S 1272 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY T w(i ,S U X
CITY OF CUPERTINO RICH.Dmc-ELECTRICAL rlsB`ip I No 1272
11
BUILDING DIVISION APPLICIVI'ION(PERMIT PLUNIlIINC..MECIIANICAL �J y 2 7 2
IIUIEDINC.PROJEC'i'IDENTIFICATION
BUIhDING ADDRIIsg: SANITARY NO APPLICATION SUBMITTAL DATE
M2'S Ni MIi: '1101,117' CONIRA "I'OR'S N ME: LIC NO: �e2
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NIC CONTROL X
ARC ]Tli UN G iR:ARVA LIC U: AD RISS: ❑
C(Nl'A; C'1` .1 N DUII PERMIT INFO
rl1��A I}��, /V Consultant Fees Paid by Applicant(Initial) BLDG fiLEM l.1!CIP�LUMwB htECH
Ir
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT PEE 1�G
I hereby affirm anal 1 and ucrnsee tinder provi.inas of Chapter 91=olnmeneing JOB DESCRIPTION
ZWZ with Scrium 9X10)of Division 31 the Bmmv,,and Piofc,don.Gree,and my license is RESIDENTIAL'
FOS µ]full force unJ eller //�� PERM IT ISSUANCE.
yymF, In IQ�Q(O� ❑SFDWL ❑PLUMBING RE
QVZU 1)cun'e Lmc.b APPLIANCES-RI?SIDEN'TIAL ❑ADDITION ❑PLUMBING RBPII'E
0QL Dutc Cammctnr
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURN.
'=,,o PANELS MODIFICATION
O Z-�' 1 unJemmrJ my plans shall h awul as pmhlic raardw /
�—It" 11PT02nn AMPS [I INTERIOR El CHIMNEY REPAIR
Fa ed F',O Lice nsed Professional 201-I000AMPS IMPROVEMENT QSWIMMING POOLS
S0.sy�Ey� that IamBUILDER DE CLARATION OVER I000AMP$ ❑BATH REMODEUREPAIR El DEMOLITION
d C W U herchy affirm that 1 am exempt Iran the Contractor's C License Law fur the
1�dd 04 U which ng rices it arromam 9Ul S,rl.Business and prove,debo l Code:Any city or county SIGNS[LECTBICAI. ❑(7fHER
Tzl 3
U.y which requires n permit m ametme6 cher,improve,eumollsh,or repair any structure
F nu j prima its issuance,also requires the applicum mrsubt permiuo file a s'igneestamment SPECIALCIRCUIT/MISC.
M�i Oat he is license)pursuanunthe pmvisiomat of the Commnors license Law lChnpmr9
IKRa000 (commencing with Section]WO)of Division 3 of the Business and Professions Cale)or '1'F.MP.METERORPOLEINS'T. COMMERCIAL
L L2== that he is exempt therefrom and the Crowns lir the alleged a emryion.Any violation of W BLDG/AUDI'T'ION ❑DEMOLI PION
yam Section 9031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES ANT ❑FOOD SERVICE
not mord than Eve hundred dollars($500).
SSD Q Las owner of the propcny.or my employee.with wages its their sole annleruwution, SWIMMING POOL ELECTRIC OTHER IMPROVEMENT p r o
yF will Jo the work,mJthemmewrtis not imendeJ oroRctcJ for ole fSecJB14,Basin,. OTHER /V N
41`4 and 1'mfensinas Code:The Commnts's License law does not apply to an owner of ITFLLTS-SWl'TCfiGS-1'IX'TURIig
�'3.. pmiserly who builds or improves thereon,and who doessuch work himself or thoughQ8 9t;
his on cnhdnycew,provided that inch impmvcntene,arc nm intended or offered lar NEW RESIDENTIAL ELECTR SQ IT,
sale.if,however,the building o,Impmrvrancid in sold watinono yvi completion,the Ssf FLOORAREA 3/SQ.FT
nerbuilder will have the burden of proving that he did not hal ld or improve for par- Y�,//V.
11 `'
as owner of the property,am exclusively contracting with licensnl contractors to T rlf�/�
construct the project(See.7014.Business and PmEcssiom Code:)The Contmetore Li-
whmre Lxw dons nortpply rn an owner of properly who builds ur improves tnerton,and QTY PLUMBING PERMIT FE:E
ocomate,hasashpmjccuwdha contractions)licensee tumoral tothe Contractor's
License[.a. PERMIT ISSUANCE
Q l ran exempt under See. ,B&P C for this rwson
Owner Datc ALTER-DRAIN&VENT-WATER(E ^ VALUATION
WORKER'S COMPENSN'ION DECLARATION BACK PLOW PROTECT.DEVICE //�'N ��
I herchy ul irnl under penalty of perjury one of the folhswing declaa✓tions:
❑ Ihave:mA will mnim:mina Cenificam of GmscnuosclGinaurc lar Worker's Compen- DRAINS-FLUOR,BOOK AREA,CONT" STORMS TYPE CONS'TRUCr10N
nation,as pat ided far by Section 37110 of the Labor Code,for the perfoatmnce of the
work for which this permit is issued, FIXTURFS-1'ER'I RAP
I have and will maintain Workers Compensation Insurance,as inquired by Section
390Xlofthe Labor Code.for the pedmmamem'the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLRfS DICE.GROUP APE
My Wntkcrs ml la numn [.�,�{s 1 olicy num v
Cartier: II Y Na: GAS-EA.SYSTEM-OVER 4(EA)
CERT FIC MPE EXEMPT TIN PRAM WORKS } GREASEtINDIISTRI,WASTI7 INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION F'Ii1S
(This scnionnrednm he completed if the pcmlit is furor hundred dollars(SIOB GREASETRAP
or less.) PLANCHIiCK FEE �
I runny that in the performanceof The work forwhiah this Permit is issued,]shall SEWER-SANITARY-STORM EA.200 FE
employ any person m any mammy so us to hecorsubject ne subjeco the Workers'Cutest ENERGY FIiE
zz ,num Laws of California.Date WATER HEATER WNT:NTIELECTRIs
Q Applicant GRADING FF.F.
fq NOTICE TO APPLICANT:If,ofmr makingthis Certificate of Exemption you should WATER SYS'rEWTREATING
h" becamo
e bject to the Wofkers Compensation previsions of the Labor Code,gnu most SOILS FEE
WIimhwiifi,moly with such pro,oxmsnr this prnnd Nall he Created revoked. WATER S17RVTCE
Y A
U O that here isac ns LENDING AGENCY NEW R[SIDENTIALI'LMB. SQ,FT. PAID Date Receipt#
[hereby affnm that there Isoard(Scelon IenC' agency battle pefnrnumce oI
the work for which chis permit is issued(Sea.JW].Co,iv.C.)
u" H Lenders Name TOTAL:
WLcnJcr's AJdreas TOTAL:
1 certify tbat 1 have read this application and sure Nat the above information is BUILDING FEE
TM
u7i1 comect.l agree mcomply with all city and county ordinwces and sum laws relating to QTY MFCHANICALPERMIT FEE
U G buildinge ourretion.nne hereby ambmizu cwe
mPrmmiu vmf this City to enter,often the SEISM IC IFF.
above-mem finned Conti for inspersion Purryusas' PERMIT ISSUANCE
(We)agree tat save,indemnify and keep hamdusx the City of Cuperm.against ELECTRIC FEE
habilities,judgmems,costs and expenses which may in any waynecoacquinst said City WALI ER OR ADD TO MECH.
in amsegocnce of the granting of this permit. PLUMBING PEE
APPLICANT UNDERSTANDS AN WI I, V WITH AL NON-POINT IR HANIILING UNFI TO 10.0a1CFM)
SOU
Blur. ONS. MECHANICAL PILO
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
igwm mnnphrant)eontn ua Dote EXI IAUSTHOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSUR HOUSING MITIGATION FIiE
Will the applicant or future building occupant store or handle hereabouts material I IBATING UNIT(TO 100,000 BTU)
u.dclined by the Cupertino Municipal Code,Chapmr 9.12.and me Heath and Safety
Coda,Seen i 25532(a)? IMATING UN1'f(OVER 100,000)RTU)
❑Yes ❑No VENTILATION FA N IS I NGLE RESIDI PAID Dont, liecciPlk
Will the applicant or future building occupant use equipment or devices which BOILERCDMP(311P OR 1010X1 RTU)
emit hu mdods air eomaminam as d - ,
efined by the Bay Arca Air Quality Management TOTAL:
District?
❑Yes ❑No BOILER-COMP(OVER Ilk),(")BTU)
I hovercWt ho hmanioumn,nal.r....morons door,Chapter 6.95 of he Cab- AIR CONDITIONER ISSUANCE DATE
from.Health&Safny Gee,Sections 2.5505,25533 and 25534,1 node r nd that if dm NEW RISIDEWIAL MECH. SO.PC
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which must od mel prior to issuance of a Cenific le of t e',ree nay.
Owner or uabarized agent nate TOTAL: ISSUED BY:
OFFICE