S 1147 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
16171.
ITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT i NG PROJECPIDE?aNIFIC S 114 7
B W LDING PR(IJECI'IDENTIFICATION V
bARCI1ITj:O:r/
ING ADDRESS: SANITARY NO. AI-.ICA""PION SUBMITTAL DAT
i SI
R N ONE: CONTRACD)R'S NAA \ LIC NO:
t N/C CONTROLa
ENG EER: LIC NO: ADDRCSS: - ❑7 ACT: PHON BUILDING PERMIT INF(J
0�0 � ElConsultant Fees Paid by Applicant(Initial) HL ELP PLUMB li JP'125 2S3 ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JA DESCRIPTION
1 hereby afMn that 1 urn licensed under provisions or Chapter 9(annmeacmg
OCZ, with Smcio.700[hofD,,iiimr3.fmm Ibromessand l'rofesxiois Cral my license is RESIDENTIAL'
al p O PERMIT ISSUANCE
F� in full force and effcd. ❑SIV WL ❑KITCHIiN REMODEL.
NU License Class Lic.N APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING BE PIPE
I- W Due Conrranm
N 4
ARCHIT iCTS DECLARATION PANIiLS ❑MULTI-UNIT []STRUCTURAL
MODIFICATION
OZ-,
flu d tandm ansshal{ xpublic rec s ❑INTERIOR ED CHIMNEY REPAIR
OZ- —!� y us UP 70200 AMPS
Ir 4� Licensed Prnfir"Jonal 201-1000AMPS IMPROVEMENT [:j SWIMMING POOLS
Y J OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEIJREPAIR ❑DEMOLITION
K 6 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
�ppPCCrr 4 U following reason.(Sedum 911.31 5,11a.i.ess and Pud'osalans Code,Any city or moot, SIGNS ELECI'RICAI. []OTHER
r+a 4 O f' which requires a permit to construct.altar,improve,demolish,or repair any structure
prinrmirs i.esuance,also requiresthc applicum for such permirmfilcasigneJ emmmcm SPECIALCIRCUIT/MISC.
�y rhmbaislice.sedpursuamit,the provisionsoftheContractors Lieemel.awrClarptersd
wad (commencing with Section 7")of Division 3 ofthe Business and Professions Csdgor TEMP.MMERORPOLEINST. COMMERCIAL
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑ EW BL.DG/ADDITION (:1DEMOLI'TION
i� WN Sta nen]1Dls by any applicant for a permit suhjectsthe upplicam to n civil Penalty of POWIiR DEVICES 9LNANT ❑POOUsERVICE
m marc man Eve hundred dollars(5500). IPROVEMENT
^ O ❑ I,us owner of rhe progeny,nr my employees with wages as Meir sole compensation. SWIMMING POOL ELECTRIC
Ste+ will do the acwk,vad thextrvelum isnot role kdnrotiired for side(See 904q Business ❑OTHER
W 3 and Pmfcsiore Cade:The Contractors License Ww does nm apply to an owner of DO LOTS-SWU CHES-FIXTURILS
property who bai,d.s or improves thereon,and who dims such work himself or through I
NIiW RESIDENTIAL ELF.CIR S
his own employees.Provided that such improvemems are not intended or offered for
ode.If.h.vea the buildingorindrevement is sold within one yemofcampldiomtho SQ.IT A ,1V $/SQ.F-T
ow r-builder will have the burden of proving that he did net build or improve for Pur- LIf IVa
pose of sale.), r
❑I,in owner of the progeny,am exclusively contracting with licensed contactors so Vr V urtKl//y
instruct the project(Sec.9Ik4,Business and Profassions Cade:)The Ca diuman's Li- / 11
cense Law does not apply In an ow.erofprapany who builds or improves thereon,and QTY. PLUM RING PERMIT FEE
who contracts forsuch pmjmrs with a contmnnKs)licensed pursuant to the Contactors
License Law. PERMIT ISSUANCII
❑I am cxw tpr under Sec. .B&P C fur this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Awnur Dateml
(D aTC?Q
WORKERS COMPENSATION DECLARATIO BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
❑I Internal will mandairaCenificme of C..,.,wself-in.mre lar Worker's Compcn- DRAINS-FLOOR,ROOK A REA,COND. STORIES TYPE.CONSTRUCTIO
moon,u provided for by Section 37W of the bobor Cade,forme Performance of the
work for which this permit is issued. PIX'I'URFS-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as restored by Sectkm GAS-EA.SYSTEM-1 INC. 0U3'LITS
37004the Libor Came.far'be performance al work Our which this permit is issued. OCC.GROUP PN
My Worker's Compensation Insurance carrier and Policy number are: GAS-EA.SYSTEM-OVER 4 TA,)
Canner: Policy No.:
CERTIFICATE OF GXEMpTTON FROM WORKERS' GREASEANDUSTRI,WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDI i k S N FEES
(This section need not he completed ifthe Fermi,is fortune hundred dollars($100) OR12ASETRAP �r1 n
or less.) PLANCHECK FEIi
I realty,that,.me Perfmaninceormi, wk for which this permit is issued,l shall SEWER-SANITARY-STORM F.A.200 Fr.
not employ any person in any manner so as m become subject to me Wurken'Compen- ENERGY hili
OZ satio.Lawsof Cvlifomia.Dam WATER BEATER WNEN'19ELECTR GRADINGF
7 O Appliced
❑ NOTICE TO APPLICANT:If,otter making this Ccnificato of Exemption,you should WATER SYSTEMII'REATING
h hecome s.hjOct In the Workers Compwnamion provisions of the Labor Cade,you must SOIIS
forthwith comply with such provisions or this permit shall be deemed revoked. WR'I'ER SERVICE
O PAID
CONSTRUCTION Ltion lending agency
NEW RESIDENT AL PLMB. SQ,FL D'e Receipts
L) O Thereby ulRrm munhere lsucnnswction lending vgency far the performance of
the work for which this permit is issued(Sec.3097,Ci,C.)
T(Y1'AI,:
O V Lender's Name Lenders Address _ 'f OTAL:
aI certify that I have read this application and state that the above information is BUILDING 'EF.
�4 V) correct I agree to comply with all city and county ordinances and state laws relating a QTY, MECHANICAL PERMIT FEE
V z building conclumme,end hereby awharim representativcsofthis city(owner upon the SEISMIC iE
above-mentioned pmpeny,for inspection Purposes. PERMIT ISSUANCE; ELECTRIC F.
(We)agree w save.indemnify..it kap ha wless be City of Cupertino against III
liabilitiea,judgmems,costs and expenses whichmayinanya, accaeagammsaii City ALTER OR ADD TO MECII. PLUMBING FEE
in causegeancA this permit.
APPLICA�JT AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO d)(XI CPM) MECHANICAL FEE
SOUP. RE0 AIR HANDLINGUNIT(OVER I0,000CFMI
CONSTRUCTION'1'AX
Si aw Ar Date EXHAUSI'1I00D(WIDUCI} HOUSING MITIGATION FEE t
HAZARDOUS MATERIALS DISCLOSURE
W,,,thaepP,iand or Imus hmldi.grweupam atom or handle hum-loos material ABATING UNIT('10 100,000 BT U)
as defined by the CupeniW Municipal Cala Chapter 9.12,and the Health and Safety f[WATINGUNIT(OVER 100,000 BTU)Gvlw,Section 2.5532(x)^ ��❑Yes ifV Nu ION PAN(SINGLEERESID) PAIDDote Rmeiprp
Will the applicant orr futurree building occupant use equipment Or devices whichCOMP(3HP OR 10emit haaardeas air commer awls as defined by the Bay Arca Air Quality Management 'TOTAL:
Di n"? COMP(OVER 100,❑Yea RhVI have read the hwadous materials tegairemcn6 utakr Chapter 695 of the C.li- ITIONER ISSUANCE DATE.forma He.hh&Safety Code,Sections 25505,25533 and 25534.1 understand that If theDENTI AL MECI I.
building does not emtently have a tenant that it is ray responsibility In andify the occupant
of the requirements which must he met prior to issuance ofa Certificate of Occupancy.
Owner ter authorized agent Date ISSUED BY:
OFFICE i—^