S 0380 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PI,[ZMIT ND 0 O
CAL
BUILDING DIVISION APPLICATION/PERMIT PING Pact IDENTIFIC l`7
BUILDING PROJI?CT IDBN'I'Ia'ICA'HUN
BUILDINGADDRE.SS: SANITARY NO. APPLICATION SUBMITTAL.DATE
in. ItNI
OWNER"NA I?:T
PHONE: CONTRAiC1 ORS NAME: LIC NO:
( I N/C CONTROL.N
�gNCHI'1".CpENfi1NEER. LCNO: ADU SS:
CONTACT: PHONE: I' BUILDING PHRMIT INFO
-nnsultant Fees Paid by Applicant(Initial) 1 B ELECT PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hemby affirm that I am licensed udder provisions of chapter 9 button rcing JOB DESCRIPTION
M%Z with Sevilla aflEvii,ma 3 title Businessand Procluiote Code,rnd mylZu,sis RESIDENTIAL;
Yl O O 1'IiI1MIT ISSUANCE
F+ full fume and effect. ❑:I'IJWh ❑KITCHI?N RP,MODEI.
�UzV License Closes Lice APPLIANCES-RESIDEN'LIAL DDITION El PLUMBING RE-PIPE
in6L Date Conwmne ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION
b,p co PANELS MODI IICATION
Z O Z I understand my plans shall be used as public records
OZ O UI'To 21X)AMI'S ❑IN'1'ERIORq/�yy pp ❑CHIMNEY REI'Allt
r"4,p uLLIl Licensed Pmfemiomal - 201-10110AMPS IMPROV1 IiNy ' .{^/ ❑SWIMMING POOLS
C 2; OWNER-BUILDER DECLARATION OVER 1110p AMPS ❑BADIREAMODELREPAI R [I DEMOLITION
O W U I hemby affirm that I am exempt from the Carburetors License Low for the OM
6 fallowing reason.(Section]031 S,Business and Professions Code:Any city or county SIGNS ELECTRICAL
a W which mquims a pcno t m construct,vlrer,improve,demolhh,ur repair aay suuetum
0
prior its issuance,also requires the applicant fir%ach pxiat to File asigneJ nammcnt SPEC1ALCIRCUIT/MISC.
M`rk,{} That he is licensed pursuant pmvi.smar.sofbhe Commil License Law(Chaptert)
�r.G� (commencing...hsemion](NMB of Uivision7of the Business and Profcssinns Cade)nu TEMP.METGR OR POLE INS'I'. .t�•(�� �y,
IL a that he is exempt thcmfmm and dm basis for the alleged oxnnpdion.Any v''alition of ❑NEW BLDG/ADDITIONN\LI DI3M01.1'I'ION
y Section 7031.5 by ally applicant for a permit subjects the upplicunt to a civil Penalty of POWER DE ICES TENANT ❑FOOD SERVICE
F.ZY eta mom than fisc hundred dollars($500). IMPROVENIENT
a0 ❑ 1.as owner ofthe property.or my employees with wages as their sale contpensmion. SWIMMING POOL ELECTRIC
will do the work,and the swcmre Is not imanded muffered hassle(Sea.904q amulets ❑011 LER
and Pro1'cxsions Code:Tho Can.,,T's Li",rin Law does nal apply to an owner of OUTLETS-SWITCHES-IFX'1'ORE'S
p' property who builds art improves daemon,and who does such work himself or through
his own employees,provided that.such improvements am not intended nr offered for NEW RESIDENTIAL ELECI'R SQ FT.
sale.IL however the building ca improvement is sold within one year ill
completion.the SQ.FE II,pOR AREA SISQ.PI'.
m-huilder will lune the bmJ.t of proving Ihab he did not build or improve far pury
False tussle.). t
E] L m owner of Nc property,am exclusively cumulating with licensed cnmmdon baIs
o ennarl the project(Sce.01144,Business and Professions Calc:)Thc Conniou,s Li.
ass,Law does not apply to on owner of property who builders or improves thereon,and QTY. PLUM GPERMITFEE Ul'.
who contracts for such profess with a eon¢vcturb)licensed Fluxu bat to the Contractor's
License law. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this reason
AI:LF.R-DRAIN VEN ATER(I?A\ I JVAIIVAITO
Owner Date
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.UEV E
I hereby effinn under penalty of penury one of the fnlloei el-W.0asutions:
❑Ihave an)vidc maimuinaCenihcate of Cunxmm Code,sur ,the
Worker"Compete DRAINS-II.00R,ROOT°,AREA,C( STpg _S TYPE CONSTRUCT[ON
sedan,as provided lin by Senior 3]IIU of the Labor QNc,Iia the performance of the
work l in which this period is issued. PIXI'URES_,, TRAP
❑1 have and will maintain Wnrkds Compensation Insumnee,as required by Section
3100of Ne labor Code for the performanccof Ne work for which this permit isiss.N. GAS-EA.SYSTEM-1 INCAOUTL1:IS DEC GROUP APN
My Worker's Cmmpensulian Insurance tamer end Policy numher are:
Camicr. Policy Na.: GAS-EA.SYS'I HM OV ER 4(EA)
CER[I PICATE OF;EXEMFI'ION FROM WORKERS' GRIiASFI1NUUS"TRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILD G SION FEI6
(This scetiaimednm becompincil iflhe permit is fmonehundred dollars(SI00) GRHASETRAP
or less.) PLANCIIfiCK Ilii!
I certify that in lheperforndanmofthe work forwbieh dut,,,not is Issued,Island SEWER-SANI'T'ARY-STORM EA.20X1 FT.
not employ any person in any manner m as to bessnne suhjen to the Workers Compete ENERGY pE
o ,Z safirm laws n I hm'r.I sat WATER HEATER WNENTMLLCTR GRADING
Applicant - &4—t
[[[Rjrrr .N•t
NOTICE 10 APPLICANT.IL after making this Certificate of Exemption,you should WNI PIC SYSIEdit]REA'I'ING
become subject to the Workers Compensation f the Labor Crde, must SOILS ' L
3 pe Pmvisimnso You
forthwith comply with such provisions or this permit shall he deemed mucked. WATER SERVICE
Q
UZ CONST'RUCTION LENDING t NEW RESIDEN'T'IAL YLMH. SQ.FT. PAID Uc R<mipte
I herehy u[finn thatthere Is n constructionction lending.,aagency tin the pcd'nrmmneo of
UU. - the work fou which this pmvitA issued(Sec 3097.Ci,CJ
OU Lender"Name TOTAL:
ltd Lcndees Address )
L11 I certify that I Imveceld this application and state that the above inhumation is BUILUO'ALITE
y earn..I agree m comply with.11 ray and worry oMinunccs roil cram laws relining n' QTY. MECHANICAL PERMIT' FEE SEISM
U Z building construction.and hereby cathodic representatives of this city to after upon the
r above-nscmicnW pmperty for inspection purposes. PERMIT ISSUA NCE
(We)agree m save,in leamify rad keep harmless the City of Cupertino against HLEC
Iirbilities.jadgmeal,cocas and va,vmvs wush,nay in an,way accrue ngai ,1 said City ALIHR OR ADD'I'0 MSCI I. PLUM
in consequence of the granting of this permit.
APPLICANT UNDER STANDS ANDW COMPLY WITH ALL NON-POINT' AIR HANDLING UNIT TO 10,000 CFM) MUCH
SOURCE REGU NS.
AIR HANDLING UNIT(OVER IO,IH111 CPM) CONS
SlgoaamofAppllcam(COmil Date EXHAUST HOOD(W/DUCT) HOUSING MI rl(r ION PEI.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant mfuam laiddingrwcupas smmor handle hazachas material HEAPING UNIFC10 I00dN1013TU)
as defined by the Cupertino Mm i,ipnl Code,Chapter 9.12,and the Health and Safety -
Cale.Section 25532(09 HUATING UNIT(OVER IOgINg)BTU)
❑Yes E]No VENTILATION FAN(SINGLE RF-SID) PAID
Dam Rcccipte t
Will file applicant nrfntrc huildirl,wcuptml useequipment ordevices waiHt IfUILEIt-COMP(3HPOR 100.000 B'I'U)
emit havarems air ca imminame as defined by the Bay Arca Air Quality Management TOTAL:
DlstrictV BOILER-COMP(OVER 100.000 BTU)
❑Yes ❑Nn
I hive real]the hazutdous materialsreynmmen is under Chapter n 95ot the Cali AI R CONDTI'IONER ISSUANCE DATE
Limit health&Safety Code.Sections 25505,25533 and 25534.1 understand that lithe NEW RESIDENTIAL MECII. SQ.FT.
building Jots not currently base a tenant,that it is my mspomibility m anify the rccupold
of the r,"imments which man he met prior In issusave nl a Ccnifieste of Qcupaney.
Owner or authorized agent Date 1 ISSUED BY:
OFFICE