99080052APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY1,� -- Y 1Q QQ 5-6L
OFFICE
CUPERTINO BUILDING - ELECTRICAL
DIVISION APPLICATION/PERMIT PLUNIRING-MECHANICAL
BUILDING PROJECT'IDENTIFICATION
E MITNO.
DRESS: �1 I 1 a
LL /P` III
E,1'
SANITARY NO.
APPLICATION SUBMITTAL DATE
HONE
CONT CFOR'S NAME: LIC NO:
NIC
❑
CONTROI x
�CNITECT/IiNGINEER:
LIC NO:
AD )RESS:
Vo T< le r v-<--
CONTACf: PHONE:
BUILDING IILRMIT INFO
UL LgVS k 73 - I/ f/l)
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT' PLUMB MECH
ID El ElU
LICENSEDC TRACTOR'SDECLARATION
1 Hereby mfirmn ma 1 am Emen.ed ander nmeiaom of chapter 9 (momnmendng
whh Sanien 7000) of Division 3 oflha Business and l'mic.chmv, C de, and my ll eno, is
in full force and a-t�� %-� �G
Licenser Clas. Lic.p V
Dam a �A _ A 9 Commao
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SIUWL El KITCHEN REMODEL
[]ADDITION ❑PLUMtlING RE -PIPE
[I MULTI -UNIT [I STRUCTURAL
MODIFICATION4,4—UPTO
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT i] SWIMMING POOLS
❑ BATH REMODEUREPAIR El DEMOLITION
❑OTHER
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PERMIT ISSUANCIi
APPLIANCES-RILSIUENTIAI.
ARCNITF,LTS OECLARA]O'
' 1 understand my plans shall be reed as public ree it,
PANELS
20) AMPS
Licensed Pink,sslon.]
OWNER -BUILDER DECLARA'T'[ON
I herchy affirm that 1 am exempt from the Carourna's License Luw for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair stay someone
prior to as issuance. also requires the applicant for such permit to file v signed statement
that he is licensed pursovnt to the provisions of the Contractor's License Law (Chapter9
(motmmincing wish Scmlion]((N)ptf Division Sof lbe Rosiness and Profcxsinnc Ctdc)m,
'hat he is exempt Iherefmm and the basis for die alleged exemption. Any violation Of
Section 7031.5 by any applicant for a permit mbjects the applicant to a civil penalty of
not more than five hundred dull.,, (S50(l).I
I. as OvarT of the positivity, or my employees with wages as their sole compensaion.
will do the work. and the vampire is not intended or offered for sale (See .]0l Business
will
and pndeaionx Cede: The Contractors License Law does not apply ret an owner of
Property who huilds or imprnvex thereon, and who does such work himself ur Ihrongh
his own cmplo,cs, provided that inch improvements are not intended ur oll'aned for
xale.If, nmvever. the huilding or improvement is sold within one ycso of completion. the
201-I000AMPS
OVER ]"AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/M ISC.
'I FMP. METER OR POI.27 INST.
COMMERCIAL:
El NEW BLDG/ADDI'F ON ElDEMOLIT[ON
01C] TENANT ❑ FWD SERVICE
OVEMENT
ER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWTFCHFS- FIXTURES
NEW REMDEN'I'IAI, ELECTR SQ IT
SQ. FT. FLOOR AREA
L5G�FT
weer -Wilder will have the burden of proving that he did rot build m impmve for put -
TOTAL:
pose of sole.).
❑ 1, as owner of the property, am exclusively contracting with licensed enntmemrs to
met the project (Sec. 70,14, Business and Professions Code) The Cmaraeor, Li-
nseLaw does not apply munowner of property who builds or improves mention, and
QTY. PLUMBING PERMIT FEE.
whtt,anmucta far vucb pmjees wilh a conrramo0s) li¢msed pursuant to the Contractor's
PERMIT ISSUANCE
Limens, La,
❑ I am exempt under See. .B&P C Etthis reason
ALTER - DRAIN & VENT- WATER (LA)
VALUATION
Date
W'S COMPENSATION DECLARATION
q
HACK FLOW PROTECT'. DEVICE
1 hmrchy affirmununderder pennhy of perjury one of (lie following dednrationa
❑thaw andwillfor by Secunl37M of the LaborCode. for thsr Werkcdsce of the
for by Semicon J](x) of the Lahr Csdc, far the performance of the
scion, as hick this
work Por which this permit is issued.
work
as required by Section
I have and will maintain heWorker's manceheCompensation h far which
PWof the Labor Costs, for the perfoannce of the work for which this pewit is issued.
V
DRAINS - PIAOH, H(X)F.AREA. COND.
STORIES TYP5-CONS I—e'RUCTION
7 /� —2 -
2 Z�
F[%TURES - PERI RAP
GAS - EA. SYSTEM- I INCA OUTLETS
txC. GROUP _
GAS- EA. SYSTEM OVERJ(EA)
My Worker s Compensation Insurance carrier and Policybt ,p S,
Can ien Policy No.:AIpy^rIIO.S%-QMP
GREASMNDUSTRL WASTE INTERCF:111'OR
I_IGHIICATEUTC 12MMONFHOM WORKERS
COMPUNSA'I]ON INSURANCE
BUILDING DIVISIO
GREASETRAP
PLANCHh:CK FEE
(Thi.section need nal bcattnpleed ifthe permit is Toro. hundreddollars(SIR)
or Icss)
SEWER -SANI'T'ARY -STORM EA. 20(1 FT
ENERGY FEE
I certify that in the performance of the work for which this permit is issued, l shall
not employ any person in any manner so as to become subject o the Workers' Comte^-
WATER HEATER WNENT/ELECTR
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.anion Laws of California. Dam
1
Apploma
NOTICE TO APPLICANT: If, after making this Cvmfi,rIv of Exemption, y.a should
become subject to the Worker's Compensation provisions of she labor Code, you most
forthwith Comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDINGAGF,NCY
Ihnrehy a0irm thnuhen, is a mnstuctian lead'mgagi,my ho,he perlormonce of
the work far which this proon is issued (Sec. 9097. Ci¢ C.)
Lender's Name
WATER SYSTEM/TREATING
WATER SERVICE
Rc ctpx
N17W RMID12M IAL PLMB. SQ. FT
TOTAL:
TOTAL:
hcndcLc AJJrucs
SEISMIC FEE
1 certify shot 1 have mad This ap,hemion and state shat the shove mfo..so a x,
correct. l agree m comply with all city and county ordinances and state laws relating lo
building construction. and hereby authorize representatives of this city to enter upon Ne
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
aho c -anotia Ord property for inepectlan pu tswe'.
(Wc) ogre, m save, 'nulentnlfy and keep hm'ttdc, 0c City of C,v0ino a,oarn
ELECTRIC FEE
PLUMBING FEE
Iichadices,judgm,in,, emsmd extencs which may our, way avenue against said City
ALTER OR ADD TO MECH.
in nugaeme of the&Taming of this permit,
AIR HANDLING UNIT(TO IQIMOCFM)
MECHANICAL FEE
APPLICANT ER STANDS AND WILL COMPLY WITH ALL NON -MINT
SOURCE RF' O': ^
AIR HANDLING UNIT (OVER I0.0 CFM)
CONSTRUCTION TAX
V 7
Siomourcol Applleam/Conlrncntr Data
HAL RDOUS M FP AUS DISCLOSURE
Will the applicant or for buil gOccupant &tine or handle hatmous material
F.XI IAUST[1001) W/DUCT)
HOUSING MITIGATION
HEATING ON]F(TO 100," B'FU)
as defined by the Cupertino Municipal Code. Chapter 9,12, area the Health and Safety
Cede. Section 25532(v)1
HEATING UNIT (OVER 100.000 -TUI
VE(SINGLE RESIUI
MILATION FAN
o Yex 0 N
PAID
Da¢ Reeeiptp
11OILER-COMP(3HPOR 100,000 11'1'1))
WIIlthe upplieamor)more building.,cupant os equipment or devices which
.it naaaNmns air cnmaminnms as ]dined by the Nay Arca Air Qutdity Muwgamm�t
I' 'AL'.
BOILER -COMP (OVER 100.001 DFU)
District?
E) Vex F1 NO
AIR CONDITIONER
I have mad Ne hmardous matetim, requirements under Chapter 6.95 Of the Cali-
forma Health & Safety Code, Sections 25505, 25533 and 25534, 1 understand Thar if the
ISSUANCE DATE
9 it
NEW RESIDENTIAL. MECH. SQ. FT.
builds •Jocxnm currcndy havcawn,an,loa it ie my rcxlxmnihility mnmil'y thuxcupam
/
of c n rets which moa nc inert prionoinsuanm nfnCmifm�Cof
TOTAL:
r
ISSUED BY:
Ova authodecdagem Dole
OFFICE