S 0004APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OBUILDN CUPERTINO BUILDING - ELECTRICAL PIU MIT NO. 20094-
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ING DIVISION APPLICATION/PERMIT r1.uNlnmc-MEcxANIcpI,
I4UILDING 1'ROJEGT IDhN rIFIlAT10N
i NG ADDRESS
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I. VD NORS PWQJ0/ elzaA
N/C
TFIl PN(INGGRr LIC NQ, ADDRESS: _ _ _ _ _ ❑
CONTACT:
❑ Consultant Fees Paid by Applicant (Initial)
I herebyfirm Nat 1 am licensed under envisions of Chapter 9 QTY F'LECTRIC PF:Rh11T FEF:
a p n [«,mnanamg
Q❑=Z with Scellon 91XX1)of Divivion3nflhe Business end Prolbavlons Codau drny1wimseis
W - in toll fnreeandeRea. f9�
%UU License Cl hie.p
N Q 4 Datc Conrm[lorOW
ARCHITECTS DECLARATION
ZN Z I understand my plum shall be used as Public records
41twp Licensed Professional
i, OWNER BUILDER DECLARATION
CC Q I hereby allilm that I um exempt from the Comraemr's License Law for the
LV following reason. (Section 1031.5, Business and 1'rofirWons Code: Any airy or county
W OLL N whicM1 require, a Permit in combuc% alter, intprwe, demolish, or repair any almcmre
prion, its kwonce, also ra,mo s the applicant mr.uch permiuo file assigned statement
�y tIna licI,ticcnaadPmstmm, , the provlsions,fthe Coalraaba,License Law (Chapter 9
IYpO (commencing with Section I",of Dieision 3nfthe Business and Pmfeclana Code) a,
yq Oral he is exompt thanafnnn and the huis far the nllegeal werinion. Any violation of
NSection7031.51dy anyapplicantfornparmhobjectsthe upplicann,aciril Penalty of
not more than five hundred dollars (8501),
Sp ❑ Las owner allow property, or my employees with wages as their sole compensation,
bo will dome work,anderestmemrei,nor mumdedm,(&red forsale(Sec.]IWq Bminoss
13 m and Prbass
into Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does .all walk himself or through
his own employees, Provided on., such improvemen, are or intended ,r offered for
sate. IL however, the buildingon improvement is sold within one yearof completion, me
owner -builder will have the burden of proving that he did not build or improve for pee
pose of sole.).
1, as owner of the propery, an exclosively contracting with Iicereed contractors m
mi the F.Pe, (Sec. 7044, Business and Professions Cd,) The Contmotori Lb
sola. does nm apply,,, anawnerofproperty who builds,. impmve, thereomund QTY
who contracts for such projects with a Canuannr(s) licensed pursuant n the Cormose s
LimnseLaw.
0 I am exempo under Sec. . B & P C for this mason
Owner Dam
WORKER'S COMPENSATION DECI.ARA'rION
I hereby aflb in under penalty of perjury one of to following declarations:
L] rheas anJ will maintaineCmidcmc of CnnsenuosdGinsumforWorkersC,mPcn-
sation, m provided ko by Section 390X1 of the Labor Cede, for the,cordenance of the
work for which tis Permit is issued.
Q 1 have and will maintain Workers Compensation Insurance, as required by Senior
3100 of the labnt Cdc. for the pedmince a of to work for which this permit is issued.
\/ MyWmkefs Compensation Intone, carder end Policy number ore:
Carver: Policy No.:
C17RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissuetion need normo completed if doe pemiii is furans hundred dollam ($100)
or less.)
1 terrify that in me performanceof me work for which this permit is issued,I hall
not employ any Person in any manner so as to become subject as the Workeri Compen-
O Z "mann Laws of Celifomia. Dale
rz Applicant I
y NOTICE TO APPLICANT: If, after making this Cenlficate of Exemption, you should
a ; bTonn subject 1, the Worker's Compensation provision, of the Labor Code, you nmol
forthwith comply with such provisions or this permit shall he discord revoked.
CONSTRUCTION LENDING AGENCY
V 0 I herchyaffinm thatthere In a a hatiation lending agency for the pa.Etrmenev of
h the work for which this pemtit is issued IS., 3097, Civ. C.)
0 U Lehi Nanta
L3I Isnders Addmss
C4 1 minify that I have ted this application and stale that the above information is
rr y correct. I agree to comply with all city and county ordinances and slate laws relating to QTY.
U
above-mentioned
property
herebyamhorizerposes. atives of thiscirymenterupon the
nhnve-menti,nree to arty for inspection harp es.
(WO agree t, save, indemnify end keep harmless the City of Cupertino s against
liabilities, judgments, corns and expenses which may in any way acetas against said City
in comequenm of the grouting of this permit.
: OULI ! ULATIOfN NDS Apy) W/o.INCO �WI'1'll ALL NON -POINT
Sig to IX IIrnv1/G nom — Date
HAZARDOUS MATERIALS DISCLOSURE
Will tho applicant or future building "cn,Pnnl store or handle harardoux mnmfial
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Cdn, Section 255320)1
Z] Yes ❑No
Will the applicant or future building occupant all equiprnem nr devices which
emir harard,us air centaminanu as defined by me (fay Area Air Quality Management
Dlsldaa
❑Vas Fl No
I have at the hvardaus materims mgainamenes under Chapter fi 95 of the Cali-
fomia I lcahh & Safety Code, Sections 25505, 25533 red 25534. 1 understand that if the
building does not currently have a tenant, tat it is my responsibility to notify the occupant
.fine na,mearances which mus he mel prior m Lssuunee of a Cemnall, of Occupancy.
PERMIT ISSUANCE
APPLIANCES -RFSIDEN'I'IAL
PANELS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. MINER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECT RIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDEN'1'IAT, ELECT 'IS, SQ FT.
UILDING PERMIT INFO
BLDG HL13CT PLUMB MSCI
❑ ❑ .6r- ❑
JOB DESCRIPTION
RESIDENTIAL:
0 SFDWI,
0 KITCHEN REMODEL
❑ADDITION
O PLUMBING RE-PIPH
UMUI.TI-UNIT
[_1 STRUCTURAL
GAS- FA. SYSTEM -I INC. 4 GO rLETS(&jYROL;'
MODIFICATION
O INTERIOR
F1 CHIMNEY REPAIR
IMPROVEMENT
O SWIMMING POOLS
O BATH REMODELIREPAIR ID DEMOLI'I'[ON
❑ OTHER
WATER HEATER W/VIMA7.LECTR
GRADING FEE
COMMIiRCIAI:
❑NEW BLDG/ADDITION UDEMOLHION
O TENANT 0FOOD SERVICE
IMPROVEMENT
0 OTHER
AREA I SISQ, FT.
. PLUMBING P T FEE
PERMIT ISSUANCE
AL'I El- DRAIN &'U3 - DEA)
b VALUATION
�(' S TYPE CONSTI
�ry ` 8
MIN
V
BACK FLOW PROTECT'. DEVIC ItCll,
DRAINS- FLOOR. ROOF, AREA, CON'.
FIXTURES-PERTRAP
GAS- FA. SYSTEM -I INC. 4 GO rLETS(&jYROL;'
GAS- F.A. SYSTEM -OVER 4(EA)
GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FOGS
GRGASE'I'RAI'
PLANCHECK FEE
SEWER - SANI'T'ARY - STORM 13A. 200 IT.
ENERGY FEE
WATER HEATER W/VIMA7.LECTR
GRADING FEE
WATER SVSTEM/fRI:ATING
SO] ,S FEE
WATER SERVICE
PAID
NEW RESIDENTIAL('LMB. SQ. FT.
Time Receipt p
IOTAIL:
T :
BUILDING FE
EMECHANICAL
PERMIT FEE
SEISMIC IEE
PERMIT ISSUANCE
;Lt.CTRIC FEE
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNITRO 111,000 CFM)
MECHANICAL PRE
AIR HANDLING UNT ((OVER 10,000 CIM)
CONSTRUCTION TAX
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,010) BTI)
HEATING UNIT OVER 100,0011 BTU)
PAID--
VENTILATION PAN (SINGLE RESID)
Dae Raceipl a
BOILER -COMP (301' OR 100,000 BTU)
TOTAL:
BOILER -COM(' (OVER Iq),BIXI BTU)
AIR CONDITIONER
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. Pr.
a