C 0424APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - IJSE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. ELECTRICAL /►PfRMITNOa#1� 0424
BUILDING UrvI51oN APPLICATIONIPF,RMIT PLUMBING. MECHANICAL SOoo� `vim �jf�G
s f( BUILDINGPROJECT IDE,,N'PIFICATIONT'-^f (.'xl
I null DINn ADDRESS: - _ SANITARY NO. I APPLICATION SIBIMi'ITAL DATE
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OFFICE
CONTACT: ruunr.:
Consultant Fees Paid by Applicant (Initial)ELECT
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D CON9RA( TORS DECLARATION
(hereby afro Inn lid d p lChapter v ma,tn ',g
with Section70yroflY om,3oftheBu.ne.. ndPdesmonsGN,andmyliceree,,
full force nude^t.
Licetwe lass Ge.
CoIT
ARCHUEC'S DECLARATION
I moba land my pleas shall be used as public recordsOZQI^
,QTY , • ELECTRIC Pl RMIT
.t
JOB DESCRIPPION
ALWOO
❑ KITCHEN REMODEL
❑PLUMBING RE -PIPE
❑STRUCTURAL.
❑CI{Ih1N1iY RI!PAIR
IMPROVEMIiNT SWIMMING POOLS
❑ BATH RI:MODE1lREPA1R ODEMOLITION
❑O"ITER �(t1
PERMIT ISSUANCEy�F+in
A
APPLIANCES-RISIDESDIAL
PANELSMODIFICATION
UP TO 2W AMPS
Licensed Pnoressmal
OWNER- BUILDER DECLARATION
herchy offnn (hal 1 eo exempt loom the Common ar's License law lira the
following reason (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit In continue, a)te, impolite, dominion. or repair any ,Wclurc
priuno its issuance, also requires the applicant forsuch permit to fleasigned statement
that he is licensed pursuant tothe Provisions ofthe Contractor's license law Clattery
(cnnnncnnng with Seminn]INNp of Divi+inn3of tM1e Businca+and PmfessinnsCWe)ot
that he is exempt therefrom and the basis far the alleged exemption. Any violation til
SectionIOI IS byany applicant for a per it object, the applicant to a civil penalty of
not ..or Nan Five hundred dollars (SSgO.
� Li,twncroftnopropeny, ormyemplayees with wrgnsaslheirldr,antemurron,
will do the cork, and the stmmure is not innndW or offered forsale (Sec9Md, Business
and Processions Code 'Flue Contmcler's License Law docs not apply to an owner of
property who builds or improves thereon, and who docs such work Lionel in threegll
his own employees, provided that such improvements am not intended or offered for
sale.I(.howovcr, the In or impmvardm is sold withinone year nl mmpinion.lhc
owner- will have the harden til proving that he did not build or improve far par-
201-I1 WAMPS
OVER RNXIAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUI'1'/h11SC.
TI! MP MEFER OR POLE INST.
COMMERCIAL; '
EINE W IthDG/ADDITION [I DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMI' QYEMLM'
EIOT-_•_•��,
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RES IIIENTIAL PLECTR FF.
'
'u'•�'���{jA rx
6 (S 19
g Q T
g
ll f
pont of sale.(.
❑ I, at owner of ate, property, am excnuively conmmting with licensed contractors It)
/ - -. v _
QTY. - PLUMBING PERMIT iIf EE
''• �. .' ,,. •r^•.e
r..trucuha projur (Sec. 7114. Business and Pofesaions CWe:) •Die Coulmciors Li-
cruse Low does not apply m un ownerofpropcny whobuilds or improves thereon. and
'Iniamt¢rmsach'an,cr,whhaeamractar(s) licensed Panama to the Contractors
rac
L y
Li,enm Law.
❑ I rte exempt under Sec. .B& 1' C far misnomer
1117RMIT ISSUANCE
ALTER -DRAIN or VENT- WATER IIIA)
_
Dixon, Dale
VALUATION
I 'D
WORKER.ilia E C(hl ofIsSA'1'IO n DECLARATION
under nab of e t f Me f
I herchY alarm pe Y perjury on g
nllowin JManvrion..
ler Worker'sdeopen-'
�Lhrve andwill fabynrt.. ierlvnfConsemn, Code
snook, as provided for by Section 3]INI of Ne Lahr CWe, home performance of the
work far whichisnin issued.
RACK IIPW PROTECT. DEVICE
IIRAINS-n.0(d0. ROOF, AREA, CONI(.
STORIES
"PYPit CONS 'IRDLTIOh
hIXTURES - PIER TRAP
i
l aintain Workers Cn nein he Insurance, h required , i Section
❑ I have and wililmri
39W of the Labor Calc, far the pedamnm �o of the work for which this permit is issued
GAS - BA. SYSTEM -1 INCA OUTLETS
OCC. GROUP
AI'N
CAS - EA. SYSTEM OVER 41F.A)
My Worker', tp s'o In t race ca 'er.ad Policyn m r
Carrier. 1'alicr Nn.:
GRFASOINDUSTRL WASTE DDERCEPTOR
CERTIFICATE OF EXIEMPTION IROM WORKERS'
A'I
COMPHNS'ION INSURANCE
BUILDING DIVISION FE -S
O Z
Q
r'^jl
a['
Lia Iny
F
❑ U
Fr0./I
rZ
(This sunedivrd non necompletW ifthe purrom is hour hundred dollars (SIM)
lir ho") (This
I cenify that in the pctfmmance ofthe workforwbich this permit is issued, l shall
not employ any person in any mann }U ct t ) the Workers' Comport-
srawn LatytklEf Ca i`pptio`I t � c _
Applic f f S
GREASE MAP
FEE
SEWER -SANITARY -STORM FA.2fp Pf.
ENERGY FF.F:
WATER HEATER W/VENDELECTIi
-
GRADING FELT
e..q
NOTICE TO APPLICANT: If, afar making this Ccmfieste of Exemption, you should
the cmuc..hjcn in the Worker's Compensation provisions of the Labor Code, you must
fonsvida comply with such provisions or this permit shall be deemed ruvoked.
ONLENDINGAGENCY
CONSTRUCTION a c w of
I haffirmereby enn Ratinonscuun lending agency flubs Parana once
the work for which (his permit is issued (Sea 3097, Civ. C.)-
Lomita Name
WATI:R SYSTEMOREA'1'ING
SOILS PER
WATER SERVICE
('AID
Dae Receiptp
NEW RESIDENTIAL. PLMO.. SQ. 17.
TOTAL.
TOTAL :
Lenders Address _
OUILIIING FT:I"
1 cenify that I have read this application and some that he .1 cu mrernanmt is
e to comply with all city and county ordinances and store Inwlating no
correct. I rsrns m
QTY. r MECHANICAL PERMITI FEE ,
SEISMIC FEE '
PERMIT ISSUANCIi
ELECTRIC I iL'
verve -mentioned pml'eny for inspection purposes.
(We) agree m save, indmrnify Iced keep harmless the City of Cupertino uguinsl
liabilities, judgments, costs and expenses which may in any wry acerae against said City
ALTER OR ADD TO MECH.
PLUM B ING FEE
' mse...nce ofth Tmtin �l Nis permit.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FE.
APPLICANT II :R" '1S ANpe .1. C y11,1.Y WITH ALI. NON -POINT
SOURCE .ATI . S
-
AIR HANDLING UNIT (OVER 10,00)CFM)
I CONSTRUCTION'I'AX
Slgm roe APPHoino/Comm Dvte
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fair, building occupant store or handle hazardous material
as defned by the Cupertino Municipal Calc, Chaplin 912, mrd the Hcnllh and Safety
Code, Section 255320x?
❑Yet, VNO
EXHAUST HOOD(W/DUCf)
HOUSING MEEIGADON FEE
HEATING UNIT (101W." BTU)
HEATING UNIT (OVER IMIX, BTU)
PAID Date Receipt#
VENTILATION PAN (SINGLE RFS III)
BOILER-CGMP(3HP OR I W.M0 BTU)
•
Will the applicant or future building occupant use equipment lir devices which
emit hawrdous air contrmu inenus dofnal by the Bay Arca Air Quality Management
TOT,
BOILER -COMP (OVER 100,100 BTU)
Owed'
❑Yes No
CONDITIONERISSII
NCE
I have read •hazindem melurlals lcquimmunx under Chnptu fi.95 of aha Cab -AIN
sty •. Sec; s 05.25533 and 25531 L understand that it the
naddlid trtermalmf nn n' .r r�,p,rosnday n,nmiry me acapam
IscoAh!
NEW RESIDENTIAL MECH. SQ. FT.
lubewhi< mus dap c of o Ccnific `lir pa
_. TOTAL:
_
LS'SUED BY'.
OW orauthndzed .gent Dae
OFFICE