S 0748APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
ItU1LDIN1:-ELECTRICAL Pli 11'NO.
PI,U.IRINC.-MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT 070
It111L111NG 1'RO.IBC'. DmN', IF'ICATION
1255 STEVENS CREEK
CWIAC . PHONE:
TIMOTHY STEAD (303)220-8900
LICENSED CONTRACT'OR'S IIF.CLARA'1'IOX
I hereby allirm had I am licensed under provisions of Chapter 9 (commencing
CWZ with Smlion7IXXgof Divi.iun 3ofthe Bmm1avndptof,,,am Code.mad mylicame is
�
F W O in full farce and effect.
%UV License Class Lie#
x! zI� Q a Dat Cnnlmclor
VI T, A L S I ECLARATION
~ v=i Z Je d m1}plan be vs public records
OZ= -0
F F m Lfa Pmfm.d, nal
- UILDERDECLARA11ON
W Q I hereby affirm that 1 am exempt from the Convector's License law for the
�°(' a O folbwving reaxon. (Becton. 7031.5. Business and E4o$Cade: Any CaAny city or county
1x13 as , which requires it )comet to convract, altar, impnrve, demolish. or repair any %mmone
F.WC j prior in its issuance, also requires the applicant lit such permit rile a signed smamnamt
F, Y that he is licensed pursuant the provisions of the Contractor's License law (Chapter 9
�CpO (rommencing with Section 7000) of Uivisinn)of the Rosiness and Professions Coca) or
11 q M 1' that he is exempt therefrom and the basis for the alleged exemption. Any violation of
YXI 4. Section 7)11.5 by any applicant ant I'or a perp it stieects the applicant to a civil penally of
rN
no more than five hundred dollums(8500).
G ❑ Las owner of the propany, or my employee• with wages as their solo cnmpensmimn.
F will do the work, and the stmctum is not intended oroRcted for sale (Sm. 70414. Rusin'14
tai] 3 m and Professmov, Coda The Commctors License Law dots not apply in an owner of
property who holds or improve, them, and who docs s,.all work M1;t i,Cll'or IM1roughw
his own employees, provided that such improvements am not intended or offcted Our
sale. IL however, the building or improvement is sold within one yearof completion, the
owner -builder will have the burden of proving that he did not (wild or improve for Pur-
pose of 'fie'),
I, as owaC, oI the properly. uta cxdusivcly contracting will, hce-ed contocmre m
co struct the project (Sec. TOO. Business and Prnfessims Cod ) me Contract,);. Li -
se, Law does not apply to an owner of propcnY who builds or improves thereon, and
who contracts for such projects with a contmemgs) licensed pursuant o the Connectors
License law.
L] Iton exmnpt under Sec. .11&P C for this most
ADDRESS:
❑ Consultant Fees Paid by Applicant (Initial)
EI"IECTRIC PERMIT
1112RMIT ISSUANCE
APPLIANCES - RESIDEN PIAT,
PANEIS
UP TO 200 AMT'S
SIGNS ELECTRICAL
SPECIAL CIRCUI I'IMISC.
TI:MR. METER OR POLE INST.
POWER DEVICES
SWIMMING IV RB, ELECTRIC
NEW RESIDENT IAL
Owner Date
WORKERS COMPENSATION DECLARATION
I hemby ulliam under p,m l y of ,olony one of the Gdlawing declarations'.
0 I M1avc and will muinmin a Canilieam of Cr)nsem m sell insurefor Worker's Compcm
scion, as Provided for by Section 37(X1 of the Wbor Coal for the performance of the
wok far which This Permit is i ... ad.
❑ theme and will maintain Workers Compensation Insurance, as required by Section
�]INI nfthe Lahm Gale. R), the v,rfo m Cwt o1,hC work tar word, this pennon is iuso,d.
My Worker's Compensation lnsorance carrier and Policy number am:
Carrier, Policy Na:
CEn,TCATB OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE:
(Thi sea flon neednot heunoplwed Ifthe Far is Enron,madolddoll,rs SIIXB
talus.)
I mnify that in the performance oRhe work forwhich this permit is ,xmd.I shell I
nm employ any pc,,a in any mmmnerso as to hcome snhj,ct to the Worker; Cnmpcn-
Z snion Lvw,,,l C likerms. Data
ZQ Applicant
(� NOTICE FYI APPLICANT: If, after making this Cenilic:nc of Exemplinn, you should
F bccons, subject to the Worker's Compensation provisions of the Jahn Coca. you muse
forthwith comply with such provisions or this pcnnil shall be neat revoked.
Oki0
CONSTRUCTION LENIIING AGENCY
UO l hereby affirm that hem is a constmaion lending agency for the crom ince of
D. —the work for which TMs ),mmol is issued (Sec. YN7. Civ. C.)
O U Lcader's Name
Lender's Add, a,,
r U
6. 1 certify Ibal 1 have read this upplicalion and stat, Ibut the above inf retie ion is
Fr h correct. I agree to comply with all city and county ordinances most state laws relating to QTY.
V Z mildingam.amction. and hereby authorise repoesenlieuvs ofthis City mcmnerupm the
ahmve-aandmad pmlany torhwpcNan pnrloses.
(We) agme to lave. indemnify unit kccp harmless Thu City of Cu=7,'!:dC a
liabilities. judgments. costs and ex,prow%which may in any way acerae ugain'"sail Ciry
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON"POINT
SOURCE REGUI,A'I'IONS.
R
Signature of Applicanl/Cnntmcmr Dale
HAZARDOUS MATERIALS DISCLOSURE.
Will the IgTli,rnl ser Thiole himiding occupant Gore sur handle ha arduns nuneritd
as defined by the Calendar) Municipal Code. Chapter 9,12, and the health and Safety
Code. Section 8532(a)?
C] Y. CNo
Will the applicant or future Noldim oev pant .,a equipment or d,vice, which
mit hvmdous air Connotations us defined by the Bay Arca Air Quality Management
District?
❑Yen 0 N
I have read the hazardous materials requirements tinder Chapter 6.95 of the Cull-
fomla Heald, & Safety Coale. Sections 8505, 25513 and 25511.1 tradervard that it the
building Jou not currently hove a tenant that it is my responsibility us notify ther mupam
of the m.g6teril nu which most to met prior to issuance of a Certificate of Ucupancy.
AL DRAIN&VWI- WATER (HA)
BACK FIL PROTECT. DEVICE
PRAINSel,O(ftGOOF. AREA. GOND.
FIXTURES- :R TRAP n3
GAS -EA. SYS 11, C.4 OUTLETS
GAS-EA.SYS'ITM-O - A)
OR S USTRL WASTE I E
ISO, I"
wnrER
�y�
SQ
UILDING PIERM11' INFO
R RHEA
UG 131.1 CT PLUMB MECH
® ® ER
AIR HANDI,I NG UNIT (TO 10.000 CFM)
BEEJOB
DESCRIPTIONENTIAL:WL ❑KI'rCHENREMODEL
ITION ❑ PLUMBING RII IPF
TI -UNIT CSTRUCfURAI"MODIFICATION
RIOR CCHIMNEY REPAIR
ROVIiMENT CSWIMMINOI'001"B
H RFMODI?IJRI',PAIR C DEMOLITION
ERF1
2-
EXHAUST HOOD(W/DUC) 0.30
I IEATING UNIT(TO 100,0I) BTU)
L9600
VAhUAI'ION.00'I'YI'
ARAN ING UNH' (OVER 100,000 BI G
VENTILATION PAN (SINGLE RESID)
I IlCIAL BLUG/ADDITION X]DF,MOLITION
ANT ❑FOODSERVICE
ROVEMEN'I'ER
IIOILl3R- COMI'(OVER H0.0gq BTU)
SQ FI'.
R RHEA
SISQ. FR
AIR HANDI,I NG UNIT (TO 10.000 CFM)
DTAL:S'F
Alli HANDLING UNI'I'(OVER 100liCFM)
EXHAUST HOOD(W/DUC) 0.30
I IEATING UNIT(TO 100,0I) BTU)
L9600
VAhUAI'ION.00'I'YI'
ARAN ING UNH' (OVER 100,000 BI G
VENTILATION PAN (SINGLE RESID)
32P[ORIUIVISION
IIOILl3R- COMI'(OVER H0.0gq BTU)
AIR CONDITIONER
FEES
2001-7.
SQ. 17.
PERMIT I FEE
IT R M IT ISSUANCE
NTERORADD'IOMECII. /,{.��gg
,2Q
AIR HANDI,I NG UNIT (TO 10.000 CFM)
Alli HANDLING UNI'I'(OVER 100liCFM)
EXHAUST HOOD(W/DUC) 0.30
I IEATING UNIT(TO 100,0I) BTU)
ARAN ING UNH' (OVER 100,000 BI G
VENTILATION PAN (SINGLE RESID)
BOILER - COMP OFF OR 100,000 RTU)
IIOILl3R- COMI'(OVER H0.0gq BTU)
AIR CONDITIONER
NEW RESIDENTIAL MSCI I.
SQ, FE
GRAVING
SOII S FEE
PAID
Dmc Rcccipnp
DOTAL:
BUILDING FEE
SEISMIC FEE
ELECI RIC FEE
TLUMBING ITE
b1EC11ANICAL hili
CONS I'RUC'IION ']AN
HOUSING MU1C TION Plili _ / _
PAID
Data Receipt #
/r V
__' Il�fl"A � •�