30117 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPER'1•INO BUILDING•ELECTRICAL PERMIT NO. a�01
BUILDING DIVISION APPWCATIONA'ERMIT PLUMB NG MECHANICAL x( 17
BUILDING PROJECT IDENTIFICATION �! .L
BUILDING ADDRESS: SANITARY NO. AP/P'LICATION SUBMITTAL DKO
IWfly
OWNER'SNAME: PHONE: TRACTOR'S NAMP.: LIC NO: -�6
M� IN LI-CHIP 25z—BSS Mme, rI ca NAC CON'IROL0
1RCHITECTIF.NCINEEft: LIC NO: ADDRESS:
U RrJ Ca( 3-rG
CONTACT. PHONE: BUILDING PERM INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB M�EEC1H
V V ITOR' Ill 1�I X� ILy
Lm that ED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEP.
I hereby affirm that I um licensed ands pnrvisions of Chapter 9(commencing ]OB DESCRIPTION
WIZ with Section it effect.
Divisinn3of the Business and Professions Code,and my licemeis RESIDENTIAL:
H WU O in full force and effect. PERMIT ISSUANCE
�FU�j License Class Lica ❑SFDWI. ❑KITCHEN REMODEL
N<L Date Contractor APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
ARCHITEC7CS DECLARATION ❑MULTI-UNIT []STRUCTURAL
Z 4 my std p PANELS
I understand I shall be used as public MODIFICATION
OZ c UP TO 200 AMPS 0INTERIOR ❑CHIMNEY REPAIR
Licensed Professioral 2II-1000AMPS IMPROVEMENT '
f Oat I un cimarEn fr m Ce Ciour ON OVER 111(1(1 AMPS [:]BATH REMODEUREPAIR 0 DEMOLITION
yy�N 1 hereby affirm the 1 am exempt from the Contractor's License Law for the OOTHER
u13 a'Ufollowing reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ,
a]
U. which requires a permit to constmct,alterai
,imEmuo,,demolish,or repair any r
0 prior toits issuance.also requires the applicant for such Permit o file asignedsuament SPECIAL CIRCUITIMISC. '
y that he is licensed pursuant the previsions of the Contractor's License Law(Chapter 9
W GAO (commencing wiN Section 7nnq of Division3 ufthe Rusincss and Professions CalO or TEMP.METER OR POLE INST. Coll
'f`�'��7�''�'
F�qd,c eG
that he is exempt Ihercfrom and the basis for the alleged exemption.Any violation of ❑NE\ - G/ADDIT'/Oyf�p ❑DEMOLITION
W^2n Section 103 1,11,anyapplicantforaperam euHecta the npplicam lnacivll pen:dty of POWIiIt DCVICES' �T NANT 'ZdEl FOOD SERVICE
> t more than five hundred dollars($50(0. ./
C< 01,es owner of the pmp<rty,arra to ccs with we cs as their sole mm ration. SWIMMING POOL ELECTRIC PROVCeM4NT
�O
will do the work,and Neswnureis net nendeJ ondfcred(or sale(Sec.71D4.Business \'rL
CC OTHf:R
W 3 and Professions Code:The Contmemts License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES ,v
property he builds or improves burns,and who does such work himself or through
his own employees,provided that such improvements are not amended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sole.If,however the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA $/SQ.FL
owner-builder wit have the burden of proving that he did not build or iiuprove for pur-
of sole.).
n as owner of the property,am exclusively contracting with licensed enrmnm'a to 1 Sir—
fruit,
r
caroms,the major,(See 71W4.Easinessand Promi,ior&Code:)The Contractors U-
censeLawdoes not apply to an owner of pmpeny who builds or improves hereon,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a cumbrous)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE.
❑ l u exempt under Sc ,B&PC forthis reason
ALTER-GRAIN&VENT-WATER(EA)
Dam VALUATION _
Owns
WORKER'S COMPENSATIkIN DECLARATION BACK PLOW PROTECT.DEVICE � �
I hereby airrm under penalty of,c ja,one of the fallowing declarmlons: i
❑Ihavc nndwill mainwin aCenificam of Cnnoem to self-insure for Wader's Compen- DRAINS-FLOOR,ROOF,AREA.COPED, STORIES TYPE CONSTRUCTION
smion,as provided for by Section 37M of the Inbar Code,for the performurce of the
work for which this pcnrit is issued. FIXTURES-PER TRAP I r— (J
0 1 have and will maintain Waders Compensaian tImumace,as required by Section
37M of the Labor Code.far the performance of the work for which this permit is issued. GAS-PA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE:]ME ERCEPTOR
(This section need not be complied If the Penn t is forme hundred dollars I$1 W) BUILDING DIVISION FEES
or less.) GREASE'TRAP 41�E
NCHECK FEC
1 certify that in the performance ofthe work for which this pemdt is issued,l shall $
nalemploy any person in any munnermas In becnnlc subjcs to the Worken'Campen- SEWCR-SANITARY-SIKIRM I?A,300 ET.
Z smion Laws of From.
Data RGY FCREll
b
O Applicant WATER HEATER WNENT/LLRCfRDING Iq'.
N NOTICE TO APPLICAM:IL ofter making this Certificate of Exception,you should WATER SYSTEM/TREATING
nocturne subject to the Worker's Compensation provisions of the Labor Code,you must LS FEC
Wry forthwith comply with such provisions or Nis permit shall be Deemed revoked. WAD?R SERVICE
Q
CONSTRUCTION IENDINOnGCNCY N13W RESIDENTIAL PLMB. SQ.PT.
V 0 khereby whaffirm that isued(Sec.30aOnding.gcncy for performance of a RecciptN
F Newall ter which Nis Penni,is issued(Sec.l(yp,civ.C.)
0 umsaea Name 'ITITAL:
a :4 Lenders Address
�.t 0. 1 certify that I have read Nis application and state that the above information is LDING FEE
Ft h7 contact.I agree to comply with all city and county ordinances and&tate laws relating to Q y. MECHANICAL PERMIT ai On holding consmetion,and hereby authorize representatives oflhiscitytomrer man,Ne MICPCCabove-mentioned property far inspection purposes.(We)agree m revs,indemnify.nJ keep branders the City of Cupertio ugninst PERMIT ISSUANCE. CTRIC FEE
liabilities.judgments.costs and expenses which may in any way sector against said City ALTER OR ADD TO MECH.in cam equerce,of the granting of Ibis permit. PLUMBING Fl
i Eli
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
AIR HANDLING UNIT(TO 10,00(1 CFM)
SOURCE REGULATIONS. MECHANICALE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIO TAX
Signmmo of Applieunt/Coahtatar - Dec EXIIAUS'I'HOOD(W/DUCT) HOUSING MITI TIO
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or future building oecupmmmore or handle hazmdous material HEATING UNIT(TO 100.000 BTU)
as Jebned by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Code,Section 8532(.)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ON. VENTILATION FAN(SINGLE BESIDE PAID
Dae Receipt p
Will the applicant i future building niche Ti use equipment or devices which-
emit hazardous air contaminants as defined by the Tiny Area Air Quality Munugement BOILCR-COMP,CHIP OR 100,000 BTU)
Delricl7
I'(1TAL:
❑Yw 71 No Boll.lift-COMP(OVER 100.000 BTII)
1 have read the hazardous memorials �fi
requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
red . ISSUANCE DATE _
Inman Health&Safety Code,Sections 25505,8533 and 8534.I urdemand that if the NEW RESIDENTIAL MECH. SQ.ET.
buildingdoes not currently haven¢rant,Nm it is my responsibility, notify the occupant
of the requienen0 which must bet e mprior to issuance of.CaniOeme of Occupancy. � /N
Owner or authorized agent Dee ISSUER BY:
OFFICE