S 0142 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD INC-ELECTRICAL - `941T No
BUILDING DIVISION APPLICATION/PERMIT PLO.MBING-MECHANICAL 0142
BUILDING PROJECT IDENTIFICATION
BUILDINGADIIRESS: SANITARY NO. APPLICATION SUBMI'PI'AL DNI I
IA Y .No Ce•-L�s��
+ — NCR' AM�a� 0.0 PHONE
-5IS — 14�' 1 CONTRACrOR'S AMI:: LIC NO: N/C CON'1'ROLM
ARCHITECAENGINEEEER: �VYV.L LIC NO: ADDRESS: ❑
CONTACT: PHONE: DUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) HLDG EVICTUMB MF,CH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE ❑ E:1I hereby infirm mal 1 me licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
gcgZ with Section 70(kpof Division 3ofthe Bmina toad Professions Codeandmy license is RESIDENTIAL:
�Op PERMIT ISSUANCE
lyp-. acro farmanderect. ❑SFDWL. ❑ ITCHENREMODEL
da-i' license Class Lic.tl APPLIANCES-RESIDENTIAL. ❑ADDITION MBING RE-PIPE
Dain Cnmrunnr ��,�A_
FOy ARCHITECTS DECLARATION MANIAS ❑MULTI-UNIT ❑STRUCTURAL.
Z O ns Z I understand my plans shall M used as public omards MODIFICATION
OZ- , UP TO 200 AMPS ❑INf17R[OR [:1 CH I MNEY REPAIR
�4 ty Licensed Prnl'essionl 201-1000AMPS IMPROVEMENT ❑SWIMM INC,POOLS
OWNER-BUILDER DECLARATION OVER IIXX)AA11'S ElL
BATA REMODIREPAIR ❑DEMO JTI
c 6'�6 1 hereby anion Thal I am exempt from the Contract License Law for he
ciiyy5506U following meam.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. DOTTERi++'�wvF11 which acquires v rymot m construct,alter,Iniperve,demolish,or repair any mar, c
�mJ prior m its iOmiuc,attlsu requires the applicant for such permit to rile a signed statement SI'IiCIAL CIRCUIT'/MISC.
�to that he is licensed pursuanothe previsions ofthe Contractor'r:License Law(Chapter 9
W IS, (commencing with Section]0(X)af Division 3 of the Business and Professions Cade)Or TEMP.DIETER OR POLE]NST COMMERCIAL:
'but he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BI,DG/ADDITION ❑DEMOLITION
^,f 4• Scolio 9031.5 by any u,punt lar u p,aiii subjects theimplicanno u civil penalty of POWER DEVICES
y ❑TENANT ❑FOOD SERVICEk�
malnutrition five hundred m($SW).Q ❑I,unwner of me pmpenl y,aorr my employees with us their tale compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
❑OTNEN
O will do the wmk.and theswcmm item intendedoroflend mrsale(See 70,14,Business
am and Professions Code:The Contractor's License law does not apply m an owner of OUTLETS-SWITCHES-FIXTURE.
properly who build.,Or Improves thereon,and who does such work himself arm old,
his ton employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELP,01'R SQ FT.
sale.If.however.the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA VSQ FT
owner-builder will have the harden of proving that he did not build or improve for pm-
pose of sale.). TOTAL:
E:11,as owner of the property,nm exclusively contracting with licensed convacmrs is A '
construct the project(Sec.7 1 ,Business and Professions Code:)The Contmctols Li-
c selawd«snot apply tonownerofpmpeny who builds orimpnwex thereon,and QTY PLUMBING PERMIT- FEE
who contracts for such projects with a contracmrts)licensed pursuant o the Contractor's
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. .B&P Chu.,Ihlc re wn
DIVER-DRAIN&VENT-WATER IIA) / [ VALUATION
Owner If 40,ii...bact
WORKER'S COMPENSATION DECLARATION HACK PLOW PROTECT.DEVICE
1 hereby dlirm under penally of perjuryone of the fallowing declaration,: rL
`❑I have and will maintain a Certificate of Consent to self-in.,uric for Warket's Carpet- DRAINS-FLOOR,ROOF.AREA,COND.
satin,vs Provided far by Sieben 37M of the labor Code,for the petinmence of the STORIES TYPE CDNS'1'RUCr]ON
wort for which this permit is ixsund.- FIXTURES-PER TRAP
❑ 1 have and will maintain Wnrke/s Compensation In amnce,as rcyuiroJ by Sedinn
3700 of the Labor Code,for the performance ol'the work for which this permit isoxned. GAS-IA.SYS I N-I INC,40UTLE'IS OCC CROUP AI'N
My Works/s Cnmpenwtinn Imumnce ceritt anJ Policy number are:
Cartier. Policy No.: GAS-EA.SYS HN-OVER 4(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFYINDUSTRL WASTE INTERCEVIOR
BUILDING DI ISION I'E•Ii5
(TTis taction need nal be ttnnplemJ if the Pettit ix brnnmhundrod Anllum($IBB) GREASE TRAP
or less.) PLANCHECK FEE
(certify that inthe aparfirmempre nymannero the work astohimma,subjech ct it)
perthe W isissuedpshall SEWER-SANITARY-STORM EA.Vitt FT.
not employ any person in any manner so as m hewma objet m the Worlcrs'Compero ENERGY I'EE
Onation laws of Cal fomie.Dma WAI FIR HEATER W/VENT/FLECfB
Applicant GRADING FG
O
� y NOTICE TO APPLICANT:IL after making this Cenifimm of Exemption,you should WATER SYSTEMITREATING
parim a suhjen to the Worker's Compensation provisions of the Labor Code,you most SOILS hili
forthwith comply with such provisions or this permit shall Ac deemed revoked, WATER SERVICE
CL G
UOCONSTRUCTION LENDING AGENCY NEW RESIUEMI']ALPLMit. SQ.FT. LAID Date Recei p
the work for which this petard is issued(Sec.3097,Civ.C.)
OI"' Lendds Name 'TOTAL:
Len lm,Addres, 'DOTAL:
0. 1 certify thin 1 have reed this application and state that the above information is BUILDING F ��
it (7AA correct.I agree to comply with all city and county ordinances and state law,relating to QTY, MECHANICAL PERMIT FEE
3 a bulldingammonstlomand hcmbysomorim n,pxxxidatives of this city m enterupan the SEISMIC I9
ahnvcmemioneJ property Ina inxpe'etinn purpxnc's' PERMIT ISSUANCE O
(We)agrcc ro ave,indemnify and d keep hurmlms City of Cupertino against ELEQ]R] FEE
liahildies.judgmems,costs and expenses which may in any way mcnic against said City ALTER OR ADD TO MEC]I.
in asequence of the granting of this permit. PLUMB GFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT 10,000 CFM)
SOURCE R,EGIJI�i'IONS. e MECH
�wI'� AIR HANDLING UNIT(OVER IO.W()CHD CONST RUCTION'TAX
Siltation,of pplicvn mariamr Date EXHAUST HOOD(WIDUC11 HOUSING MITIGATION FEE
AZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant pato or le ndle hu'ennlo s material HHAUNG UNITTO 100,000 BTU)
at defined by the Cupertino Municipal Cole.Chapter 9,12,and the Health and Safety
Code,Section 25532(a)1 I]HATING UNIT(OVER I0O,IXX)BTU)
❑Yes ONO PAID
VENTILATION PAN(SINGLENESID) Date Roxviptp
Will the applicant or future building occupant use equipment or devices which
emit bazvdous air contaminants as defined by the Bay Arca Air Quality Management HOILER-COMP(3HPOR 00.OMBTU)
Diariet, TOTAL:
❑Yes 0N BOILER-COMP(OVER 100.IXp BTU) _
I have tool the hecommus materials requirements under Chapter 6.95 ofthe Cali- A]It CONDI'1'IONER ISSUANCE DATE
fomie Health&Safety Code,Sections 255115,15533 and 8511,1 understand that if the NEW RFSIDENTIAL MECIL SQ.IT.
building dies not urently have a tenant,that it is my n,spnnsibiliny to notify the occupant
of me rcquiremem,which muss be met prior to issuance of a Certificme of Occupancy,
Owner or anthodecd age., Date 'TOTAL: ISSUED BY:
OFFICE