licensed Professional 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
aa OWNER-BUILDER DECLARATION OVER 10MIAMPS ❑BATE REMODEUREPAIR [I DEMOLITION
Q 1 hereby off rm that I nm exempt from the Contractor's License Law for the
�_4 U which
a lermiit ]O7LS,Busher, mprve,demolish,
Co de:Any city.,county SIGNS F,LECfRICAL BOTHER
Ww0 y which requires a permit re emAmC4 nlam improve,demolish, fi repair nay stmcmre
priorlos eetlecedso requitespmai,i w.f,msuchperm',Liceufacal(na,ement SPECIAL CIRCUITIMISC.
f;!jam rite he is limnsed purwanuothe provisions of the Conlracmr's Licenselamai Cod¢r9
�ap0 (commencing with Section(XIU)of Division3nf@e Business and Rnfessiona GNel or TEMP.METER OR PoLT:INST.
as`M� that he is exempt Iherefndi and the basis for the alleged exemption.Any violation of [INEW BLDG/ADDITION ❑DEMOLITION
�m Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES ❑TENANT El FOOD SERVICE
F3anot more than five hundred Ndlars WOOL IMPROVEMENT
❑I,mnwner.!rite norm tufo ees witM1 wa theinnle compensation, SWIMMING POOL ELECTRIC
ProPe Y Y e P Y 8es ox penia
will do the work,and the structure is not intended or offered for aale(Sea.7044,Business []OTHER
Cal end Professions Code:The Continuance.Lici.se Law does not apply to ea mune,of OUTLETS-SW ITCHES-FIXTU1y.S
property who builds or improves thereoa and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NF.W RESIDENTIAL F. - SQ FT.
sale.If.however.the building or improvement issnld within one year of compinlnq the SQ.FT.FLOOR AREA 8/SQ.FT.
wmepbuilder will have the bmemdof posing that he did nor build or improve for Pr-
u
pose oo
F7 1,asotitw..r of lite property,am dam, alit contracting with licensed contractors i- TAL:
conswct Ne project(See.](dal.Business entl Professions Code:)The Contractors Li-
...law does nntapply to..owrierofpmpany who builds.,improves thereon.and QTY. PLUMBING PER! F.
who contracts for such projects with a emnbacans)licensed pursuant In the Commear's
License Law. PERMIT ISSUANCE
❑ I was exempt under Sec. .B&P C far this memo
AI:1£R-DRAIN ffi VENT WATER(FA7 VALUATION
Owner Dae
WORKER'S COMPENSATIONty'iad DECLARATION BACK FLOW I'ROl'EC'I'.DFVICIi O 0
Ihereby affirm under penalty to perjuryoneofthefollowing Worker's
Co 'll
�lhevn and will lot
maintain of Corson.Codes for
orthe Worker'sce of the DRAINS-FLOOR,ROOEAREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section J]U0 of the lahnr Codes far the performance of the ,
Ek for wmi
hich,his pert ie issued. FIXTURES-PER TRAP
have and will maintain Warker's Compensation Insurance,as required by Section
of the Labor Code,far the Performance of the work for which this permit is issued. G OCC GROUP APN
My War r�r mCcnsadan anee eerier and Policy ma�e�223/R c - .Svs X� nR 4(FA)
Cartier. d�I g2TA1 BI'I fflwoolicY No.:
CERTIFICATE OF EXEMM'ION FROM WORKERS' G S INDUSTRL WASTEIM'F.RCEPf
COMPENSATION INSURANCE BUILDING DIVISION FRES_
(This secti.aneed not he completed iflhe annout is Bmmc hundred dollars(SIM) GRi T19P=C 2 3 1998
ar less.) �. FLANCHF.CK FEE
I Certify that in the perforrearsof,he work for which this permit is issued,I shall IWA
LSANITARY-STORMEA.20017 ,
not mnploy ypcnon in any manner s.nsmhsC n -tib Worker Campeau- ENERGY FEE
O7 Z sonioa Ll Ofomia.U / NENT/ELECIR GRADING FEE
OAppliwn - , - -
NOTICETO APPLICAN'C If,aTtcr making I is ertWcu e n L poen,you should SOILS FEE
I'+ become subject m the Workers Compensation presudoes of the xCollor Code,you must
Forthwith comply with such provisions or this permit shallM deemed revoked. WATER SERVICE
Q
CONSTRUCT ION LENDING AGE NE RESIDL?N'DAL PLMB. SQ.FT. ['AID
U O (hereby affirm that there is a Construction lending agency for performance of Date ReceiptN
U. F the work(or which Ibis Perini,is issued(Sec.3091,Cie CJ
OU Lender's Name TOTAL:
,r W Lenders Address TOTAL:
y I mnify that I have read this apdicmimi and Care that,he above information is BUILDING FEE
IFi h correct.I agree m comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEF.
U FEE
building Cum suuC,ion,and Iscom,tum im representatives of Nis City m enter uqm the SEISMI--
above-mentioned property for inspection Initiatives. PERMIT ISSUANCE.
(We)agree m save,indemnify and keep humlexs the City of Cupertino against IiLECTRIC
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH. PLUMBIN
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM) MECHANICAL I:E
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I0,000 CFM) CONST 0ON TAX
Signature of ApplicanJContrecmr Date EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle m.ardom material HEATING UNIT(TO 100.000 B"PU)
m defined by the Cupertino Municipal Code,Chapter 9.12,and,he Health and Safety
Cole,Section 25532(a)] BEATING UNIT(OVER 100.000 BTU)
❑Yes 111Nn V 1iNTILAI'ION FANS INGLE RESIDE PAID
�/"- Dam NceciplM
Will the applicant or future building occupant use equipment or devices which BOIL ER-COMPDIIPOR IM.00(1 Bill)
emit Weardous air contaminants m defined by the Bay Area Air Quality Management TOTAL:
DimrlcV BOILER-C'UMP(OVER 100. 0013TU)
C]Vex
l have mud the humorous materials m,mo mens under Chapter 6.95 of the Cali AIR CONUII'ION[R ISSUANCE DATE �]
fomia H.IN&Safety Gds,Sections 255()5,25533 and 25534.1 undersand Nm if the NEW RESIDENTIAL.SUCH SQ.Flt
buildingd.cs no currently have a tenant,Nat It is my msponsibiliry m moify the ceseupaal
of viremems which mus`bemetpnormiss acefaCmif �oLt)c� rlcy.
O CJ K/1- fit`
Owner tuamhnmmid bffITa6' TOTAL.: ISSUED BY:
OFFICE