S 0014 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII DING-ELECTRICAL PERMIT NO.
Ruu,UING DIVISION APPIACATION/PERMIT PLUnfBING-MECHANICAL 11y
BUILDING PROJI!CI'IDENTIFICA'1'IDN .�L� i�G
BUILDINGADDRESS:_ SANITARY NO APPLICATION SUBMITTAL DATE
-moi/I+ x /`>�- L{/./,` f�Qw(L`
OWNERS NAM- PH E: CONTRACTOR'S NAME: LIC NO,
r4 FLP M e NIC CON//T��ROLM p��
RCIII'I'ECTIENGINEER: LIC NO: ADDRESS: ❑ y( Li /
V-4—
CONTA�Cr'r PHONE: BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) D ELECTMOCH
LICENSED CONTRACTOR'S DECLARATIONQTy F,ECTRIC PERMIT PF
1 hereby affirm that 1 am licensed under pmvuimv of Chapter 9(commencing - - JOB DESCRIPTION
Dixie with Section Y000)ofDivision 3ofthe Business and Professions Code.and my license is RESIDENTIAL:
!-�VO�O� in roll force and eRect. PF.RMI 'DANCE ❑SFDWL ❑KITCHEN REh10DF:1.
C U F- License Class Lie.p
F. V ADPL C '-RIiSIDENI'IAI. ❑ADDITION [I PLUMBING RLI'll'E
F Z W pate I'SDEIa
'/tQa ❑MULTId1NIT El STRUCTURAL
p,Oy ARCHITECT,o DECLARATION
PAN
3P*
O to 1 unJcnaM my plans sheJl he used as public records MODIITCAfION
O'Z-O UP HI 'S- ❑INTERIOR 0 CHIMNEY REPAIR
W Licensed Professional 201-1 fling MI. IMPROVEMENT E]SWIMMING POOLS
Q OWNER-BUILDER BE LARATION
C ly, OVER 1006A 5 ATH RIiMODIiIIkEPAIR _1 DEMOLITION
Q I hereby storm that 1 am exempt from the Commehas License Low for the
3 a E following reason(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRI OTHER
a y which requires a permit to construct.alter,improve.demolish,or repuir any nmmurc
IO'u'O st priorm in issuance,also nauires meupplicant for such permit to file.signed samment SPECIAL CIkCl11T/MISC.
f 1t > mut he is licensed pursuant to the provisions ofthe Contractors License tawlCha _
�ge�i (commencing with Section]000)nfDivision}nf the Business and Pmressimts Cmle)ur TEMP.MI'INR Ok POLI:INST. COMM /�
W Ileo: that he is exempt therefrom and the basis for the alleged exemption,Any violminn of 0 NEW BLI]GIA DDITIUO "U lE;tIbLIT10N
Oy6colm1011.5 byanyapplicent forapermitsubjects haeapplieratmacivil penalty of POWER DEVICES L1 TENANT I ❑FOOD SERVICE
not more than rive hundred dollars($51X1). IMPROVE [a
f=�O 0 [,ns ownendthe prorty.
peonny cntpinyecs with wages as their sole cnngteltn;pion, SWIMMING POOL ELECTRICV/r Il Dl'Q!p
will doth.work,andthentracam is not imended oroll'ered for sale(See TM4,I1usineos ❑OTHER "I,ind
3 and 1'rafeio
sns Code.The G rmacha s 1moor
icee Law dnot apply ,,an owner of OUTLETS-SWI'I'Clili9-NIXTIIRPS !'t
LLt property who builds or improves(hereon,and who does such work himself or through
his own employees,provided that such intptovcmems arc not intended m offered far NEW RESIDENTIAL FLECTR SQ FT.
sale.If.however,the building orimpmventent is sold within one year ofenmplmion,me O SO.17.FLOOR ARBA �SISQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pear- r l
of sale).
C] Lowner r ohne PmpenY,stn exclusively contracting with licensed contractors to 7 'r
consaoet am project(See.'IIM4,Business and Professions Code:)Tsc Contractor',Li-
cos,I...
i-c scl..w does notapplymanownerof propcny who builds ce ireprnvesthcrcon,and QT}', PLUMBING PERMIT FI;E
who contracts for such projects with a commcags,licensed pursuant m the Contractor's ' 6�gIL a(jIR/KA7^/ -
License Law. PERMIT ISSUANCE -II
[:J I ant exempt under Sec. ,B&P C for dukorason
ALTER-BRAIN&YEN T-WATER(IA) VA LUAl'[ON
Owner Dam
WORKER'S COMPENSATION DECLARATION I BACK FLOW PI GI ECT.DEVICE
1 hereby w alarm under pon.lty of perjury one of me fidowunsure for declaratinm
❑(hive ono will for
nection3mc of theConsent to
Labor
eod.fartforerf.sComped- DRAINS-PLOOIt,ROOF.AREA,COND. STORIES TYPE CONSTRUCTIOp
Minn,as provided for mi Section l]IM)of the Labor Code.(or the perfnnnence of the
r which this permit is issued. FlXTURES-1'T:k TRAP L
w 1 hove and will maintain Workers Compensation Insurance,as required by Section
pql of the Labor Cade.fnnhe pedbmtance or the work for which this permit oiswed. GAS-EA.SYSTEM-1 INC.J OUTLETS OCC.GHOUL' AI'N
My WodersC to murmur Insurance artier and Policy number are:
C.mcc-jo��n �Policy Nu.://�1 GAS-EA.SYSTIiM.OVERJ(NA)
CATS Eli EMPTIONFROM WORK RS' GREASFJINDl15TR1,WASTE INTERCEPTOR
COMPENSATION INSURANCE II1116D C DIVIElIbN FEES _
(This section need not be compleledo thellsom,is unions,hundreddallurv($100) GREASC'I'RAP
or las.( PLANCHEC
lccnlfy that inthe perfnrmammofthc work far which this permit isinwcd,lsha0 SEWER-SANITARY-STORM EA.203 FT.
not employ,any person in mymannerso ax to beaomc stdica mthe Workerx'Cir,,e- JPAID
ERGY Fels .r
O ,Z sation Laws of California.Date WATER HEATER WIN ENMLECTR ADING T:!
z O Applicant a er ma
N(T1ICETO APPL mg this Certificate of Exemption,you ahnulJ WATER SYSTEMRREAfING ILS
become subject to the Workers Compensation provisions of are Labor Code.you must
{TJ forthwith comply with such previsions or this permit shall he deemuf rcvokcd, WATER SERVICE
Q
� z
CONSTRUCTION LIiNplNGAGENCY
agem, NLWRF.SIDF.NTIAI.I'hMB. SQ.FL Date Receipt#
L hereby arum that mere is a cnnawcrnm lemma agency rte the p«h,tmartce of
V O the work for which his permit is Issued(Sec.3097.Civ.C.)
Q ULender's Name 'TOTAL.
IU Lender's Address .T 1'
fy I certify that I have mud this application and state that the above infornwtion is ILDING PI?E
In corer.l agree mentally with all city ad county ordinances and sate laws relining to QTY. MECHANICAL PERMIT FEEbuilding construction,and herchumhnrire rencsenmtives of this city as enter open theISMICPEIiamwe-mentinnal property for inspemion pumses. PERMO'ISSUANCE(We)agree to save,indemnify and keep handless the Ciry of Cupertino againstECTRIC Fiili
lianilitiss,judgments,rostsand expenses which may loan,wayaccme against said City ALTER OR ADD TO MECH.
in mrmequence of he granting of this permit. PLUMBING FEI
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10,000CFM) MECHANICAL EE IF
SOURCE REGULATIONS.
AIR HANDLING UNII'IOVER I0,000 CFM) CONSTRUCTIO TA%
Sigmtircof App enUComovemr Date EXHAUST HOOD(W/DUCT) HOUSING MITIG TION FEE /a'
HAZARDOUS MNIVItIALS DISCLOSURE
Will theappluend nrfaare buildingiscepent store or handle harmums internal HEATING UNITE)100.00 BTU)
as Jeti A by the Cupertino Municipal Code,Chapter 9.12,and the Heahh and Safety
Ctsie,Section 255321.,] HEATING UNIT(OVER I D0.010 BTU)
C]Yes C]No VENTILATION FAN(SINGLE RESID) PAID --
Date Rc eiptp
Wilt the air corntrdfumrc building by
ed use Bay Area
Air Qualitmem or y
Management
BOILER-COMP(3HP OR 100,001 BTU)
Or
emit htzmdous air conmminana az Jef neJ by the Bay Area Air Qmliy Mawgcmcm TOTAL:
District]
❑Yes ❑Nn BOILER-COME OVER 100.000 BTU,
I have read the hazuNous materials eaquinamnts under Chapter 5.95 of the Cali- AIR CONDITIONER ISS NCE DATE
fomin Health&Safety Code,Seetiono 255115,25533 ono 25534.1 understand that if the NEW RESIDEN'PI Al.MSCI I. SQ,FI'.
hnildinexhumments reemlywhich have amount.thrm is mace ofa raffeenhcncory. —VQ r,;\J V'�
nl'tha tcg rte.,ma t welch and be Incl priorm k no,l ear CenlBmm of torridly Ilw occus
Owner nr authorized agent Date T ISSUED I)Y:
OFFICE