S 0595 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL)ING-ELECTRICAL i'ITI hIIT NO
BUILDING DIVISION APPLICATION)'PERMIT PIAJM1HNC,-MECHANICAL SJ 0595
LLUl1.DINO 1'ROJF.CT IDFNflF'll'A'riON
BUILDINGAD)RISS: SANITARY NO APPLICATION SUBMITTAL DAD
-.11 10
OWN• 'S NAME: ( PHONI ��`�^/ CONTRACTOR'S NAME LIC NO:
A7 D a9 K i C NIC CONrRln.a
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: B111LDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) BLD ELHCT
_ Pik MEct�,
I.ICENSI?D CONTRACT'OR'S DI2CLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OOZ with Sectian7011(Bof Division 3cfthe Bosineusand PsofessionaCode.and mylicense is RESIDENTIAL:
1--0p in full force and PERMIT ISSUANCIi
W F- effect. - ❑SFDW'L ❑KITCHEN REMODEL�U License Class Contractor
APPLIANCES—RESIDENTIAL El ADDITION El PLUMBING RE-PIPE
F4 Z{il Ullle CFallDECL
aa' ARCHITBC'IlS DECLARATION El MULTI-UNIT ❑59'NIIC'TURAL
I..N Vt PANELS
Z O I undermimA on,plans shell be anal ux pnhlic rcrnNv CHIMNEY
MODIFICATION
UP TO 211UAMP5
O Z^O ❑INTERIOR ❑S IMMING Poon
F real Licensed Porfessional 2111-lfgU AMPS IMPROVEMIiN'I' �SWIMMINGPWLS
OWNER- UQ 1 hereby strata Il I am axdmpt from LDHR the Cnnlra mi.v License Law for IM1e ECLARATI
OVER IfIUfIMII'S ❑BATH REMODF CFS ❑1 'MOLITI �-
gOpW,U following reamer.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER {j�'�
D- whichrequires" p roll construct, Its p dem IIs) p y'1 marc
�
prior to t Is fey In, ppll tl ,permit
g d,rmmem SPECIAL CIRCUI'UMISC.
} Ilim lie is licensedp r G the provisini,oI'd Contractors LFew(Chlpler9
(oommenemg wnh,tecle 7gx1F of D'visinn 30 tie Busmessund Pont v,sons Core)or TEMP.METER OR POLI;INBT. COMMERCIAL:
6y n
that he is exempt therefrom and IM1e basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DFM01.1'TION
W^ Section 7031.5 by anyapplicant fora period xubjecAdeapplicam ma civil pecalry of POWER DEVICES C3 TENANT ❑FOOD SCRVICE
not mare than foe hundred dollars I55oI�
F Z> IMPROVEMENT
�SQp ❑Lothe owner kf the property,or my employees with wages azlhei(Sec. 0,14,Bsiien. SWIMMING M)OhI!hF,CIRIC
(r will dathewons and the mmnouresnot ho'%Lndnse Law do for saleapplyoI an wrier of ❑OTHER
..� mA Prnfessionv Code:The Cumracmrs License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who no Ids or Improves thereon,nod who does such work hlinxclf er through
Ills own employees,provided that such improvamenm are nm intended ur offered for NEW RESIDENI'I Al,ELECTR IrL
sale If.however,the building orimpmvemenl is sold within one year ofcompletion,the SQ.FI'.FLOOR AREA VSQ.FT.
owner-builder will lave IM burden of proving that he did not build or improve for To,
Tom of sale.).
❑I.as owner of the property,am exclusively contracting with licensed comtmaors m TO'T'AL:
construct the project(Sec.71414,Business and Professions Code:)The Contractors Li- - - P All)
-
cense Law does notapply to an ownerm property who buildvar,improves thereon,and QTY. PLUMBING PERMIT' PC.
who c+mtacts for such projects with o contaclm(x)licensed pursuant to Tho Conlmcmrx o9
Licen I,aw. PERMIT ISSUANCE 'AUG N�
I m em,pl matt'. ,LL&fetor lois reason
(Owner DateALTER—DRAIN&VI7W—WATER O:AVALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PRODiCT.DEVICE CITY Uh GurcHTINO
1 hereby uRrnt under penalty of perjury one of the following declarations
•D l have unit will maintain a Cerificam of Consent to self-insure for Warkee.s ComNn- DRAINS—FLOOR.BOOR.AREA.CONE). STORIES '1 YPE CONST RUCTION
smion,as provided for by Section 37M ohne Lubar Code,for performance of the
work for which This Isrntit is issued. FIXTURFS—PI!R'I'RAP
❑ I have and will n ainluin Workers Compensation Inmradre,av rmyuimd by Scelion
370X1 of the Labor Code.for the performance of the work for which his penmil is issued. GAS—EA.SYS1 lint-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance artier and Policy number ore:
Cameo Policy Nor: GAS—EA.SYS Him OVER 4(EA)
CER3'IFICAM OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GREASF/INDUS'1'RI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This sermon need not be completed folie permit is Tonins,hundred dollars Shop GREASETRAP
or less 7 PLANCHI!CK PI!li
Ieerify that in the performance oflhewmk limwhich lhislwrnil is Issued.Lshull SEWER—SAN ITARY—STORM EA.21X1 ITL
not employ any person in any manmer so us la Neale subject to the Workers'Grmpun- ENERGY FEE
D ,Z smion Laws of California.Date WAI ER HEATUR WNVNT/ELECTR GRADING ITE
Z Applicant `
N NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYST'INaR1;ATING
b+ Income subject path,Workers Compensation pmvisians m the LuMx Code,you most SOILS FEE
forthwith comply with such provisions or this permil vhall be deemted revoked. WNIERSERVICE
0. A
V CONSTRUCTION LENDING AGENCY NEW RESIDIIN'IIAl,PLM11. SQ,Pf. PAID Dule Rece"0
I beRny am rat Ism ionthemi is s con(See 3 m emdmg Ceenuv far nm nerranttanae of
I" r+
,he work Na which this pcnnil is issued fticc.31197,Clv.CJ
!!�� Lender's Name TOTAL:
Isndcr'I Adifyt 'IDTAL: BUILDING ITE
!(ti' 1 eerily that 1 have mad this application and dinn ces the starve information is
raA correditco., to comply with all cityand
representatives
and smut laws repongm QTY. MECIIANICAI.PERMIT FEE
V � building cnmWclinn.and hereby mthrnize rcprescntatives of this cirymenmr upon the SEISMIC FI!Ii
aMve-mentioned protnrty for inspection purposes' PERMIT ISSUANCIi
(Wo)ogres or xnvo,indemnify and keep homilies the City ol'Cuperlino against ELECTRIC Flai
iabililies,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in asequence of the grmoug of this permit. PLUMBING FEE
AN72��
NDS AND WILL COMPLY WITH ALL NON-POINT AI R HANDLING UNIT(To I o.IXRt CFM) MECHANICAL FEE
S
AIR HANDLING UNIT LOVER IQIMI(1 CFMI CONSTRUCTION AS
pplicaMGl mar Dam EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
HAL DOGS MATERIALS DISCLOSURE
Will the uppllcant or future huileinguccupml slope or hmdlo hasutlaus material UpA'I'ING UNIT('I'01110,010 BTU)
as defined by the Cupertino Municipal Cole,Cbeple,9.12,and the Health and Safety
Crude,Section 255320)? 1 HEATING UNIT'HOVER IW."BTU)
❑Yes ❑Nm VIiNTiLAT10N PAN(SINGLF.RESOD) PAID
Dam Receipt#
Will the applicant or future building occupant use eyuipmem or devices which
emit huzallous air romantimnts as defined by the Bay Are.Air Quality Management BOILER—COMP(3HP OR I00,001 BTU)
TOTAL:
Di-xltim^ BOILER—COMP(OVER I01,001 BTI)
El Yes El No
1 have rcuJ the notorious mdnalx mm
yuinmes ander Chapter 6.95 critic AIR CONDITIONERe Cali- ISSUANCE DST E.
fomia HwIIh&Safety Code.Socaus 25505,25533 most 25534.1 undreamed Nat if the NEW RESIDENTIAL MECH. SQ.Irr,
building dues not currently have a union,that it is my responsibility to notify the m'upam
of the requirements which must be met prior m issuance of Certificate of Occupancy.
Owner or earn.....vdneem Date - TOTAL; ISSUED BY:
OFFICE