S 0126 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE$M IT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMB INO.MECHANICAL Je
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SURNIMAL HAD
C, to �IA \ 6 —(/(- Q
OWNI?R'S I PHONE: ICONTRA 'S NAME: LIC NO,
ge�� 3�a2If ✓E�Y/f N/C CONTROL#
�ARCUTECT/ENGINEER: I.IC NO: AD IitiS S• "j ❑
CONTACT: PHONE: BUILDING PCRMIT INFO
❑ Consultant Foes Paid by Applicant(Initial) BLDGELECT PLUMB MECH
LJ L� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm Nut 1 ten licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DZ with Section 7")of Doium3 nDhe Business and Prrfensinas Cody, and my license is NTlAL
Irl Oa O PERMIT ISSUANCE
Fly in lull forceand effim. a NOW,
[I KITCHEN RFMODEL
P7W License Class Cera APPLIANCES-RFSIDI?N'I'IAt, ❑ADDITION El PLUMBING RE�PI F
rF�a Date ContntCL
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAh
1'ANI:IS
Z p v�Z 1 undersmnd my piens shell he uutl as public records MODIFICATION
OZ—Q UP T0200 AMPS []INTERIOR ❑CHIMNEY REPAIR
[-�4F' Licensed Professional 201-IfgIBAMPS IMPROVEMENT SWIMMING POOLS
ay�� OWNER.BUILDER DECLARAB'ION
y�y I hereby afrom that I am exempt from the Cammet."a License Law for the OVER 10(10 AMPS [I BATH REM DELIREPAIR [I DEMOLITION
pe,06 U fallowing res n(Section 7131.5,Business and Professions Gale:Any city or county SIGNS ELECTRICAL [I OTHF,R
Yu1l O . which requires a permit m cnmtroi alter,improve,demolish,or repair any structure
primloitsis...are,alsnrequircs thcapplicant tmsuch permit lolilmrsigned,tworaent SPECIAL CIRCUIT/MISC. C
yjhal he is licensed pursuam to the provisions of the Cnntrecou's Liccrose Low(Chapter 9
O
(commencing with Section FETER NM))of Di vision J of the Business and Professions Code)or TEMP.MOR POLE I NST.
A. o that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW LDG/ADDITION ❑DEMOLITION
Section 101Is by any em
pplicim for o petit subjects the applicant to a civil penalty of POWER DEVICES VTENANT ❑FOODSERVICE
of mote than five hundred dollars($500).
F Z Y IMPROVEMENT
pO ❑Lmowner ofthend property,
renryotinumeeswit wages
rsate(Sm.compensation, SWIMMING FCl01.ELECTRIC
will Pothewons ande The
inumi License Law offered
sate(Sm.
It)
easiness ❑OTHER
and Professions Code:She Continuum's License taw then not apply to un owner of OfIT1.FT5-$WITGBE$-FIXTURES
property who h olds or improves thereon,and who does such work himmif or through
his own employees,provided that.such improvements um not intended or offered for NEW RESIDENTIAL FLEETS SQ FT.
sale.If,howt,m.the building or inrlmwcment isudd within one ycnndnnnpimion,the SQ.FI'.MOOR AREA S/SQ,rr
ownv-hudder will have the burden of proving that be did not build or improve for put,
prose of role).
❑1,as owner of the property.um exclusively contracting with licensed contractors to AL:
construct the project(Sec.7044,Business and Professions Cade: 'Me Conoacto's Li-
muselawdoesnotapplymanownerafpropenywhomildsorimprovesthereon.and QTY PLUMBING PERMIT FEE
who contracts for such projects with a cunuacmrfs)licensed pursuant to the Committees
License Law. PERMIT ISSUANCE
C I am exempt under See ,1{&P C for this reason
Owner D.I. ALTER-DRAIN&VENT-WAF17R(EA) VALUATION
WORKERS COMPENSATION DECLARAI'I ON BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the fallowing dcciarabotls:
71 I have and will maintain a Certificate of Consent to self-insure l'or Worker's Comber- DRAINS-FLOOR,ROOF,AREA.COND, STORIES TYPE CONS'TRUCT'ION
salmon,as provided for by Section 3700 of the Labor Code.for the Performance of the
work for which this permit is issued. FIX'ITIRES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section '
3700 of the labor Code.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCC.GROUT' APN
My Workc(yCs �jgysn ureC miNnace m Policy NoPolicnu GAS-F.A.SYSTEM-OVER J(EA)
CERTIFICATE OF EXEMPTION FROM WOR CERS' _ A..
COMPENSATION INSURANCE. GREASFANDUSTRI.WAS)'li IrpiR03
B1111.UIN I ISION ,?.S
("is section need not he completed dthepernut is forme hundred dollars(51TO) GREASE TRAP
nr IcssJ PLANCHGCK 14pi
I certify that in the perimancirenfthe work for which this permit is issued,10mi SEWER-SANITARY-S'
not employ any person in any manner so as to become suhiccl to the Workers'Contpen- 210 ENERGYphi
0 z section Lars f 1'fo Dme WATEN IIEATER WNI?NTRiLIiCTR
Z Applicant �Ogists GRADIN
ti NOTICE TO APPLICCNT.If,afar making this Cenifieale of Exemption,you should WATER SYSTEM/fREA G
become subject to the Workers Compensation provisions of the Labor Code,you must SETS FEE
Ir farhwithmardy with such provi musrthis pconasheill hedeemed mvokcd. WATERSERVICE
G A
CONSTRUCTION LENDING AGENCYagency NEW RESIDENTIAL.PLMN, SQ.FT. PAID
U O Dam Necelpr N
I hereby affirm that There is s eanmmc.30l7nding agency fnrthe perl'nrnonee at
t+ the work for which this permit is issued(Sec.309].Civ.CJ
F' Lenders Name TOTAL:
LUkI IsnderAddmes TOTAL
I :
y ttnify that 1 have and this application and store that the uMwc information is BUILDING E
F V] c..I.lagreetocomply with.Ileityondc... nNinances end antro lnwx rclatingm QTY. MECHANICAL PERMIT FFai
V Z buildingeone0m
uction,andhemby ahorizerepowentmives ofthiscity toenmrupon the SEISMIC FE
r ahovomemki property for inspection purposes. PERMIT ISSUANCEO
(We)agree to save.indemnify and keep harmless the City of Cupertino against ELECTRIC FEC f
liahilities,judgments,costs and expenus which may in any way aceme against said City AI,TF.R OR ADD TO MECH,
on rmeyaence of the prompt;of this permit. PLUMBING IFC
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AIT. ON-P INT Alit HANDLING UNIT(10 I0,u(o CFM)
S(]URCER A ON ` MECHANICAL PIAT
1;1/
AIR HANDLING UNIT(OVER I0.000CFM) CONSTRUCTIONTAX
Signature mApplievnt/Conis Date
EXHAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAZARDOUS M ERI DISCLOSURE
Will the applicant or future building oecupam store or handle ho ca dous material ORATING UNIT(TO I00,010 BTU)
as defined by the Cance n sda a,l Cotte,Chapter 9.12,.1 the Health and Safety
Code,Section 25532(a)? IIEATING UNIT(OVER I(Efo)BTU)
E]Yes XNo VENfI I.ATION FANS I NOTE RESID) PAID
Date Reecho#
Wil the applicant or future building by the Bl use equipment Qu of Ma es which
emit District'
s air cnmaminums ns definW by the Buy A.Air Quality Managmmmo IIOILER-COMP(31111 OR IIg1,IN)(1 liTll)
Dlstrin? TOTA I:
❑Yes IR No BOILER-COMPtOVER I00,00OB'TU)
If
1 have mad the hazudnux materials requirements under Chapter F vs of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Codi Sections 25505,25533 and 255N.1 undematvJ that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,dun it is my respomihility to ratify the occupant ///
of the ri,,mrernems which must he mer prior to issuance of a Certificate(if Occupancy. I 1
Owner or authorired agent Date TOTAL: ISSUED BY: D
OFFICE