S 0545 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF I_lUPERTINO BUILDING-ELECTRICAL. Plitt hllT NO.
BUILDING DIVISION APPLICATION/PERMIT _ PIDn1BmG-ntecFIAMCAL S 0545
tlU1LDING razInal IDENTIPICATIDN
SANITARY NO, APPLICATION SUBMITTAL DATE
BUILDING ADDRESS:
WNER'S NAME PHONE: CONTRACTOR'S NAME,', LIC NO NIC CONTROL.#
F=AW 67
ARC T /ENGINEER: LIC NO: ADDRESS. ❑
VVV
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) 1:0 ELECT PLUMB MEER
LICENSED CONTRACTORS DECLARAUON QTY. ELECTRIC PERMIT FEE:
1 hueby affirm di t l upped u e p tf Chapter 9 moolu o tong JOB DESCRIPTION
GCz with Sutmn7000)of Dwi,i 3 flhe Buinessand Prom, ms Code end mylc tea is RESIDENTIAL'
WOp PERMIT ISSUANCE
rs, In full force and effect. - [ISFDWL ❑KIT'CHEN REMODEL
�Upp� License Class Lic.M - APPLIANCES-RESIDENTIAL E:1 ADDITION El PLUMBING RE-PIPE
Fti W Date Coruucmr
m GRAL
❑MULTI-UNIT ❑MODIFICATION
OLEISTRUCTATIO
F 7 rn ARCHITECT'S DECLARATION PANELS
to 16nduslunJ my plwsahall he used as public reasN. MOMNEYR P
ZON� UP T02011AMP5
O',1,..,q ❑IN'I'IiR10R Ll CHIMNEY REPAIR
Ir r,/Iq^W Licensed Professional 201-10()OAMPS IMPROVEMENT ��y1�CW IMMING POOLS
OWNER-BUR-DER DECLARATION OVER IIIfX)AMPS ❑BATH REMODEUREPNR>�UEMOLITION
W,fY I hereby aftimt that I am exempt from the Contractor's License Law for the ❑(p'HER
O y U following reason.(Section 7031,5,Business and Professions Code.Any city or county SIGNS ELECTRICAL
FqQ which requires a permit m conswcL when,improve,demolish,or repair any stm are
of, pno,ou its issuance,also requires the opplicam nonsuch permit to filen signed smmment SPECIAL CIRCUIT/MISC.
`� y
that be is licensed pursuant to the provisions of the Commends s License Low(Chapter 4
00 (commencing with Secdon70W)of Division 3 oflhe Business and Professions Cdda)or TEMP.METER OR POLE INST COMMERCIAL
1y cr� than he is exempt IlnreeBom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iCm4, Section 7031.5 by any applicant For a permit subjects the applicant to a civil penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
non more than five hundmd dollars S500) IMPROVEMENT
� C ❑I,as owner of the pmpeny,onny employees with wages as theirsnle compensmion, SWIMMING POO .,F.CTRIC
L. will do the work, d the spracureis not intended oraRued misile(Sor.7044,Brunie, OTHER
an
3 m and Professions Code:The Comracmrs License Law does not apply to an owner of OU'T'LETS-SW CHCS-FIXTURES
_ propony who hands or Improves Ihuum,and who does such work himself or through
his own employees,provided tathsuch improvements are not intended or offered for NEW RESIDE AL GLECTR S
Sala m
If,however,the building or improvement isaold within oneycofcompluien,the -SQ.FTaiiLOp.R.4R�B $/SQJnI'.
owner-builder will have the burden of proving that he did not build or improve for pun-
pose of snleJ. 45
La owner of the pmperny,am exclusively contracting with licensed contractors to - TOTAL.
con,trnd the prujoct(Sec.7044,Business and Professions U.,,inc-....min Ll- - AUG 2
me Law does not apply m an owner of properly who builds or improve,thereon,and QTY. PLUMBING P, FEE
who contracts nor such projects with a cwntrauons)licensed pursuant to the Compactor's 'ry t. y'�I
License Law. PERMIT ISSUANCE 111 we wriaffl Q
El am exempt under Sec. ,B&P C Por this roman
ALTER-DRAIN&VENT-WAI ER(EA) ■e VAALLUATION
O �'T WORKER'S PEN NDECLARA'1'ION BACK FLOW PROTECT.DEVICE gb� ��
1 hereby anirm under penally of perjury one of the following outstations:
❑I haveand will deartinn Cerdficamrf Consenuosell=insum for Worker's Cnmpen- DRAINS-FLOOR,RODE,AREA,CORD. STORIES TYPE CONS'IRUCTION
cation,as provided for by Section 37M or the Labor Cale,for the performance of the
work Fnn which this pemtit is issued. FIX TURES-PER TRAP
E]I have end will maintain Worker's Compensmion Immomee,as required by Sullen
3700 of she Labor Code,for the performance ofihe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 CUTLET'S OCC .ROU APN
My Workers Compensation Insurance carrier and Policy number are:
Cnnien Policy Nei: GAS-EA SYSTEM-OVER 4(EA)
CER'T'IFICATE OF EXEMPTION FROM WORKERS' GREASEANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE ROFLOHIG DIVISIBN PEES_,
(Thissection need not be crmplaed irthepumit is fnrnne hundred dollar($100) GREASETRAP
tt-
or lea,) PLANC
OI
Loy any Into int he any
as tohe
birk object
I. he Wlisi,sued,]shall Coulson SEWP.R-SANITARY-S'T'CRY EA. Fr.
not employ any person in any manner so as to become uub]al m the We kers'Coulson- EN P 31,
Z
ambo Laws of Cal prompt.Date WATER HEATER WNENT/ELECT
Applicant s OR DI .B
NOTICE TO APPLICANT:IL after making Im.,Cerndlerne of Exemption,yon should WATER SYSTEM/TRE.A'FING SOIL' ;E"
rF become subject no are Worker's Compensation provisions of the Labor Code,you must _
!� � fnnhwithemnply withsuch prnvisionxmthispermh shall be deemW revnkedl WATER SERVICE.
4 Q
CONSTRUCTION LENDING AGENCY NEW RESIUENTIAI.PLMB. SQ.Ff. PALO
I hereby affirm that there i,aconstruction lending ab'rr'ey for the of Dam Raelptp
the work for whiab This permit is issued(Sea 3097,Cr,CJ -
O U Len 's Name TOTAL:
Lender's
Lender's Address TOTAL:
OWn I unify that I have read this application and state that the above Information is BUI DING PEE
M cotrecW agree to comply with all city and county ordinances andslale laws relmingm QTY. MECHANICAL PERMIT FEE
V oZ building construction,and hereby authorize mprosentanius of this city to enter upon the SEISM/ P.
aMwe-memumed properly for inspection purposes PERMIT ISSUANCE
(We)agree to save,indemnify and keep hermlc s the City of Cupertino against ELECTRIC\E
liabllllies,judgmenls,costs and expenses which may in any wayacuue against said City' ALTER OR ADD TO MECH.
PLUMBING FF,
in nICAN ce Nthe RSTAN of ANpermit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'(TO 10[410 CPM) MECHANICAL EF.
SOUR EREGULATIONS.
��///) AIR HANDLING UNIT(OVER 10,1100 CPM) CONSTRUCTION TA
Signature of Applianl/Carpecmr Date EXHAUST HOOD(W/DUCT) DOUSING MITIGATIO FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sure orhrndle hazardous material HEATING UNIT(TO 100.030 BTU)
as defined by the Cupenino Municipal Coda,Chapter 912,and 111 Heal ,and Safety
Cade Section 25532(a):' HEATING UNIT(OVER 100.004)BTU))
❑Yes El No PAID
VENTILATION PAN(SINGLE RESIDI Date Rerun # -
Will
s hazardous
foo dir,must ir futuan,a building by the B use equipment of devices which
emit hazallonu air cormminams Be defined by the Bay Ara Air Quality Management BOILER-COMP(3HPOR II40,0I0 BTU) TOTAL'
Owned? BOILER-COMP(OVER 1010,M0 BTU)
❑Yes FI No
I have mad the haznedeasfestinate mciimnrems under Chapter E95 of the Crrh- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Gds Sections25505,25533 and 25534.1 undefmnnd that ifthe NEW RESIDENTIAL MECH. SQ.Fr.
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which must be met prion to issuance of a Cenific le of Occupancy.
Owner or authorized agent Dam TOTAL' ISSUEDBY:
OFFICE