S 0882 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
k CITY OF CUPERTINO BUILDING.ELEC'fRICAI, I'tJiMITNO. oA ^tea
ll APPLICATION/PERMIT IBBLDING.ELcTRUCA 1. V\V\ CyS8 l8L
RUING ADDRNG IVISION "- BUILDING PROJECT WENT IFICNFION " 7 :+
BUILDING ADDRESS: t� � / SANITARY NO. APPLICATION Sl111MITl'A I.DATE
D D S FDKcS wk'�re S 5>ri, t 0/ Yo or/ `Z-. _CV1
OWNER'S ME: (/-HO�- 1010.
CONTRACT ORS NAMIi: LIC NU'.
r NIC CON Him p
-� ARCHITECT/ENGINEEIC LIC NO: ADDHESS ❑
38y r oil
CONTACT PHONE: t''•'4 r`' "•HUILDINGPERMIT INPO,',;
t ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECII
cr S 5 tw.S ❑ ❑ �' ❑
r ,
LICENSED CONTRACTORS DE CLARATION QI Y "( i l LECTRIC PERMIT nO
1 hereby nfrom that 1 am licensed der pr f Chapter 9(commencing ,.' 1. JOB DESCRIPTION
Wonsit3 dmvmsncs:and Pn r.s itdCale and mylc nxcs IDENTIAL:
Z with SeUmn]IXNI)nl D'WO PERMIT ISSUANCE,fence CteanJ client. l b �' , DWI,ITI ❑KIIPLUM IiNG BE PIP I.Care Clms Corn (o O U G Y US a.I AI'I'LIANCGS-RESIUIiNTIALDDITION ❑PWA1HING k1>1'IPE
FZonDate - GomDE UCI'LUNIT ❑STRUCIURAI.ARC ll hot..i DF.CLNtAT10NZO14Z lundersmnd myplans holt be used es politic rccoN, PANELS CHIMN YREPh.❑ UP'1'O200AMPS TERIOR ❑CHIA1NIiY RIiPA1R
W Licensed Prufessinnnl 201-IOmAMPS PROVEMENT (]SWIMMING POOLS
OWNER-BUILDER DECLARATION�'+� , OVliIt IIKKIAMI'S ATH RIiMODEI/RIH'AIR ❑DEMOLI'fIQN
O V e naso ,(Sen that 1 um exempt from he Contractors License ly u for the
following reason,(Section]IIJLS.Businos and Prnfcasions Cade Any pity or rnuntY SIGNS ELECTRICAL. ❑OTHER �y
W 3 k y whld,regnirev a paone m dmrlmc6 ahcr,improve.demolish,or repair nny samdure W
f"'u`OQ pricrm its issuance.also requires the applicant for such French to file a signed statement SPECIAL CIRCUIT/MISC. Nn LOS
}-� that he is licensed pursuant est the provisions ofthe Conuactors License Law(Chapter 9
OC (commencing with Section AHNI)(ir Division 3 ofthe Business and Profusions Gnle)or TAMP.METER OR POLE INST. COMMERCIAL:
d c that he is Csempt llmmfntm and the basis for the alleged exemption.Any violation of ❑NEW Hl.DG/ADDITION ❑DEMOLITION
,sane Section]1131.5 by any applicant for a pemut subjects the applicant to a civil Penalty of POWI7R DEVICES []TENANT ❑FOODSERVICE
F.
yy^h not more than five hundred dollars($500). IMPROVEMENT
xp ❑1.as owner ofthe property.or my truecyeea with wages its their sole Compensation, SWIMMING POOL ELECTRIC
F
will do the wurk,mW the sonre etuis nut intended ter offered ITn sale(See9194,Business ❑OTHCN
W and Professions Code:The Commerce,Later.I.C.Ore,not apply to an owner of OUTLETS-SWITCHIi$-Il%T'l) ;S
gs 3.. property who Wilds or Improves thereon,and who does such work himself or through
his own employees,provide that such in"ou"o'ems arc not Intenlal m uffere l for NEW RESIDENTIAL ELECICK SQ FT.
sale.If.however the building or improvement is slid withimmalc year of...... ism the SQ.PC FLOOR ARTA $ISQ.IT
owner-milder will have the burden of proving that he did not build or improve for pur-
pos r I ) %,D
71 f due proPerly,am exclusively contracting with licensed couraCtur,t
constrvn the project Sec7194 Business and Profession,C cite)The Corldrui L - - �
to
Carom Live does notapply t f property who bold:or impausesth n and QTY a "t�''PLUMBING PER1411 lr EF
is hit lochm anAr nt jCCt,wth a.anolle)I ilensal To.alan,u m
theC ill ors , 't"" O
License law. PERMIT ISSUANCE
Cl 1 nm exempt under Sec. .B&PC for his woom,
Owner Dnte ALTER-DRAIN&VIiMC-WATER(DA) �\VV �r
WI ION-
ORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE `
.I hereby affirm under Penalty of perjury,one of the following declaration
❑I haveard will maintain a Certificate of Consent to selfasure for Workers Cmntpen- DRAINS-FLOOR.ROOT,AREA.COND. STORIES TYPE CONSTRUCTION
sation,as provided ser by Section 39011 of me labor Code,lest the arlormance of the
work fill which this permit is issued. FTRUIRES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,on Ilia pannnunce of the work for which misoermit k c,sued. GAS-EA.SYSTEM-1 INC.4 OIG LETS OCC.GROUT' AIN
M WnrkedsQ� fi Ensu c rand Polis 2j �/f
Camue�Thgpnsa ya prince "rrie Policy No, ���H • GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/INDUSTRI,WASTE INTERCEPTOR
COMPENSATION INSURANCEBUILDING DIVISION FRES
Gbisseaion need not hemmolc¢dif the Permit is fnronehundred dollars($1 W) GREASE'I RAI'
m less.) ILANCH[CK TEF.
I certify flat in the performance or the work for which thi s pernth is issued.)shall SEWER-SANITARY-STOR M PA.20111rf.
not employ any Pason in any manner so as m become subject to the Worked CoinE
gem ENERGY FE
Z mita.Laos,of Califomia.Date WATER HENITR W/VENT/ELECfR
z Applicant 1 GRADING PC:[
NOTICE TO APPLICANT:IL alter making this Cenllicam mf Exemption,y a should WATER SYSI'i?M/TRI?NFlNG SOIIS FEE
Mcomeevbjufto the Worker's Compensation provisions of the LaMn Code,you must
Wforthwith comply with such provisions or this permit shall he deemed revoked. ,� WATER SERVICE
O• CONSTRUCTION LENDING AOIiNCY NEW BESIDES HAL I'LMB. SP FT. PAID Dnlc NCeeiPIN
U O 1herehyaffinn that the.isomnstmNms lesdingagency for the performance of
E" the work for which this permit is Lsond ISec.30m.Ci,C.1
OLender's Name
>1 Lenders Address
ly I certify that 1 have read tapplicators and starell t the aM f t n i BUILDING i IiE
his
E" rp correct l agleam comply with all City unit cotmy ordnance, and.tt laws r Ttnbt -QTY t MECHANICAL PERMIT 1 FEE'
'Uz building construction and hereby arthritic oncescomtives,f this city to enter upon the 'i / ` - 't /' SEISMICILI7
above-mentioned propcny for insolation purposes. PERMIT ISSUANCE
ELECTRIC PEE
(We)agree tp save,indemnify and keep harmless the City of Cupertino against
Iiabilities,jidgnents,costs and aapensus whichmay is any wily uceme against snid City ALI ER OR A DO TO MECH, PLUMBING PEE
in ns quare mf Ota gmn' g of Otis pent.
APPLICANTU !RS NUS AND L COMPLY WITH ALL NON-POINT qjR EIANDLING UNI'I'('fO lq(Mg)CFht) MIiCHANICALFEE
SOURCE TI S,
/ AIR IANDLINGUNIT(OVER IgOm CE11P CONSTRUCT iON'fAX
Sign reef ppican Conusct r Date E%HAUST HOOD(W/DUCq HOUSING MITIGATION FEE
HAP.Nt DOUS MATERIA :DISCLOSURE
Will he applicantor failure buildingoccupamodule ter handle ImeardOtsnmlerial HEATING UNIT(TO Emom OtH
as defined by the Cupeninm Municipnl Cade,Chapter 9.12,and the Health and Safety
Code.Section 25532m)? HEATING UNIT(OVER 100.000 BTU)
El Yes E)No s PAID-
VIiNTI1.Al'IONPANISINGLEk1?SID) Date Receipt#
Will the applicant ter future Molding occupant use equipment or devices which
cricit hoo,odous nil cmmaminnnrs as defined by the Bay Area Air Quality Management HOILER-COME CHP OR 100,000 BTU)
TOTAL:
District? BOILP.R-COMP(OVEK 100.00)BTU)
Dyes ❑No
Ihove read theho,rodou,no,hands requirentans unites CMyner 6.95 of the Cali- AIR CONDI'T'IONER ISSUANCE DATE
fomio Health&Safety Cee.Section,25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MI!CH. SQ.Fn
building does not currently have a tenant,that it is my respumsibiiity to notify me acupnnt
or the nqulrements which mnmq 1 M stet prior to issuance of a Certificate of Occapancy
Owner authorieedagent Doc TOTAL: ISSUED BY:
OFFICE