B 0640 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. � G
BUILDING DIVISION APPLICATION/PERMIT PING PROJECTIDFICpnnpj 6.r'k/_ n
BUILDING MECHANICAL IDENTIFICATION L9�VI 'JV o
BUILDING AIIDRESS: � SANITARY NG. APPLICATION SUBMI'1'fAl.DATE
(�oSA i2, A vc:—�u� .
0&ES NAME: �pHONE/ C NIEAC.TOR'S NAME " ^ LCNO:
T 3
NIC CONTROLN
ARCHITECf/FNGINESR: LIC NO'. ADDRESSp ❑
CONTACT: PHONE: l g� 1AIY cel? BUILDING PERMIT INFO
E] Consultant Fees Paid by Applicant(Initial) BLDG ELECT/' PL;UyM�Iy METE
' ❑ LfC ICJ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 nm licensed under pmm
visions.0 Chapter 9 .mmenemK - . . JOB DESCRIPTION
Oa'0 wire Sedi.n 7txln)rrDlvi,ion3onhe Bu,inessane PmPoaai.n,CrNe one mylieenaeia � �S RESIDENTIAL:
RIO PERMIT ISSUANCE V ❑SFDWL ❑KITCHEN REMODEL
Flu In full Coreov fo ��
< J Lic Lic.M / APPLIANCES-RESIDENTIAL ❑ADDI'PION [I PLUMBING RY PIPP.
F W Datc Crn¢ecmr
ARCHITECT'S DECLARATION El MULTI-UNIT ❑STRUCTURAL.
Z C 1 PANELS MODIFICATION
I underemnd my plans shxll he uvel as public records
O z,+O UP T02l10 AMPS [I INTERIOR ❑CHIMNEY REPAIR
Eq"{vI Licensed Professinwl 201-1000AMPS IMPROVEMENT SWIMMING POOLS
.�y J Oat I am exempt
front
DECLARATION OVER 1000 AMPS ❑BATH REMODEL CPAIR ❑DEMOLITION
IIIQ 1 hereby al5nn that 1 am exempt from the Contractors License Low for the
Lid$O y U folbwing reason.(Section 7031.5,Business and Pndescions Coda Any city or marry SIGNS ELECTRICAL ❑OTHER
w a!L vFi which requires a permit m wnxtmel,alter,Improve,demolish,or repair oily dru.lure CA
F�Ost gum-anis issuance,alurnmires thrapplican0'.,such permit mfile asignedswtemenl SPP.CIALCIRCUIT/MISC.
ypK�r� "1 ButheNlicenecd purswtono the pmvi,ions of the Comrwer,License Law(Chapter9
W�q� mm(commencing with Section 7000)(if Division 3ofthe Bnsinx,mal Professions Code)or TEMP.METER OR POLE INST.R.RI
x
M p��C that he is exnpt thereGoand the basis for the alleged eaem dila.Any violation of L1 NEW BLDG/ADDITION DEMOLITION
lit^m Section 7131.5byary applicant for.promah,unces do.pplicanl to a civil penalty Of POWER DEVICES ❑'I'HNANT ❑FOOD SERVICE
y not more than rive hundred dollars($5007. IMPROVEMENT
L] Las owner of the progeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the shumure is not intended.,offered lot sale(Sec.704Q Business El OTHER
and Professions Code:The Comrnctur',License Lvw does not apply to an owner of ' OUTLETS-SWITCHES-FIXTURES
property who huilds or improves thereon,and who dace such work himself or through
his own employees,pnoided that such impmvemente are not Intended.,offered for NEW RESIDENTIAL ELEC'FR SQ FT.
sale.If,however.the building or improvement is sold within me year ofcompietion.therMAY
ORAE A $/SQ,FT.
mer-builder will have the burden of proving 0m he did not .,buildimprove for pur-
pose of sale.). TOTAL:
❑I,us owner of the property,am exclusively contracting with licensed c.mmctara to6 1999
onsrtnct the purport(Sec.9044.Business and Professions Code:)The Contractor's Li-
- cense Law does not upply to an rwrerofpmpeny who builds or improves thereon,and QTS'. s PLUMBING PERMIT I MFE
who contracts for such projects with a conlocump f licensed pursuant o the Conhveter's
License Law. - PERMIT ISSUANCE By
Ism exempt und &aide,Sec. ,BP C for thisreason
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUA
WORKER'S COMPENSATION DECLARATIONBACK FLOW PROTECT DEVICE
1 hereby oll7rm under penalty.f perjury one of the following doclanualls:
AI have and will unhand a Certificate of Consent o self-Insure for Worker's Compels- DRAINS-FLOOR,ROOF,AREA,GOND, STORIES TYPE CONSTRUCTION
nll.m.as provided for by Section 37M or the Labor Code,for the pcdmmench of the
work f n what,this permit is issued FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3700 oftthhee gUmmi--CCeonde,,for�thhe p[errpn�iongcee ofthe work for
�which
this
�p_er�miit its issued, GAS-EA.SYSTEM-1 INC.4 OUTLETS 'OCC GROUP APNMYW .
C �.rCW/Cc Y't�lClZ-�h✓Gi/Poll,No,y w`N l�U'i GASB-EA.SYSTEM-OVER 4(EA) ,
CE WIT FICATF,OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASERNDUSTRL WASTE INTERCEPTOR
(This section need mol bo completed if the permit is forone hundred dollars($100) 'BUILDING DIVISION FEES
rr less.) GREASETRAP PLANCHECK FEE -
Icemtyt nthe performanc which this permit is issued,Lball SEWER-SANITARY-S'IORM 5A.200 FT. -
a.,ham.y an er m in any mann so as a centre so to the Workers'Camper ENERGY FEE
,Z satinn Lucas C .mDe
in. c WATER HEATER W/VENT/ELECTR
O O ApGRADING FEE
G r~A NOTICL'I' APPL[CANT:1I, er making Ihip Centhcnte oC Exemption,you should WATER SYSTEMC REATING
F httrme subject 1.the Work,,,Compcar,miim....War,of the Labor Code,you most SOILS FEE
Wforthwith comply with such previsions minis permit shall he deemed revoked. WATER SERVICE
Q
(Y CONSTRUCTION LENDING AGENCY NEW R53IDP.NTIAL PLMB. SQ.PT. PAID
UO
I hereby action Nat there is construction lending agency for the performance of Date Receipt if
the work for which This permit islssued(Seo.30 309'!.Cis.CJ -
0 U Lender's Name TOTAL:
L) Lenders Address TOTAL: -
i?t W0. BUILDING PEE
[.y. I wnee that I have read Nie application
lyand o slate ces athend shove iws relatinn Is
Ut4 correct.I buildigrmnornicompld with all
auffiria eepresntativeafthis stale city to
QTY. MECHANICAL PERMIT FEE
U 4 building cnnstmdion,and hereby au0oriu representatives of this city t.emerugm the SEISMIC FEE
above-mentioned property for impectmn purposesD
(We)vgree1.save,indemnify and keep hm
arless the City of Cupertino against PERMIT ISSUANCE s� ELECTRIC FEE
1
liabilities,judgments,costa and expenses which may in any way wmue against said City ALTER OR ADD TO MECH.
in con
sogt cc ofthe gra 11. tuts PLUMBING FEE -
A111 IN UNDP.RSTA Ys ILL. I PLY WITH ALL NON�POIN'I' AIR HANDLING UNIT(TO 10,0110 CFM)
SOl CE 'GULATI)NS. MECHANICAL FEE
AIR HANDLING UNIT(OVEIt 10,000 CFM) CONSTRUCfIONTAX
Signature mApplirmWC mctov JData EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MA'1'F.RIALS DISCLOSURE
Will the applicant or future building occupant senior handle hazard.nstmneicl HEATING UNIT(TO 100,000 BT U)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x):' HEATING UNIT(OVER 100.1100 BTU)
❑Vas o VENTILATION FAN(SINGLE ReSID) PAID
cant
Dote Racoiptk
Will the air contaminants
bending by the
se Area
Air
ntlity or Management
BOILER-COMP(3HPOR 100,0000TU)
emit hazardous air eonmminants us defined by the Bey Arcu Air Quality Management TOTAL:
Dl,ldm7
❑Yes (.!No BOILER-COMP(OVER 100,000 B'I'U)
I " AIR CONDITIONER
Ji—,
codthe ha-21requirements uude3Chapter6.95o than if i- ISSUA CT DATE&SafeCod eatia ,Intel25533and25534.iuudcrsmndtheifNe NEW RESIDENTIAL MECH. SQ.Nf. �� /ortcut� tthatiiE�teonsis.. eofaCc ,oto
.IG �afOwnerrrigent �� Dee T(YI'ALo ISSUED BY'.
OFFICE