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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. ELECT
BUILDING DIVISION APPIACATION/PERMIT 1'LUAIISIN<:-AII!CHANICAI'
IIIJILDING I-ROJRCI' IDEN'DITICAI'ION
PE IT NO
PES
2036-
BUILDING ADDRESS:
10,201To�RG Aft=NUI-�N�1'Q C�-�
S CCi-t -
SANITARY NO.
APPIJCA'DON SUHMITTAI. DA'Z'E
—1 Q
OWNERS NAME: PHONE:
CONTRACTOR'S NAME: LIC NO:
NIC COQQNTROgLM
❑
/'
ARCHITIECI'/IENOINIEER: LIC NO
ADDRESS:
A 1 T
COs ACC PHONE:
,/
.�'� �Y1
❑ Consultant Fees Paid by Applicant (Initial)
V /
BUILDING PERMIT INFO
BLDG ELECT PLUMB MITCCIH
� Rid ❑ ice.
LICENSED CONTRACTOR'S DECI.AKATION
1 Mrchy affirm Ibm 1 am licenced under provisions of Chaprer 9 (commencing
with Section 7O 0) of Division3 of the Business and Professions Code, and my license is
in full force aryl effect.
Q9'Y. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL 9
❑SPUWL KITCHIEN REMODEL
PERM] ISSUANCE p
APPLIANCES-RIESIDIENTIAL
License Class Lic.#
Dace Con-cmr
❑ADDFLON El PLUMBING RE -PIPE
❑h1ULTLUNII' ❑ MODIFISTRUCCATION
MODIFICATION
El INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
❑ BATH REMODEI/REPAIR ❑DE•MOLITION
OTHER
ARClll I EC'I"S DECLARA'T'ION
land and myp ns shall used ��a puMiyuo
/, s f aS
PANELS
UPTO200AMPS
�pA
jLx Profesponal GGiiaa-HH
NER.BUILDERDBCLARMION
I herehy affirm Thal 1 am exempt from the Contractors Liccnse Low for the
O follgowinrresrsn. (Seclion 7131 5, Business and Professions Cale: Any city oaounty
2111-IIMXIAMRS
OVER ❑TAMPS
SIGNS ELECTRICAL
which requires a permit to concwm, cher, improve, demolish, or repair any somaare
I prouto its issuance. also requires the applicant for such penning file a signed statement
that he is licensed punuam to the provisions of the Contractors License Law (Chapter 9
Icomnaacing with Sec tion 711001 of Division 3 of the Business and Professions Code) or
' Section 703 IS hyany applicant for a ramal subjects the applicant o civil penalty ofDEVICES
Nat he is exempt Iberefrom and the basis for the alleged exaninum. Any eiolmlot of%DRAINS-FI.0OR,R0MKJ
SPECIAL CIRCUITIMTSC,
TEMP, M E'ER OR POLE INST.
COMMERCIAL
❑ NEW BLDG/ADDITION ❑ DEMOLITION
TENANT ❑ FOOD SERVICE'
not more than Eve hundred dollars (0580).
C I, as owner of the property,
(] prep yannyo intended ed with cared for Neireole70D, BoonealEl
wall do the work. and the structure is pros License nwdosnotapplx. to
i prat Professions Gale: The Comment's License Law Jlrs not apply to an owner offS-SWITCHES-1
weer of
IMPROVEMENT
OTHER
INGPOOLIELECI'RIC D
RESIDENTIAL ELECfR SQ IT.
property who hudda or improves nemm, and whit does such work himself m lhnsugh
his own employees, provided that such improvements are not intended or offered for
sale. If, however, the building., Improvement is sold within one year ofconlpledon,NeSp.
FI'. FLOOR AREA
S/SQ. FT.
owner4ailder will have the burden of proving that he did not build or improve for put -1
pOw of sale J'
❑ I. as Owner of life property, am exclusively Contracting with teemed contractors In
construct life project (Sec 9041 Businecca cad Prof cions Code:) the Cnnlrafmrs Li
cause law does not apply m an owner of property who builds or improve, thereon. andPLUMBING
�^ �y� 1
CEO %
TO'fAl.
PERMIT FEE
who contracts tors -la projects with a commdnr(s) licenced paramnt (,,the Comracmre
ISSUANCIE
License Low.
❑ l am exempt ander See. .B& P C for this reason
-DRAIN & VENT - WAI ER (EA)
LOW PROIEC'I'. DEVICE
VA I.UA'I'ION
2 0..9 Q
Owner Data
WORKERS COMPENSATION DECLARATION
I I herehy onion under penalty ofperjury one of the following declarations:
I miscued will maimaina Cerifcaaof Consent m wlf.inwrefor Workers Compen--FLOOR,ROOP.
STORIES
TYPF. CONST RUCTION
station, us provided far by Section 3700 of the Lahor Codas for the performance of the
work for which Nis ser nit is issued
-
19XIU RES-PEB`(gA
l
[iA5-EA.SYS'Tirvyt WC.JOUfLhTS
❑ I have and will maintain Workers Compensation Insurance, as required by Section
37M of the bor Code. lar the performanccof the work for which this actual is Issued.
L
OCC. GROUP
APN
GAS - EA. SYSTEM OVER 4 (EA)
My Workers Compensation Insurance carrier and Policy cutter are:
Cartier. Policy Na:
GREASErNDIJSTRL WASTE ING ERCEPTIIOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
RU .DING DIVISION FEES
GREASETRAP
PLANCIIE r
('Ihk Ore ianneed not hceomplmed ifthc per mit is fnrnne hundred dollaa(S LW)
or less.)
I ceni fy Nal in the perfamence of the work for which Nis permit is issued i shall
nm employ any Lee rwn in any canner m es lm becomn.mbjecl to aha Waders Cnmpen-
SEWIER-SANITARY-STORM EA. 2W FT.
F.Nf:RGY PE .Ito
WATER HEATER W/VEN'UHLECTR
GR
sauum Lawsof Culifomia. Data
Applicant
NOTICE TO APPLICANT: If, after making Nis Cenificane of Exemption. you should
become sulgml m the Worker's Con pan,; )a pmvisions of the Labor Code, you nun(
forthwith comply with such pmvisions or permit shall be licensed revoked.
WATER SYSTEM/I'RIEATING
SO
WATER SERVICE
CONSTRUCT ION LENDING AGENCY
I hereby dolor that there is n afndmcfion lending agency for the performance of
Na work for which this permit is issued (Sees 3097, Civ. C.)
P
DatecciplM
NEW RESIDENO IAL PI.MII, SQ.FI'.
O
L.ma,'s Name
Danders Address
TOTAL
HULL TNG FIiE
L ihove 1 ramify that I read this application and a state thNe above information is
0 correct. I agree to comply with all city and county nNinances and spas laws relining m
h tildog conswction, and hereby authorvc representatives of Nis city to neer upon the
property for inspection proposes.
(We) agree to save, indemnify and k«p harmless the City of Cupeninn against
llabilines.judgemnn, costs and expenses which may in any way creme against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI'fit ALL. NON -POINT
QTY. MECI4ANICAL PF.RMI'F FEE
SEIS ICFFF.
PFRMII'ISSIANCE
ACI ER OR AUDIO MSCI I. G
iabnvememioned 1'RIC FEE
PIX MIN GI'F.E
AIR HANDLING UNIT (TO IWas CITM)
MFCHANI LFEIE 2
SOURCE REGULATIONS,
AIR HANDLING UNI'r(OVER 10,001 CFM)
CONSTRUCHONTAX
Signature ofApplascr COnwctor Dan,
HAZARDOUS MATERIALS DISCLOSURE
Will motpplEcamnr futhre building --Into mnrc nr haaAc hazodausnpmrial
as Jeficed by the Caperlimf Municipal Code, Chapter 9.12, and the Health and Sultry
Cale, Section 2553200'
❑YesNo
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FELE
HEATING UNIT (TO IFITHDO B 1 O
HFATING UNIT (OVER 1110.000 LOU)
Oat pt
VENTLAfION BAN UNNGLE RISID)
BOILER - COMP OHP OR 100.000 BTU)
Will the aPplicam or pure twilding uccuaant use equipment or devices which
each hmpdaus air contact I,, as defied by the Bay Area Air Quality Management
BOILER - COMP (OVER 100,000 BTIJ)
District'
❑Yea n
AIR CONDITIONER
ISSUANCE DATE
I have read the hmurJnu,neac d, requirement muter Chapter 6.95 of the Call-
fomie Health & Safety Code, Somans 25505, 25533 and 25534. I understand that if me
NEW RESIDENTIAL MEC)). SQ. EI'.
hailing des nut cnarod, haven pnam.lif. it is my responsibility to really the cecupam
ofth uire xnas hie must be nlet d rm'ssuafee ofa Cenilic. sof cupme'.
(!
L:
O romhonzcd ag One
ISSUED BY
uFHut