S 0785 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL
PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT r1.UMmrvf1'MF_,C eel. S 0785 7 8 5
BUILDING PROJI,'T IDEN'I (CATION V / t!
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
'S DAME: PHO E: TR �$.QI B' X1'1 �' NIC CONTROLtl
'IARRRCCHtl'.TECT/ENGINFER: LIC NO: AUDRESS: V\ �.
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V PHONE:Ir let. wt) 1.. rn "1 BUILDING PERMIT INFO
CONTACT:
❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
qya
LICENSED CONTRACTOR DECLARATION QTy. ELECTRIC PERMIT FEE
I batch,art,,.111.11 alicensedrude'precision'of Chapter 9("ouramencing r JOB DESCRIPTION
�oZvr,hSeetlar9WB)afD . 3 off,Bu' dP fri...Cede,andraylicon,cis ERMITISSUANCE RESIDENTIAL'
F+W Or in full force and effect, ❑SFDWL ❑KITCHEN REMODEL
�UU License Class Lic.k APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING RE-PIPE.
F Z W Date Contmclor
m G 0. RCHITECTS DECLARATION F1 MUhTI-UNIT El STRUCTURAL
E,D to PANELS MODIFICATION
ZOm4 lett ndm 1 s 1 be uxedaspublre record,
OZ-O on UP T0200 AMPS El INTERIOR El CHIMNEY REPAIR
F[21 m Licensed rofesumal 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
k OWNER-BUIL4 DECLARATION OVER IINIO AMPS *5401,IT REMODEUREPAIR E3 DEMOLITION
a t4 a 1 hereby alnnn that 1 am exempt train the Contractors License Law for the
O y U following reason.(Section](131.5,Business and Professions Code:Any city or county SIGNS ELIiC'I'R'CA]. OT ER
which requires a permit to construct,anus improve,demolish,or repair any swaure
prierm its issuance,also requires the appiioanlforsuch permit In flea signed stmemem SPECIAL CIRCUIT/MISC.
ythat he is licensed pursuant the provisions ufthe Contractor'a License Law(Chapter 9
pt�Q (commencing with SeIlion]INN1)of Divisimn3oDha Business and Pmfessinm Cntle)ar TEMP.METER OR
POLF.INST. COMMERCIAL'
d`yoy
but he is remind therefrom and he basis for the alleged exemption.Any violation of — \ NEW BLDG/ADDITION ElDEMOLITION
iCm tie Section 1031.5 by any applicant for a permit subjects the applicant ter a civil penally mf POWER DEVICES TEN ❑FOODSERVICE
H�>s onto ore than five hundred dollars(SNR. IM VEMENT
d ❑I.as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
O will doth,work,nnd thestruemrc is not intended or offered for sale(Sec.9144,Business
and Professions Code:'true Cammetou's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
a' pmperty who builds or improves thereon,and failures such work himself or through to
his own employees,provided that such impmvoments ore our intended or offered for NEW RESIUENTIAI.ELECTR SQ Er.
sale.If,however,the huilding or improvement is sold within nneyear ofcompletiw,the SQ.FC FLOORAREA S/SQ.Pp.
ownu-hullder will have the hntden of pmAng Om,he did sol build or Improve for pur-
pose of tela). A p�
E]T,as owner of the properly,am exclusively commuting with licenced contractors m TOTAL: M D
construct the project(Sec.9044,Business and Professions Code)'I'he Commemr's Li-
cense Law dues not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE. DEC �� ��
who contmets for such p projects with a contractors)licensed pursuant o the Continent's U tip
License Law. PERMIT ISSUANCE
❑ I an exempt under Sea. .B&P C for(his reason -
ALTER-DRAIN&VIiNT-WATER(EA) VUrC'P;;u#Tji3N
Owner Date /
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm antler penalty of peajury one of the fallowing declarations:
. D l have and will molnminh Certifcaro of Consent for Workers Compos- DRAINS-FLOOR,RODE,AREA,COND. STo
IGS TYPE CONSTRUCTION
radon,as provided for by Section 3](10 clothe Labor Code,Rome perommance of Ihe - - ,
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Cumpansation Insurance,as required by Section
3900 of dia ode,for the performance of the work rot whichthis pemdl is'surd. GAS-EA.SVSTBM-I INC.40IITLETS OCC.GROUP APN
MyW nsatim Insurance farthermost Policy
Carrier Polity No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE.OF EXEMPTION FROM WORKERS' CREASE/1 N DUSIRL WASTE I NTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES _
(Thissurian need net be eventuated if the permit is for one hundred dolls.SI00) GREASETRAP
at'less) PLANCHECK FEE
I certifythat in the performance nfthe work l'orwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.200 RI'.
not employ any pusoa In any manner so as m become subject to the Wurkas'Comped- ENERGY FEE
O z sulion Laws of California.Date WATER HEATER W/VENVELEC'I'R FEE
O Applicant GRADING F
G NOTICE TO APPLICANT:If,after making this Cmificate of Exemption,you should WATER SYS]EMU REATING SOILS FEE
abecome subject to the Worker's Compensation provisions of tiro Labor Code,you must
W forthwith comply xithnich provisions.1 thin permit shall be dermad revoked. WATER SERV ICE
Q
CGN$TRUCTION LENDING AGENCY NEW RESIUENTIAI.PCMB. SQ.FT. PAID
I hereby affirm(hot there ran wnswflimn lending agency for Ore performance of Dvm Rec IM
U the work for which this Permits issued(Sec.3097.Civ.c.) -
O U tender's Name TOTAL
Lender's AddressTOTAL:
>i LkI I certify that I have read this application and stem that the above information is BUILDING ?G
F Val correct.1 agree to comply with all city and county mdinanees and state laws refuting In QTY. MECHANICAL.PERMIT FEE
U7G building conelmeuon,and hereby hournize repreaenarrive,of Win city to enterupnntfhSEISMIC PEE
ahovermertioned pT.,,iy far inspection pmposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep lum less the Cidy of Caperton,against ELECTRIC FEE
liabilities,judgmems,costs and expenses whichmay irony way acemengainst said City TER OR ADD TO MECH.
in consequence of 0e goading of this permit.in
FF
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) _
SOU CEREGULATIO.IS. MEC(IANICA FEE
AIR HANDLING ON]](OVER I0,00)CFM) CONS'IRUCTI NTAX
Signaoreor Appli/fWW�A�p111pliicanVVContoctor L Data EXHAUST HOOD(W/DUCT) HOUSINGMITI TIONFEE
HAZARDOUS M RIALS DISCLOSURE
Will the applicant or future building occupant store or handle hawrdous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code Section 25532c)? HEATING UNIT(OVER 100,0011 BTU)
Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
- Dom Raceipl#
Will the applicant or for hulldi as oceupeal use equipment at'devlecs which
emit haieMous air conmminvnts as dclned by the Day Area Air Quality Management BOILER-COMP(3HP OR I(NI,000 BTU) TOTAL:
District? BOILER-COMP(OVER I00,000BTU)
IP ❑Yes El No
ILavr reed drm hazardous mnderinls reyuiremenls under Chapder6Y5 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cade,Seconds 25505,255331md 25534.I uada,,Iand that if the NEW RESIUENTIAI.MECH. SQ.ET.
buildi,,,,, no[omren0y hn,t r ,n,l pato no is era res of a C illty do e o fy lit Occupant,m
of iha regnilemenls which must br me priormissuenee ofm Cerlificatc if Ocfupancy. - -
Owner our adharized,gem Irate TOTAL ISSUED BY:
OFFICE