99090020/ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDING-ELECTRICAL. Ph II
BUILUINO DIVISION APPLICATION/PERMIT PLUMmrvG-MFCI{ANICAI.
BUILDING PROJECT IDENTIFICATION
BUiI.DIN-.rA DDR US S: SANITARY NO. APPLICATION SUBMITTAL DATE
O NA w, ` )NIAME
S: CONTRACTOR'S N : ^ LIC V
t` NIC CONTROLN
141
.HITECT/fiNGWEER: LIC NO: ADDRESS
:: ❑ 111A-
CON rACI
ICON'IACI: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT riUMB CH
c Yu 2 G-7-33Z- ❑ ❑ ❑
hICENSED COHTR TOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions at Chapter 9(Cnommncing JOB DESCRIPTION j
occZ with Section]000)nf Division 3af0c Business and Professions Calsz,wd mY license is RESIDENTIAL:
won in full force and effect. 1'ISRMIF ISSUANCE
U'� in fen.Class Lich ❑SFDWL ❑KITCHF F,MODEL
yGi Dam Cnnwmor APPLIANCES-RESIDENTIAL ❑ADDITION BING RE-PIPE
}.Dm ARCHITECTS DF,CLARATION PANELS ❑MULTI-UNIT ❑sTRUCfURAL
!2Z 1w+dmstmd.ry plans shall be hold us p.hlie records MODIFICATION
OZ � Oil 10 200 AMPS ❑INTERIOR C1 CHIMNEY REPAIR
IQ-N�•_ Licemed Professional 201-RNs)AMPS IMPROVEMENT (D SWIMMING POOLS
CY -? OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLI"PION
.a C W Q 1 hereby from that 1 em aempt from the Comacroe,License Law 1'ot the ED
�,C.U fountain,moom.(Soetion]11315,Bminess and Prafessinns Code:Any city or courtly SIGNS ELECTRICA OTHER
4:- LL y which requires a permit to conwa ct,alter,improve,demuliah,or¢pair any structure
I""u•OQ prinnn its maturrel.alsnrequimsthe applicant lie verb purmll o+file aligned smmment SPECIALCIRC T/MISC.
E j�'' that he is licensed pursuant the provisions of the Contractor's License law(Chupher 9 j
=,t (commencingxith Section Insist of Division Soft he Business and Professions Cade).. R
IEMP M" OR POLE INST. COMMERCIAL'
Q.1 ca c
that he ix exempt therefrom and the basis fir the alleged ascription.Any violation of NEW BLDG/ADDITION [I DEMOLITION
Xro Section 7031.5 by any applicant for a permit subjects the applicanto a civil penalty of Ib . DEVICES ❑TENANT ❑FOOD SERVICE.
U..m ot m th
nmoan five hundred dollars(4500).
Sp
1.as owner ofthc prnp ❑OTHER
enY.or my employees with wages as their sole compensation, IMMING Iv)OL ELECTRIC IMPROVEMENT
d,ym willdothe work,andtne suacture isnul+mendedoroffelcd for.sale(Sec.]Nq.Basiness
6'3- and Professions Cale: The Comfmle",License Law does nen apply fo nn—art a( OUTLETS-SWITCHES-PI%TURES -
pmpcny who huilds or improves thereat,and Who does such Work himself or th or
his own employees,provided that such improvements ere not intended or offered r NEW RESIDENTIAL ELECTR SQ FT. _
wre.if,howevcolhc buildingnrimprnvemcnt is said within one year ofcompletion.the SQ.FI'.PLQOB AR BA O $l. FT.
exec
r-builder rill have the burden of proving that he did not build or improve for put- Z, D
post of"sale.). D
TOTAL"
C] 1,as owner of the property,am exclusively connecting with licensed contractors to
criminal the project(Sea.9nW,Business and Prol'essio.s Code:)The Contractor',Li- 'J - 1 199
.c law docs not apply m;m owner of property who huilds or i reproves theme..and QTY. PLUMBING PERMIT FEE SEP
who connects for such projects with a contmenor(s)licensed pursuant to the Contractors
License Law. 1117RMIT ISSUANCE
I.,,+exempt under Sec. B&PC for this reason
ALTER-ORA IN&VENT-WR'I'ER(EA) D VALLATION_
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(TTEU..DEVICE
I hereby onion under penally of iehory one of rhe following dwlorations:
u I have and will maintain a Cenificam of Corsem to self-insure for Worker's Cowper- DRAINS-FLOOR.ROOF ARIA.COND. STORIES 'TYPE CONSTRUCTION
turas.,as provided hn by Section 3]00of We Lehr Code,or the performance of the
work lot which firs pemm is issued FlN'l URIS-PER TRAP
El I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the laM+r Cede.lin the Performance of the work far which this permit is issued. GAS-EA.SYSTEM-I INC.q OUIlETS OCC GB{{I1P AP
yWnrkcr}/rn pyyPylf ytlm dl'No yNyyjrye �� � GAS-Bh SVSIT:M"OVER4(EA) �5 o
Comer._Jh1 '/LW/ Policy Nen?1WOR/
CERIIFlCAI'h OP EXEMPTION FROM WORKERS' GREASI&IN DUS'I'St.WASTE INTERCEPTOR
COSIPENSAI'[ON INSURANCE BUILD GDIVISIONFEES
(This section real not he completed it the pcm+il is Intone hundred dollars(SIMI GRIiASIt TRAP
ar le".) I•LANCIIECK FEL?
I certify that in the prformence of the work for which this pem,it is issued.l shall SEWER-SANITARY-STORM EA,200 FL
ml entplay any person in any manner no an In necona,whjeeIn the WokCompcn" ENERGY IEE
Z .wren Laws of C..Hfumm.Date WATER HEATER W/VENT/ELEC R
Applicant GRADING RTE
v NGOCE'I O APPLICANT'.If,after making this Cenifcmc of Exemption.Ina should WATER SYSTEM?RPATING SOILS FEEFI > become subject no the Worker's Compensation provisions of the Labor Code.you mush
Lk7 foMwinh comply will]such provisions or finis petit sb.11 be deemed revoked. WATER SERVICE
4' CONSTRUCTION LE14DING AGENCY NEW RESIDENTIAL.I'LMB. SQ.ET. PAID
k 'Z' I beerhy wTrrn thus them is a conaruation lendin for the rforrow.nl Dam RuciptN
UO .C.) y P'
H.(.. the work Bn which anis permit is issued(sec.3097,Civ.CJ
OI-ender Name TOTAL:
ULunde,',Address TOTAL:
U
} 0. I mrify ohm 1 have read this appiicmiun and>mm that 0c aMrvu Inroms o-in BUILDING PCE
rzm.l ugreemenally wish all city anda+wny onhnawe—w1.umc laws reading.' QTY. MECHANICAL.PERMIT FEE
U Z budp
ding consmction.and hereby authorize representatives of this city to enter upon the SEISMIC M217
aFuve"memiuned pmpenY far tre,,nam purpuras. PERMITISSUANCE
(Wc)agree to save,indemnify and keep hemdess the City of Cupertino against ELECTRIC PhP.
Imbilities,judgmenu.costs and expenses which may is any way warm against said City ALTER OR ADD TO MECH. PLUMBING IEE
in amsequerca of the arranger this permit.
APPLICANT UNP ASTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.000 CFM) MECHANICALFEE
50 CF:R�GUL '1 .S.
pl/+.tp ryAIR HANDLING UNIT(OVER IB.OfIBC 1 CONSTRUCTION TAX
Signature ol'Aplic'anVConlmclor [),,a / EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS NIAT17RIALS DISCLOSURE
Will the applicant of future building newpanf store or handle hazwdous mmeriul HEAT[NO ON I T(101(NI,f1fN1 'U)
as defined by the Cupertino Municipal CoChapter 9.12,and the Health and Safety
Codc,Section 25532(a1R HEATING UNI'1'(OV E ),OfH)BTU7
R
p Yen E]No VI?NTILATIONFA (SINGLERESID) PAN
Dale Nc Ip N
Will the applicant or future building occupant use equipment ser devices which B01: R-C P(311P( 1W."BTU)
tit hamrdnu,air co.mmi..nns us dcfinal by the Bey Area Air Quality Management TO L:
»oha,0 ROILE COAIP(OVENifp.o(IO It
❑Yen ONa
I have mad the hazardom nmmrial.s requimanars under Chapter 6.95 of one Cah. A CONDI'I'IONF.R ISSUANCE DATE
Pomo.Health&Safely Cal,Sections 25505.25533 and 25534.1 understand tM1af dthe NEW RF,SIDEN IAL MI!CH. SQ.Fr'
hail gdoclua ly naves mnumnhm it is my msWnsibilitymnofify nuc wcupam
e realms net prior m e,trInce of a Lenin i cup y.
two tar away, u. end Dme TOTAL: ISSUED BY.
OFFICE