S 0528 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL Pigm r No. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJF.CI'IDENTIFICATION
528
BUILUINC AUURESS: � - - SANITARY NO. API'LICA'110N SUI1M1'TI'AL DAPI
/ 8/7/177
IO HR:S NAME: P CON'rRAC`10R'S NAME: LIC NO.
NIC CONI'ROIL
X
r ITECDENGINFER: LIC NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INTO
f /'�',/✓� / ��yEl Consultant Foes Paid by Applicant(Initial) xLl)C, ELECTPLumu MIiCH
Y]`
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION .I✓d�
I hereby affirm that I am Iimnswl under provision.of Chapter 9(commencing
QWz wilM1 Section]IXXI)nfD vlxinn 3 ofthe lmsinesnand Pral'essions Cole.and my license is IDEIIAL
WOO PERMIT ISSUANCE
F in full force and effect. "DWI. ❑KITCHEN REMODEL
QUU License Class Lia# APPLIANCES-RISIDEhFHAL [I ADDITION El PLUMBING RE-PIPE
F Z W Dam Cantricmr
'�rQdal) ARCHITECTS DECLARATION ❑MULTI-UNIT' ❑STRUCNRAL
F y Z I understand my plans shall he coed as public records
PANELS MODIPICAI'ION
OZ`=`LsUP'1'02WAMPS ❑INTERIOR ❑CHIMN17Y REPAIR
F-�FW Limnsed Professional 201-101111AMPS IMPROVEMENT C)SWIMMING POLIS
OWNER-BUILDER DECLARATION OVER IfKK1AMl'g ❑BATH REMODFIJREPAIR ❑DEMOLITION
C Q I hereby affirm that 1 am me in from the Contractors License Law for the ❑OTHER
O G U following musear(Section 7031.5,Business and 14nfcsxians Codri Any cion,county SIGNS ELECTRICAL.
31a.y which requires a permit us conxoaa,aher,improve demolish.or repair any structure
att I"4'O5 prior to its issuance,aka requires the applicant for such permit to file aligned stamm.nt SPECIAL CIRCU TOM ISC.
��Qf Nath :lice ed curs. 11 N providers,of am Committee.,License1-ua(Chapmr9 COMMFRCIAI
W5 C (con c 6 with Sec ]000) IU io i ftheB .- e. dl f: ns Carol nr II.MP METE OR POLE.INST.
Z.q ea that he is ormin,darefiroll ad he basis far he II g 1 cranasior,A y violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W W Section 91131.5 by any applicant far a permit subjects the apphc.m em a civil penalty of POWER DEVICES CIT EXAM ❑POOH SERVICE
m or.than five hundred dollars($5W). IMPROVEMENT
f2� ❑ I.as caner of the Property.or my employees with wages as their mile compensation, SWIMMING POOL ELECTRIC
F. will do the work,and thesWmure is but intended m oRcted for side(SeeWalkI.Business ❑O'T'HER
µ13m and Professions Code:flue Contractors License Law decs not apply to an owner of OUTLETS-SWITCHES_FIXTLRES
L property who build or improves therean,and whit does such lark hlnnelf or through
his own employee,provided that such impr.vemcnt art not intended nr offered for NEW RESIDENT IAL ELECI'K SU I-P.
sale.lf.however.the building or improvement is sold within one year of completion.the SQ.IT.Pl.11llk ARl!A $ISQFT.
.
nerbaildcr will have the burden of proving Nm he did not build or improve for par- ��� �" D
7Pos of owner
pr '
1,ns owner of the nperty,am exduxively ennvnning with licencemm
d comom to
mutroo the project ISce.]014,Holmes,and from,dons Crde:)'Ihe Contractor's Li TOTAL' W
ase Law does not upply man owner of pmpery who build nr improves Thereon,and QTY. PLUMBING PFRA FEE s1r�fV1 DCAs
who contras fo such matters with a cnmmcmrts)becn.scd ua
pursnun the Contracmr's FWJJ
License La, PERMIT ISSUANCE _
1 m tundcrti�. C d far lhss reason '
AI:1'ER-DRAIN&VENT-WA'I'L'R[CA) VALUAI'10
Owner Dam -
ff ORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT DEVICE
I hereby ahirm under penalty of perjury one
of the following declaration%:
❑I have and will maimoina Cerificamnf Comcnno self-inmrefar Wormer%Compcn- DRAINS-FLOOR.RULE.AREA.COND. STORIES TVPIi CUN\1'RUCTIOt
sation,us provided I...by Section 3710 of the Lubar Code,for permrmanceA the
work for which this permit is issued. FIXTURES-PERT RAP
❑I have and will maintain Worker's Compensation Insurance as required by Section
3700ofthe labor CAO.for the pccommence ofthe work GAS-EA.SYSTEM-]INC.J lIVfLErS for which his pranal ms issued. OCC GROUP AI'N
My Workers Compensation Insurance carrier and Policy number art: GAS-EA SYSTEM1f"OVIiRJ(G)
Carrier: Policy No.:
CERI'l171CATE Olt 17X EMPTION FROM WORKERS' GREASFJINIIUS'I'RE.WAST C I N'IERCEVI OR
COMPENSATION INSURANCE BUILDING DIVISION PEGS
(This section need not he completed lithe permit is forme hundrtddollats($IOIO GREpSETRAP
I'LANCHECK Igil3
or less.)
Ic..ifythnl in Nc pit,nuour ofon,b,k Rewhich this Permitiassued.l.off.In- SliWlik-SANII'AHY-SH)NM EA.21X1 FII
I Bol mnpiny any p.tson In any m:mn¢nn ns m beeamesubjeel e.0e Wnrkms'ConiPnm- ENERGY FEC
Oz satin.Lawsnf California.Date WATER HEAt ER WIVE.N'DEL1LC1'R GRADING
FTai
Z 2 Applicant
y NOTICE TO APPLICANT:If,after making this Ccnificam of Exemption,you should WATER SYSTEM?REATING SOILS FE-ITT
[� buome subject to the Workcds Conspcmaion provisions"of the labor Code.you must
ai I uhwith country with such provisions or this permit shall bo d.emcd minted. W/0 Ell SERVICE
6
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PND
7z Da¢ RaciPfp
Ihereby affirm that then a construction lending agency for the performance of
CUlsO the work for whichthis Permit isiored 1 Sce,3097,Ci,C.l
TOTAL
C) LenderIOIAI
's Nome :
LJ Lenders Address .
I certify ohm 1 have read mhis application and stare that the a swe information is
BUILDING I fni
F` y correct.l agree to comply with all city and county matinmces and state laws selatingm QTY. MECHANICAL PERMIT FEE SEISMIC EEE
V Z building construction,and hereby anthorim mpumentalves of this city to enter upon the
ma,m-rtentioned property for inspect Inn purposes. PERMIT ISSIIA NCB ELECTRIC ITT
(We)agree to lay..annual mlly and keep IinrnI'll'he City of CnpeNnn against
liabilities.judgments,coax and expenses which may in any way a.emm against said City ALTER OR ADD'TO MECIL PLUMBING FEE,
cmr`,,,,���J� fImg ntinB of Nin omit. /�
All LI?lYltncU T WII,1 � #'�M1?yJ W. -NOXPfYNT AIR HANDLING UNIT(TO 10.( IOCFM) MECHANICALFiE
so
Lam. {ice.L'C /L�lpL� AIR HANDLING UNIT(OVER 110.001 PMI CONS']RUCI'(ON TAX
N 171
Sjqttm App cuckontractor etc 1 17XHAUST HOOD(W/DUCT) HOUSING MI"LIGATION IPI?
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding accu,mu sore or handle haemdous mammal HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT B)VEk IINI,IXNl BTU)Code,Section 255321a1�
E)Yes- ❑No VENTILATION FAN(SINGLE BESIDE PAID Datc Ktccipm X
Will Ne applicant or future budding occupant use equipment ar devices which BOILER-COMP(THE OR 100,001 BTID
mit hazardous aur contaminants as defined by the Bay Area Air Quality Management 'TOTAL:
Disrtin'I BOILER-COMP(OVER IIXIJXXI BTW
El Yet, Fl No
I have lend he haardomsmaterials requirement uMe,Chapter 6.95 of the Cull- AIR CONDITIONER ISSUANCE DATE
fomia Health&Sel'oy Code.Sections 25505.25533 it 25534.1 mdetxmnd that if the NEW RESIDENTIAL MIiCH. SQ.FL.
building dor%not aurrnnly have it 1cnm.,that it is my resrymsibilily to notify the acutanl
of the rquirement which mast better roar or issuance of n Cenuicate of Occupancy.
Owncr can autbavcd%gem Date 'TOTAL: ISSUED BY:
OFFICE