S 0973 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO RUILDINC.-ELECTRICAL. rERM1T No.
BUILDING DIVISION APPLICA'I'ION/PERMIT TING PROJECT IDHAMCAL S 0973
BUILDING PROJECT IUEN'1'IFICATIfON
ILDING ADDRESS: SANITARY N(1. APPLICA'110N SUBM1'1'IAL DATU.
p2d. A,11an �d t " 41
IONH: CONTHALTUR'S NAME: LIC NO:
W�j�Atj�g" NIC CON'IRt La
ARCIIITF,Cf/ENGIN.:iR: LIC NO, ADDRESS, ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT Ill limit MIiCH
F�jJ�� ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 heresy affirm That 1 am licensed under provisions of Chapter 9 kommencing
0ceZ wilM1 Section Division Ousincss.nd Professions Code.cent mylicensais RESIDENTIAL;
'00 PERMIT ISSUANCE
C,cF in full tome and effect. ❑$I'UK'L ❑KITCIfIiN kEMODIiI.
QUU License Class Lica gppLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING BE PIPE
F Z W Date Contmanr
'madARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCFURAI
f-y Z I understand my plain shall he used as public recsmis PANELS MOD119CATION
OZN� Oil PO 200AMPS El INTERIOR ❑CHEMN17Y REPAIR
E.vrF� Licensed Rnkssional NII-UKKIAMPS 1PROVEMENT 0SWIMmINGI'OOIS
OWNER-BUILDER DECLARAION OVER 1000 AMPS TIt REMODEDREPAIR DEMOLITION
C Q 1 hereby.Rrm that I am exempt from the Contractor's License Law for the
XO i U following mason.(Section 9031.5.Buoincss cent Rofessions Csde:Any citycity,,,county SIGNS ELECTRICALOTHERIA "N which raluires a permit as concoct,alter,improve,de nnllsh,or repair any stdemre
E:C) prior to in,issuance,also requires the applicant for such pennitit)Me a signed statement SPECIAL CIRCUCUMISC.
St�}' that he is licensed pursudau)the prnvisionsof the Canuactors Licenu law(Chaptef 9 COMMERCIAL:
9O (commencing with Section 70110)of Division 3 of the Rosiness and Profession,Caldor TEMP.METER OR POLE INST
C.2 ey that he is exempt tbcrefmm and the basis for the alleged exemption,Any violation nl ❑TEN BI"DG/ADDI'T'ION ❑1113AfO1.ITIUN
Section 7031.5 by anyapplicanr fora permit sumecutheapplicam macrvil penalty of MOWER DEVICES ❑TENANT C1 FOOD SERVICE
not mom Ilan five hundred dollarsWish. IMPROVEMENT
E=3 ❑ Los owner of the propcnY.onny employees wirM1 w:hgcs us their role<ontfensatinn, SWIMMING POOL ELECTRI
ci t: will do the work,and the,amctum is not intended or offered for mle(Sec.]W4,Rusincss ❑OTHIiR
L 3 w and Profession,Cod,:The Comormons License Law Joel not apply m an owner of OUTLETS-SWITCHES- OR "
property who builds or impenecs thereon,and whit does such work himself or(hmugh
_ his own cutployccs,provided that.such impmvenmma art nor intended of uRemd to NEW RI-SIDENTIAL F.LE R SQ
sale If.hnwme, the building to improv ntenl is sold within nue year al annhpinion,Ih< SQ.19'.IR.O(1H AREA SISQ 19'.
er-builder will have the harden of proving that he did nor build or impnrve Iia par- P*'
,
pie f, l ). TOT :. AID
❑ 1 a t the Incivey,ton esda'i'd,coulnuainj with ble cd contractor, I,
construct theproject N 9194 H and 1 I - .C 17 IT C ( 'r L /r�/�
c s I J t pplyl bl p ry h h IL t and QTY PLUMBING PERMIT FEF, C/�Uh 12 Areal
who t sa
tfrchp h is Indiaon ra(s)Icun.td par. nnolhu Citta Iurs
Licetne Law. PERMIT ISSUANCE
1 um exec under See It&It C Ibn(his re:nmh
AtJER-DRAIN&VI!NT-WATER(EA) VAI,
Owner
NO
Date
wVkFR'S CoMP17NSAI[ON DHCLARAI'ION BACK FLOW PROTECT.DEVICE
I hereby affimh under penalty it perluq one of the following tiodaeions:
❑ I have and will maintain mCenilicute of Consent msclGinsud lir Wn k...Cn olso. DRAINS-FLOOR,ROOF.AREA.COND. STORIES TYPE CONS'I'NIICI'ION
smion,is provided for by Section 3900 of rbc Labor Cndc, or the p oloulance of the
work for which this pundit Is wined. FIXI UR17S-PER*1 RAP
1 have and will maintain Worker'.Compensation Insurance,as required by Section
390(1 ofthe Labor Code.for the peri'onomme of the work for which this permit is issued. GAS-EA.SYSTEM-I INC,40f1TLC9'S OCC GROUP AI'N
My Worker's Compensation Insurance caner and Policy number ore: GAS-EA.SYSTEM-OVER 4(EA)
Currier: Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE/INOUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Timsecdon nealnabecomplcted ifrhe pernhih i.slLrnnchundmildollan($100) GRF.ASETRAP
I'LANCIIIiCK FEE
or less.)
Loy any theinthe any manner
nnerof the work,for which this perma SEWFiH-SANITARY-STORM EA.200 IT
not employ any person in any manner so as ah become subject to the Workrn'Compete ENERGY PEE
Ozonion laws of Coliform..Dam WATER HEAT17R WNENT/ELECTR GRADING FEE
Z o Applicant -
TA NOTICE TO APPLICANT:If,after making this Ceniticme of Exemption,you should WATER SYSTENWREATING SOILS FEE
become.subject to the Worker's Compensation provisions of the Lutnr Crde,you must
--
forthwith comply u ith such p avis me,or this permit shall he teemed revoked WATER SERVICE
asz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLMR. SQ.FT. PAID
U Z I hereby affirm that is a connniction lending agency for the Performance of Data h a
the work for which this p.i,is issued(Sec.3099.Civ.CJ
O Lenders Name T(yl'AL:
U Lender's Address TOl'AL:
1 I cenify that I have mad this application and sinm that the Mice information is JE
'li
F (q correct.I agree to comply with all city and county ordinances and.state laws releing ah QTY. MECHANICAL PERMIT FEE AT
U'Z building construction.and hereby amha;Chapier
ewatatives 91fujith
as voice upon the
aMdcnrmmumd pmpeny fill inspeelinvelPERMIT ISSUANCE ITH
(WI agree to save.indemnify aharmless tCupertino against
liabilities judgments costs and expensemay in anye against said City ALTERORADDTOMECH. FEEin onscqucnce of the gooming of this pAPPLICANT UNDERSTANDS ANDCOMPLYLL NON. INT , AIR HANDLING UNIT(TO Iff"CFM) AL FEESOURCE .ULATIONS.
IRI LADLING UNIT(OVER Io.000 CFM) TION TA%Signal reofAppl' Contractor 1 t F,% AUST FOOD OVMUCT) ITIGATION FEE
HAZARDOUS MLS DISCL
Will theopplicantorlumre firmuptmt domuearduusmmerial HEATING UNIT 1(10.0(10 RTU)
as defined by the Cupertino Municipal hapier 4.1Ilalth and Safety HEATING UNIT(OVER 10U,gN1 RTUI
Code.Section 25532(.)?
❑Yeo 0 N VUNTILA'1'ION FANS I NGLE RESID) PAID
D:nc Rseciph p
Will the applicant or bunch,building norminu t use egnlpmcal or devices which BOILER-COMP(3HY OR W,(YJO RTU)
.,emit hsaallous air contaminants ns delinet by Ili,Ray Ann Air Quality Mamul a a.1 'I OI'AI,
Did'el'! BOILER-COMP(OVER 100.0001{'TU)
E]Yr, [-1 No
I have mit the laminations numnals requirement,t de,Chapter 6.45 of(lie Cali AIR CONDITIONER ISSUANCE DATE
25533c
fumin Ilcnlrh&Sufcly CnJn Sccllnnn 255115,25533;int 255?4.1 undcmwnA Ihm il'Oh° NIAl R13SIDIiNTIAL MECII. SQ.FT.
building tires,c m whicly havu a ancon,that It Ix my r c of a hiifi m motif y the oewpmn
of the r,yuirnnema which mush he mel pninr In Ixauntac nC;o Cenificnm of ocenpnney.
Owner nn.uNurieW ngcnr Oure TOTAL: ISSUI D BV:
OFFICE