00010063 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY )W _-
CITY OF CUPIiRTINO BUILD NG-ELECTRICAL. TT�� PI��ERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT rING PROD-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS 7SANN,11O. AI'1'I.ICATION SUBMITTAL.DAT
EN E _ /,�E 'SNAMr SPHONE: �V C S CONTRACTOR'. N r LIC NU: CONTROL#
66 PP / I-•�" � UCO i
ADDRI S:
hZd /A6
CONI'nCT: PHONE: CA BUILDING PERMIT INFO
❑ Consultant F".,Paid by Applicant(Initial) s BI IX/ HLECT PLUMB MF.CH
I� ❑ El ❑
1,ICE7NS HDCONIRALTOR%E!KCLAATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby abbot that 1 am licensed under provisions of Chapter 9(commencing
OCZ Ill Sm,iar7d(X)ofDivision 3ofthu Business and Professions Cale,and my license is RESIDENTIAL:
FOO w full l ince and dl"ecr I'IikMIT ISSUANCE
;X-l-W in ❑SI'DWI. ❑KITCHEN kCMODEI.
QU Limnce Claw Lie'# APPLIANCES-RESIDENTIAL ❑AUDI TION EJ PLUMBING RE-PIPE
HZW Der Ccnwclnr
r� IL ARCHI UIC'CS DECLARATION ❑MU111'1-UNIT ❑STRUCTURAL.
ZOhZ unJerxlanJmypluns shut l be itself as public record., PANELS MODIFICATION
ON
OZ�O DPIY)ZIW AMPS ❑IN'flil)VE ❑SWIMMING POOLS
^14 W Lactowd Profv,o...A 201.1000AMPS IMI'NOVIIMF:N'1' (]SWIMMING I'001.5
H
Oat lam exempt
DECLARATION OVER IfXN1 AMP¢ ❑BATH RIiMOD1iIJRIiPAB ❑DI:MOLITIQN
y Q I tachy n(Erm that 1 1. exnnpt from IM1e Co,i.n,C s 1 iAn,c Law for IIm ❑OI'l1Ek
W O F U following conceit.(Section 703 1.5.Bnsinecs self Pmlmsiona Cade Any city lir mm�lY SIGNS IiLEC'IRICAI.
W a W y which require a permit to con%wet,eller,improve,demolish.or repair any sweurc
f.u•O� prier lit its issoarm.Nm acquire,the applicant fmsuch pmnivofile a signed ummmem SPEC1ALCIRCUIT/MISC s�
rthallic is licensed pursuannn the previsions of the Convector's License Law(Chapter 9 COMMERCIAL'
W1 pC femnmcncingwia Sedion70p0)of Division 3ofthc Businessand Professions Code)on '1'17MV METER OR POLE INST
a a Q C IM1e he is exempt inercfmm and the basis for the alleged exemption.Any violation of ❑NEW 61.UG/ADDITION El DEMOLITION
X-a- Section 7031.5 by any upplicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five handled dolnn(5500). IMPROVEMENT
❑ I.as owner of the propeny.or my cmplayccs with wage%as their sole compensation, SWIMMING POOL ELECTRIC
p., ❑DTlil.k
will do work,and the orucwre is not nnended crolfcrcd for sale(Sm.2014,Business
m
and Professions Code:Tine Contractors License law does not apply to an owner of UUTLITS-SWITCHES-FIXTURES
a 3 progeny who holds or improves thereon,and who does such work himself m dmugh
his own employee,•provided that such improvements are not intended or ofemd for NEW RESIDENTIAL ELECTR SQ FT
wale.IL however,the building or improvement is sold within one year ofcomplction.the SR III FLOOR AREA SISQ.IT.
owner-builder will hm'c tae bvrdcn of proving that he did not build or improve torpor.
Ivsc of sola). TOTAL:
❑ I,as owner of the property,ate encl.'Ne y contracting with licensed contractors to
construct the project(See.Wase.Business and Pmfessions Cade:)The Conttamors I.i-
Lawdac not apply to of progeny who haddsa improve,thacon.and QTY. PLUMB ING PERM IT 17EE
who
it mnbwill,for neat pnnjes wo romr:wun(0licensrd puauum w the Cnmmmnr'x
Limn%,Law. PURMI'IISSUANCE
2 1 nm exempt ender Sec. .B&P C for this reuwn
ACfIIR-I)It AIN de V IiN'1'-WA'IEIt(EA) VN,UA'I'ION
wart Date
WORKER'S COMPUNSAIION DECLARATION HACK I7L6W PJZGI?C'I'.UUVICE
I hereby uflirnn under penally of perlury,one ofthe following definitions: . 6) D
I havcanJ will lnuineoin nCcnlf¢n(Cnnsm toself-ilnmre fnr Worker's Compen. DRAINS-FLOOR,ROOF,AREA,COND. STORIE 'i'YPE CONS'IRUM 10
satian,IIs provided for by Section 37X1 al the Labor Code,for the performance of the
weak for which Ihic pemsit is issued II%'1'l1Rli5-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section OCC.GHUUP AVN
3](0of thcl Ctde,lin IM1e perfnrmanccof the work far which this permit is issued. GAS-HA.SYSTEM.I INC.4 OUTLETS l/�
My Worker it c dPolicY a r,7G GASB-E.A.SYSTEM OVER 4 IEA)
Carrier.��Policy No.: S
CER ][of ATE aSATIONII N FROhQ3'(iRJCEIjb' 2 /IO Q GRIiASU1NDU5T0.L RC
COMI'IiNSAT10N INSURAN-� ( V 7 > DIVISION FtiGS
('mis cation nttdnm heconsplacJ ifthe pemlir is forone hundrtd Jullars(SI01) GREASE'IRAP HECK FEE
or less)
Loy any that in in anyannaneeof thework feebecome suich jecthis o the W isissued,'Comrio tiEWER-SANITARY-STORM EA.200 FL ;I
ear employ any Person in any manner m az m become subject no IM1e Workers'Comprn-
oZ .tion Lawlor California.Dmc WATER HEATER W/VENT :CTR
z o Applicant t
NODCE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYS'1'ENL TREATIN
> hoaon.e subject to the Workers Compencancer provisions ser the LaMsr,Calc. on must
fbnnwith comply withsaen provision%or this permit%hall he dermad revoked. WATER SERVICE
;D Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL D
arc Receipt at
U 0 Ihm,hyldlimnthnt them is.conslmction lending agency for the famorminecof
the work liawhich this facart is I.sued(SO,.3097,Ce.C.) TOTAL.
O U I.cndur's Name TOTAL;
Lender's Addr— BUILDING I I'll
�-I 1 malty that I bnvr road Itis npplicutiun and ,are that the above infunnatinn is -.r�.-�
F y coral.l agree tocmnply with all city rend ctmntyorduccomu mrimme laws ranI ting to QTY. MECHANICAL PERMIT FEIi I I f"Y
tiIiISMIC FIM
U z naimmg eenmrnuTen,alae nereny atoned<e rcprenentati%e%er ani.Natyte emerapem the 1 I
alawe-mmationed prnp<•ny,for inspection purposes. 11I11IMI I'ISSUANCH - div II
h Ii1.liCl'IiIC MSE
(We)agree In sac,aml ex i n,and keep harmless the City of CupcniO-st o id Cii t II 1 00
Iiabilities.juJgmenO,costs send espenses which may in any way acerae againsPcuid Ciry ALTER OR ADD TO MECH. V I'L G "til
in conompence of the granting of this permit.
APPLICA NI'UNDITRS'FAN DS AND W ILL COMPLY WITH ALL NON-POINT AIR I IANDLING UNIT(TO I 0.000 CFM) MliC11ANICAI.FEE
REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM)
SOURCE CONSTRUCTION TAX
Nignaan of Allplicunt/Cmuniclnr Date II IAUST HOOD IW/DUCT) F •H00.51NG MEIGATION+I!
HA9.AR000S MATERIALS DISCLOSURE
Will the applicant or future building occupant same or handle hazallous material HEATING UNIT(TO 1011000 BTUI
as defined by the Cupertino Municipal Crete.Chapter 9.12.and the Health and Safety IIEA'1'ING UNIT(OVER 110.000 BTU)
Aft I Coda Section 255J21a)'s _
❑Yes ❑Nn VENTILATION PAN(SINGLE RESID) PAID
[)are Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER UIIP OR 100.000 BTU)
nit hmerslnus air conmminana as defined by the Bay Arca Air Quality Management TOTAL:
DxIlat BOILER-COM P(OV ER 100,"BTU)
❑Yes 0 N
AIR CON DITION HR ISSUANCE DATE
I hove real the In'ruminus materials eforcusn,under Chanter 6,95 of the e.ah-
Etmill lbsibb of Sony Calc,Sonans25505.25533 and 25534.1undosstvnd lhal if the NEW RUSIDRNIIALNIFC11. SQ.FF. I, t/
huilding does not anmndy Invent manl,Ihal in Ivory cosprmsihll Ely et notify Inc nreupant
of the reynircmm�is whichanus(Iv Inet#tial'mi"Ourre,ofa Cenifmme of Ocalpuney.
Owner lir umWnuM agent
Uum TOTAL: ;SSUED BY.
OFFICE