S 1283 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUpFRTINO HUH.DIN'G-ELECTRICAL Pci jr NO. 1283
BUII,DING DIVISION APPLICATION/PERMIT r1,UMB NC-MECHANICAL V\
IIIJI LDINC.PROJECT I DEN'1'I FICATION
HUILDI NO ADDRISS: SAN I'IA RY NO, APPLICAr PON SUBM H1 AL DATE
NER'S NAMEPHON CON'IRACI'ORR NAME 41-116)(A LIC NO',
•, �. NIC CONTROI.M
• A CIf IECP/ENOINEER; LIC NO AtAllwI OUA-k+ ii ❑
CONTACC PHONEILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) Id_DG ELECT 111.11011 MECH
Ago in L__D 5to ❑ ❑ X ❑
LICENSED CONTRACIO 'S DECLARATION QTY. ELECTRIC PERMIT FEF:
I hereby afrrm that 1 ant licensed ander provisions or Chapher 9(eonancndng JOB DESCRIPTION
Q=Z with Scelinn]WU)nf Divi.ionJof the Basions nnJ l'rvfcsziuns Codc.and mY license is RFSIDENTIAL,
w O PERMIT ISSUANCE
F ly4 full force ane l (` ❑SFDWI. ❑KITCHEN REMODEL
c U F Ldccnsc Clan Lich /
Q U API'LIANCCS-RESIDENTIAI. ❑ADDITION C)PLUMBING RE-PII'li
F Z W Date Commctor
mQa ❑MUCTM111N1'r [I STRUCTURAL
ARCHITECTS Hli
F„O y PANUS MODIFICATION
OZ=z IundnslunJ my porus shall he used ax Puhlic mcurd% ❑p'102011 AMPS
❑INI'IiN10N 0G111MN17Y REPAIR�X..Q hkmncd Profcvrinnul 201-10(X)AMPS IMP'ROVEMEN'T E3 SWIMMING Pool'shF4
OWNER-BUILDER DECLARATION OVI. IRXIAMPS ❑BA'DI REMODEIIREPAIR [I DEMOLITION
5 C C I hereby diner mm 1 run exempt from the Contractor s License Law fm the
OTHER
X 3 i U following reason.(lection]1131.5.Business and Pe fessions Cale:Any city or county SIGNS ELECTRICAL (�
W LL hto which inquires a pertain to construct,utter,improve,Jetnolish,or repair any structure
Q prior to its issuance.aim)requires the applicant for such pertnitto file n signed statement SPF.CIAI,CBCUI'I'IMISC.
that he s licensedpursuant ithe provisions of the Contractor's License 1 (Chapter)
(con g )hS t ]1qB) ID .-i J of the Business TendP f'.- n,Coro)or TEM RMI-I ER OR POLE I NS'1'. CO�RCIA,
C,yoy th:t hex warapt thwlrn a tithe basis n Ilgd stpi Any viulmiot of ❑NEW BI.DCADDITION [:j DEMOLITION
W,v Solana]1131.5 by mry applleanl for opermit abit,as the applicant to u civil It'll,of 1'OWCIt UEVICI3S
m more Than rive hundred dollors(S5lW). ❑ MPR N'I' FOODOU SERVICEn
~_< m owncrof the n SWIMMING POOL EL[CIRIC IMPROVEMENT
I.
prone rinr my empinyce.wins wages as heir sole mmpcn>aG°°' ❑OTHER
p- will dmhewor,ande The nureatolmmndrd nrawdoo,ormle(ply AI J4,owners
' i 3 m and P'rofessians Calc:the Cnneacmr's Liccnx law docs not apply m an owner of OUI'LITS-SWI'TCHFS-PIX'I'UKI3
property who builds or improves thereon,and who does such work himmlf or through 17
his own employees,provided that such improvanentate n I intended nr ofleecd for NEW RESIDENTIAL ELECTH FT
.vale.If however,the holding or improvement is said sithdnone yearafcomplcline,the SQ,FE FLOOR AREA 95Q.FT
tinvoci-hadder will have the burden of proving thin he did not build or Impro a In,par
Q•1 an
ne
swle of die prnlwny.u exclusively contracting with license]enmraleas m TOTA 1.:
mxttuct the project(Sec.TD4.Bosinc,s and Pmievaduns Calc:)no Comon lin,Li-
cenuLow has,..,Apply man owner of prnpenywho buildsn rroprove,themes.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contrxtnr(.)licensed pursuant m the Commcmfs
License Law. PERMIT ISSUANCE
0 1 nm exempt under Seer. B&P C for this mn
At:[ER-DRAIN&VENT-WAT17R(EAI VALUATION
Owner Dote
WORKERS COMPENSATION DECLARATION RACK FLOW Pat H, ,DEVICE
I hcmby aflhnn under puac,11,of perjury one of life fallowing dcClarvnons.
❑Ihave and will tnmntoina Certificate of Conant n:self-insure lin Workers Coupon- DRAINS-FLOOR.ROOT,AREA.GOND. S ORIEs TYPE CONSTRUCT ION
.inion,it,pernaled for by Section 3700 of the IaMa Code,for the ponforomnre of the
work for which this pound is issued. FIX'GJRES-PER'I'RAP
E]I have and will muinwin M'arker's Compensation In.wraace,.%required by Seelnn
J]lpof the Labor Code.for the perform rexrunwof the work for which this pcmJt is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wark,e r yia u r d Policy
Carrico lidicy No.: GAS-EA.SYSTEM{)VER4(EA)
C17KFIIECAPIT 01'EXF,MI'I'ION PROM WOR KERS' GR HASIYI NDUS'I'R L WAS I INI'INCEPrOR
CUMPENSAH
' ON IINURANCE BUILDING DIVISION FEES
(Thi ,ocinn nocdnla be complemJ if the permit in for one hundred dellars 1511X1) GREASI3 TRAP
.I,Inst PLANCIIIiCK 1936
I ceraynet inthencrfnrtnarneoflhe work lmwhichthisicmtit i.sissud.1%hat SEWER-SANITARY-YI ORM I?A.20X1 IT.
not employ any person in any manner sit as u,keen.subject to the Workers'Compcn- ENERGY I lili
Zsution Laws of California.Did. WATER 1117ATER W/VENT/F.LECfR Q
z0 Applicant GKA N66'I:
NDPICE TO APPLICANT.if,after making this Ccnificam of Exemption,You should WATER SYS'I'LM`TREA'I'ING
N OIhS TEE
NF im onm subjccT y the wnrkv+'x Cnmpensadon nrnvisimal of me(.atom evoloo roe mart
14 KAI
!T lirvlhwilh umryly Wier'CONSIRUCI'ION LfNDINO AGENCY of revokcA. NA'll?It SERVICE (4 r
WW Ill []
.7 Z W RESIDENTIAL PLMB, SQ.EP. in Uatc „Jteccipt M
U O I hemby.firm mat there is.cna.welon lending agency fon he IKdo.n acc of
the work for which an,permit is i...ed(See.3097.Civ.C.) f v
1" 1<ndet Namc V TOTAL:
WLcn"T Addr... TOTAL:
0. 1 certify Phut 1 have read chis application and efac that Phu above infonnnuon Js HIlILU1NG FEE
TF-1IA wrreet,l agree mcomply with.11 city and emnty nr finance,a ad rare lawstclming or QTY. MECHANICAL PERMIT FEE
U Z auldingconxtruain I,a (hcmby authorieanpmscouni acs of rods c iD m ounce river theSEISMIC FEE
ths--necna oil properf,for i nspecuon purpnacv_ PERMITISSUANCE ELECTR IC ITEE
(Wc)agree to axve.indemnify and keep harp less the Cilli of Cupertino against
IiTdaiticcjudgmcnt.a lis and expenses whi.M1 may in any xray accrue again.w sail City ALT ER OR ADD TO MECH. PLUMBING FEE
in cnnsyuence of the ,,%r.'6 of this permit.
APPLICANTUN .RS'PAN . NDWH MP.Y WITH ALL NON-POINT AIR HANDLING UNITffO 10.0MI CFM) MECHANICAL FETE
SOURCE REGI' ,\PION.'
AIR HANDLING UNIT(OVER 111.0X)CFM) CONSTRUCTION TAX
Sign run ' acus Dmc I?XHAUST HOOD(W/DUCT) HOUSING MI'I'1GAFION FEE
HAZARDOUS MAI FRIALS DISCLOSURE
W,11 the applicant or fumlchad Wing ocerp.ol slamofhandl,hauadous rumen.( IIEAIINC,UNIT CTO I(XIJXMI If I U)
;is defncJ by the Cupenlna Municipal Calc Chapter 9.12,and the Health and Safety
Cole.Salion 25532(a)? HHA'iING UNIT(OVER HilmilXI if rut
E3 Yes ❑No VENTILATION FAN(SINGLE REMU) PAID - -wee,
Will theapplicantar future building aeupmn use c9uipmcnt or device%which
v HOILIiR-COMP OHP OR IIMhIXXI Ii PU)
mw it h:nanlnsir ammminant as defined by TM1e[lay Area Art Quality Manugemmnt 'R UAL:
Disricl l BOihEIt-COMP'(OVER I NP(MIf If'I U)
❑Yes ❑No
1 have moW the LvuNous tvtenalem funder Chu¢r 495 of the Cali- AIN CONDI'1'IONIiR ISSUANCE UNIT,
yuimincn p
Wmia Health&Safety Cade,Sections 255115,25533 and 25534.1 understand that if the NEW RESIDEN'V AL Ni 1. SQ.FI'. (/ 2l Z
building Joos mo currently have a tenant.that it is rey responsibility to notify me¢cupent 7 C_
of me ex,ircmnns which must be run Her m issuance of a Cedlficam of Occupancy.
0.nor or auchorimd.,cut Date 'ffyrAL: ISSUED BY: l/b —!•�
OFFICE