99100053 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY C N L 0�k�3
CITY nal•CUPERTINO BUILDING-ELECTRICAL /1 11 I'IiHMI l'NO.
BUILDING DIVISION APPLICATION/PERMIT PING P OJECT ICIIANICAI, SOOOI
IfI111,DIN1:I'RI)JI?Cl'IUEN'1'IF'ICATIUN
BUILDING ADDRESS', SANITARY NU. APPLICA'DON SIJBMl 17AL DAA
P
O FR'SNAMF: P "Me C NTRACIY)R:S NAMIi:
NIC CONTROL It
CH ELT/IiN NT:T:R: t .NO: AlI Fe : ❑
COM'ACT: PHDNF,: BUILDING PERMIT INTO
EU ic, O 1;7,3-9M1 ❑ Consultant Fees Paid by Applicant(Initial) LOU .XCr Ill +TECH
ulp
.ICE SED FRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB D. CRII'IION
�fdZ with Section 700X)of Division lof the Business and Professions Code.and my license i% RESIDENTIAL:
W O en PERMIT ISSUANCE
CSF in full hovered Acv. 0SFDWI. Q Ki rCHIiN REMODEL
`1—ULicense Class Lia# APPLIANCES—BESIDES HAL El ADDITION QPLUMBING RF-PIPE
FZW DartCon'mc'a
ARCHITECTS DECLARATIONPANIiIS ❑MULTIUNIT QS'TRUC'I'URAL
F y Z I undo,ord my pIm,,mf be uwd sex public records
MODIFICATION
ZOm,.. HP TO 200 AMPS ❑INTERR Q CHIMNEY REPAIR
Licensed Foil.ssinn:d 201-INMAMPS IM' IiMIiN'I' QSWIMMINO POOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS Alii REMODHIJRFFAIR QDEMOLI'FION
C�y�1y]1 Q 1 Imm1b,SIT a that I ani exerilp limn the Commchns Gecase Law 4n the
L U following ninon.(Section 7031.5,B-ITICFs and V M,,ions Code:Any City or romny SIGNS FLEC'IRICAL \
3 LL N which requires a Permit nm construct.aper,improve,demolish,or repair any stmc'urc
0; prion t 1, y :th ptilic II such vin fl .6 Jswm Hent SI'LCIAI,CINCUIT/MISC
that In,I,licensedp 'u; It,powimor,ithe Contractor,LLa (Chapter9 1'I I
�a � (cu neon:ng thS ti 70Np fl) '%io 3 Oh 13 %s dPr f:.lns CafO or I M MIi TI:N OR POLIi INSf
a G,pM C that he Is exempt thrrCliam and the basis lin the alle,c l exemption.Any violation of Q N W BI.DG/A )DION Q DEMOLUWN
xlySection 70315 by any upplicmn for a Permit subjects the applicant a civil Penalty of POWER DEVICES ❑TG NT EI FOOD S17RVICE
Call I'm'him Five hundred dallars(E500). IMPR fl:N'f
=Q Q
I,as.wncr nal the property.ser my employers with wages as their tole c.mpensulinn, SWIMMING POOL ELECTRIC
will entire wmk.mid the mmoure is not imeadedoroReed for sale(Se,.7 W.Business
110W PR Q
m
i 3 and Professions Code:The Cono-unnr's License law does,no'apply to an owner of NEW BES—SWI'1'CHIS—PIX'FURES
property who builds ar improves'hemon,and who d«s such work himself or through
his Own employees,provided that such improvement.,arc not intended or offered for NEW
RfSIDIiNT1A1.FLEGI'R S FT.
sale.If.howeverthe btildingor improvement isvuld within one year ofcompletion,the 6
TR 1L1 FT
Cnbuihim will have the buof, ing that he did nut build or improve for pars a J,7
rden ow
pose of vale.). T TAL:
Q I,a%owner of the property,am exclusively contacting with,licensed contractors to
.react the project(Sce.7(44.Business and Professions Calc:)The Coonactor's Li-
nselawdoesnot apply toan(wper ofproperlywho buildsorimproves themon.amt QTY, PLUMBINGPERM FEE y
who contracts for such projects with a contractogs)licensed puts part the Cummnor's
License Law. FERMI'I ISSUANCE
Q 1 am exempt under Site .B&P C for this,canon
ALTER-DRAIN&VIiNT-WATER sill, yA1.UAl'ION
)sena, Date w k`rJ
WORKIiR'S COMPENSATION DECLARATION BACK PLOW PRUTIiCT.DEVICE 7 fop
I hereby affirm under lenulty of perjury ane nf'hc following dedaraliuna:
1 I have and will neimain a Certificate of Conal to%elf-insure far Worker's Campcn- DRAINS-FLOOR.RODE ARRA.COND. STORIES '?TYPE CONS]RUCTIC
pion,a,pnot1lull tar by Scelinn 3700 of the Labor Cndc,to, Pcrl'ormrncC nal the
work lin which this,omen is Inmhd. FIX'I'ORES-PER'I'RAI'
Q 1 have nand will nminmin WorkeLs Conmennatlon Insurance,as rcqulred by Sectlon
370polthe Labor Cale,forgm,mfnnnamcat'the work fin wain his mond is issued. GAS-IiA.SYS'I'I1M IINC.J OUfI.I?'I'6 OCC('MOUI AI'N/
My Wok sCm mpnnsnhn In%'nrnncc carrier send l'nlicy numh•ra Sy(
Car Policy Na: GAS--EA.SYS'1'lIM-OVIIR J(IiA)
C ENIIIECAT:OIC li%IiMYI'ION FRO WORK R GREASIDINDUS'FRI,WAS1 R INI'ERCI?VTOR
COMPENSATION INSURANCE BUILDING DIVISION FIR
(Thiaxection need not bccontpleledirthepennd isba.nchun'heddollaIx($10) GREASE TRAP
PLANCIIECK Plili
orlas%.)
I verify that in the performance work for Which sperttdl is i%%ucd.l shall SIiWf:R-SANITARY-STI ORM EA.200 FT.
r
not employ any,clam in any rammer.asuw'o became subjhdmtbe worked Compcn- ENERGY PER
Z, w'ion laws of Cdifomie.Dae WATER HEATER WNEiNT/ELECfR GRADING FEE
Z Applicant t
Z N N(IDCI!TO Atli If,after making this Ceni6cme of Fecoarrom you should wxrER SYSTENICI'REATING SOII S FEE
'a > became subject ui the Worker's Conn cnsaran provixiona of the labor Cade.you mus'
fnplwi'hourid,with such provision,.,,his perma,hall be domed revoked. WATER ST:RVICE
1 QPAID
= z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLk1IL SQ.FT. Dam Receipt It
U O l hereby dfimm that then is a Construction lending agency forthe performance of
4. — the work for which this permit is I...Cd(Sce.3097.Ci,C.) T(yl'AL:
O U Unit" Name TOTAL:
�l LCWcrs Add.,., TOTAL
ITE
1Z I certify that 1 have read this application and nae that Ne above information is
t erred.I agree to comply with all city and county ordinances and seam laws relating m QTY. MECHANICAL PERMIT FEE SEISMIC PER
U Z huildin6 amaoction,and hereby au'borizc representative%of this city to enter upon the
adwcmen'ioned Property fill inspection particles. PERMIT ISSUANCE ELECTRIC ITH
(We)
agree m wve.Indemnify and keep hand...the City of Cupertino against
Iiabilitics,j.d,amms,costs and expenses which may In any way accrue again'said City ALTER OR ADD MIKE. PLUMBING IEE
in nwquence of the goating of thin Permit.
APVIJCAN'I'IINDERS'I'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'0010.001 CFM) MECHANICAIFI 3
SOURCE REGULAI IONS.
AIR HANDLING UNI'I'(OVER lh,fip'CFM) CONS'TRUC'HON'I'AN
Signature nal'Applicant/Conwe'or Date EXHAUST'1 IOOD IWIDUCIT I JOBS I NO M111'1'IGA1lON ITE
I IALNtDOUS MATERIALS DISCLOSURE
Will the applicant
nr Motre huilding occapunt.tlore or handle hazardous malarial HEATING UNI'I(10101,000 U'1'(J)
us def ed by the Cu,cnioa Al Gde,Chr,pm 9.12,and the Health and Surety
Cndc Section 2553200? IIIiATINC UNI'CIOVIiH 1D),(XXI Ii'HJ) D I
Q Yus 0N VENTILATIONFAN(SINGLIi RESID) PATI
Date Reoeipt It
Will the ap,licunt or future building occupant Inc equipment or devices which BOILER-COME'OHP OR 100,00a H'fU)
nit hazardous air contaminants as defined by the Bay Arca Air Quality Management 'F<YI'A
stria? BOILER-C(1MP(OVER Manna BTU)
C]YC, 0N
1
have read the h ase.S ttueri 55 5.1553ene under L 1 and 6.95 of the Cali
AIR CONDITIONER ISSUANCE DA'I3
normal
gdoes&Sa&lyae a was355at i 2s my andresp 2550.1 to nedasdthatif the NEW NP_SIDIiNTIA1.MECII. SQ.FT.
buiWingdrcs not isWhich
currently have a MCI Pol.that it is sea ce mil responsibility atcOpOfy she.crricy.
of the reyuirctten¢which must be MCI Prior m issuance of a Cenificam of Qcupatmy.
Owner or authoved agent
Date i i
TOTAL t ISSUED BY:
OFFICE