S 0567F6Q
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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPFRPINO RUILOING. ELECTRICAL
AL
RUILDING DIVISION APPLICATION/PERMIT ItU11.DING PF:-MHGHANIFICA'HON
NG P INNO.IECI' IDENI'IF'IC
T
PFRMINO.
S 0567
BUILDING ADDRF_SS
SANFrARY NO.
APPLICAI'I(IN SURMII'IAh DAII
I o 2 IJoJ�3
g.{,vvCk
NT:R:S NAMIi: PHONE:
CONTRACTOR'S NAME: LIC NO'.
NIC
CO,MROLp
❑
ARCHITECT/ENGINEER: LIC NO:
ADDRESS:
CONTACT: PHONE:
BUILDING PERMIT INFO
RLDG ELECT PLUMB MECH
❑ Cansullant FMS Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 9000) of Division 3 of the Busineu and Professions Code, and my license is
in full force sees) effect.
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWh [I KITCHEN RIihIOOli1,
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
License Class Lic.N
Date Cummnor
DITION ❑ PLUMBING RE-PHIF.
MULTI -UNIT ❑ MODWISTRU�URAO
MODIFICATION
C:1 INTERIOR CHIMNEY RI7PA1R
IMPROVEMENT SWIMMING POOLS
ARCHITECTS DECLARATION
1 underaunJ roy plan shall be used as public records
PANELS
UP TO 200 .MPS
Licensed Professional
201-I0X)AMPS
OWNER -BUILDER DECLARATION
1 hereby .hires. that 1 um exempt front the Cnnuumor's Liccnse Law fnr the
following muton. (Section 9031.5. Business mud Professions Code: Any any of enemy
❑ HATH REMODEUREPAIk DEMOLITION
(] OTHI?kGki
OVER HIM AMPS
SIGNS ELECTRICAL
which requires a permit to crn.aruct, alter. Improve, dnnollsh, or repair any structure
prions its Issuance, also mquims the applicant for such pc niuu lilt a signed atmemant
thin he is licensedpurnuntn mthe Pmv'I lc dtile Contraclnr'x License Law(Chapter9
it, towneingwith Scral 90g)of1)lvlxin1,3ofthe Business and Pmfasxiuns Cu,10cr
that he Is worn, Ih aefir I and Me ho... for the alleged esmnptiun. Any virletio. nl
Station 9031s byany upplicant for, ..mi..chjccts.M1cepplicam ht a civil penalty of
SPECIAL CIRCUI'UMISC.
'CEM P METER OR 1101.11 INS'1'.
COMMERCIAL
El NEW BLDGIAUDITION ❑ DIiMOLi'I'ION
❑TENANT ❑FOODSERVICE
POWER DEVICES
nm inure Than Evc Imndmd dollars (5500).
0Lus owner of the pmpcny, nrmycntpinyecswithwagts usihcirsnlemmpcnn.ion,
SWIMMING POOL ELECf131
IMPROVEMENT
❑ OTICER
will it,, he work, and tbest ructure is nest intended m uffeted for ale (See. 9(H4. B.—i—
and Prnfesions Ctde:'I m Comncurts Litems Law does no, apply to an owner of
DU'1'LFTS-SW1'I'CHES-FI 1RIs.
progeny who hailds or improves thereon, and who Jocn such work himself nr through
his sewn howeveremploy. J I that such im . t intruded or offered for
Wilprovd n pros sold s are nn
sale. If. however. the lwiWing or improvement is sold within one year of completion, the
the
NEW RESIDENTIAL HLEC1 R S
SQ. FII FLOOR AREA
SISQ. Pn
ser -builder will huve the lords. cf pmving the. he did nm build ar improve for pur-
Itmsc of sale).
❑ I, as nwnet of the papery, am ncwsivcly contracting with Ilcen. G contractors m
oncet the project (Sec. 9(kW. Rosiness and Rofessions Lomr) 1 nc Cmunw or's Li-
cense Law docs not applym anowner ofpu,dy who builds m impiuves thereon.and
P A I D
r I
QTY. PLUMBING PERMIT EE
who contracts for such projects with a contru'tnns) licensed pun.am to We Commctod
License Law.
JUS 14 B'D
PERMIT ISSUANCE
❑lam ex .un Sec. .R& P C for Chia reason
ALTER -DRAIN & VENC'- WATER (IiAI
VALUATION
�—��
I'°wn°Y8� �"D.jLi
WORKER:$ COMPIeNSAT1ON O[CLAHATION
uurcHTINU
BACK FLOW IR(yfECT. DIiVICIi
CITYUr
r I hereby affirm under penalty of perjury one of the following Jn1amtion:
I have and will maintain u Cerificam of Cnnenuo self -insure for Worker's Cumpen-
DRAINS- FLUOR. RIDGE. AREA, COND'
STORIES
I'YPF, CONS'TRUCION
aa.ion, as provided for by Section 3900 of the Labor CIA, for the performance of the
work for which this permit is issued
FIXTURES- PER TRAP
in 1 have and will maintain Worker's Compensmion Insurance. as required by Section
3900ofthe L.aMrc Cale.for the Nr6mnanee of the work For which this permit is issued.
GAS -EA. SYSTEM -I INC. i OUTLE IS
OCC GROUP
AVN
GAS - FA. SYSTEM -OVER J (EA)
My Workers Cominnsmion insurance carrier and Policy number are:
Career: Policy Na:
GREASIVINDUS'I'RL WAS I'E7 IN'I ERCEVIOR
CIiWIUgCA'IPOP EXEMPTION FROM WORKERS'
COMPENSAI ION INSURANCE
BUILDING DIVISION FEES
GREASE'TRAP
PLANCHECK FEE
(1'hissectiou need not becmnple¢d tithe pemtit is forone hnndreddollars($10)
Icenifythat o the an, I..uuta oft I, orkhim ne moNeihis do, Wialm,,' ocupell
not anrpluy any pamm in any nanncr sn ns m bccnna nuM1lwt lathe Wmkcrd Qnnpcm
SY.WEk-SANI'CARV-S'I'(IRM IIA. 21x1 FI'.
ENIiRGY FL'L
WATER HEATER W/VIi F1dd.LC'I'R
GRADING FEE
.anion Laws 0 Caddo niu. Date
i
APPIImnI
t NOPICIE TO APPLICANT: 11', rliar making this Cemjlcmc o1' L'scntp.ion, you should
m, proaBiom nnhe what code, you ma:.
me wmxm'x Cmors
natmwith
WATER SYSIENVI'REAL 'INO
OILS PEE
Wq'IF.R SERVICE.
or l
� fnnhwith comply with such prmixinns nr Chis pannil shall he JmnsJ revoked.
comply
NEW RESIDEM'IALP11111, SQ. vU
i CONSTRUCDONLENDINGAGENCY
I herehyufGnnthat there isacttns0ue.ion leadingugency none wifornames.f
perrni
the work for which thistin iswed ISce. 3199. Civ. C.1
PAID
Dom Reccip.p
n'nl.:
TOTAL:
Lenders Nmaw
lenders Addmss
BUILDING FEE
1 trnify.bm I have read this application and s.am that the aMve infunuahon is
c erect. l agree to comply with all city and county ordinances and state laws relating to
construction, and hereby nmM1orin reprewmatives of.bis city menter upon thea1W,c
QTY. MECHANICAL PERMPP FEE
EEbuilding
martioncJ progeny for inspection ImPaes.
agree to save, indemnify and keep harmless the City of Cupertino against
Iiabili.ies.judgments. costs and expenses which may in any way accrue against said City
PERh11T ISSUANCE
FEE(Wel
G FE
ACITRORADDTOMF.CD
in comscquence of the granting of this permit.
APPLICANT UNDERSTANDS AND ILL CO PLY WITH ALL NON -POINT
AIN HANDLING UNIT (TO 1(1,(Xp CFM)
MECHANIC FEL
SOURCE EGO) ATION
AIR HANDLING UNIT IOVLR IOpIIII CPM)
EXHAUST HOOD(W/DUCT)
Si namrcuf Applcant/Contmmnr Dam
HAYARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hamrdous mmerial
as Jetined by the Cupertino Municipal Cndt, Chapmr 9.12 and the Itea.h and Safety
Code. Section 25532(ul'!
HEATING UNIT (TO i0fi XX) BTU)
!In
HEATING UNIT(OVER 101,0X1 H'CUI
VENTILATION FAN (SINGLE RESID)
❑Yes 0 N
Date Reccipip
LWill the applicant rr future building occupant use equipment or devices which
emit humrdnus air nmmmi mates us defined by the Bay Arco Air Quality Management
BOILER -COMP pf1P OR IfXk1XX) It'1'U)
'I(YI'AL:
BOILER -COMP (OVER 100.000 B'DI)
Dilldcl'!
❑ye, ❑No
AIR CONOI'I IONER
ISSLJANC17 DATE
I base mad the harurduve rnmenakm is under Chester 6.95 of the Cull-
air
NIIW I<ESIIII!N'I'IAh MT:CII. SQ.IT.
11.111, d.hnafthc
Solely Code11,ha en nos $hud 2,,uyir and 2553q.l unloudl
M1uilAing Jtes nm currently haven rM1rr it lx my mxrynrcihll'ry est loudly
build doe, y
nl'thc rcyuircmcros which roux. bu arc. prior et isvurntcc oT n Ccniticnrc of (Rsvpancy.
�Tf�
'IMAL:
ISSUED BV: v 1
O,ecrorauthorimJ agent Date
OFFICE