S 1154APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL - - PF IT N -1154
O1154
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG-MECHANICAI.
OFFICE
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CONT>qCC1 R'S NAME: LIC NO:
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ARCFUJ C'I/ENGINE it v LIU NAT.
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030 t6`d� Y rrLo%J
CONTACT: PHONE:
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BU ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
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LICENSED CONTRACTOR'S DECLARATION
I hereby acro. that 1 am licensed under mwi,ex, oPChapter 9 mommenlIag
with Sermon nN1l17 ofDiviain nfthe Business and Prnlouinns Codc, and. license is
i nfull force and effect
License CP ss Lie .#
Date -- _ nr
ARCHITECTS
DE 'S DECLARATION
I understand my plans shall be used us public records
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL,
❑SFDWI. ❑ KITCHEN REMODEL
ADDITION C] PLUMBING RE -PIPE
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
[I INTERIOR LJ CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
❑ BATH REMODF.IJREPAIR El DEMOLITION
[I OTHER
PERMIT ISSDANCE
APPLIANCES -RESIDENTIAL 10,[J
PANELS
UP TO 2M AMPS
q"W
ej?,a
GG tYL] G
6 U
Licensed Pmfeasi... I
OWNER -BUILDER DECLARATION
I hereby of irm mal I am exempt from me Commemr's 1 "cease Law for me
fallowing reason. (Section 7031.5, Business and Professions Code: Any city or countySIGNS
201-INK)AMPS
OVER 1r1fN1AMP5
ELECTRICAL
OW ^
which requires a permit to construct, alter, Improve, demolish, or repair any structureJa prior to its issuance, also requires the applicant for such permit o file a signed statement
SPECIAL CIRCUIT/MISC.
ythat
GO(commencing
ti y K
tivll II•
rn
Q
he is licensed pursuant to the provisions of the Commam's License Law (Chapter9
with Section 7000) of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
it subjects the applicano a civil penalty of
Scene. 7031 S by any applicant for a permapplicant
not Imrean flee hund
thred dollars (S501p,
❑Las owner of the propeny,ouny, employees with wages as their sole compensation,
wdl do rhework. and the mm,mreixnm "mended or nRered fur s.I IS m 7044, Business
TEMP. M ETER OR POLE I NS' T.
M
❑ NEW ADDITION El DEMOLITION
ANT FOODSERVICE
❑
IMPROVEMENT-/�
I
THER /� �►a w
POWER DEVIC.
SWIMMING O EC I
r
0. m
and Professions Code: The Cunlnxldfs License taw dine not apply to an owner ,f
property who builds or improves thereon, and who does such work himself or through��--If
his own employees, provided that such improvements are not intended or offered for
sale. If, however, the building or improvement is sold within one yean1 wmple.ion,theSQ.
OUTLLTS- SWITCIi' "f URN'
/ is /Q /t L
-7�
NEW RESIDENTIAL E E SQ Ff.
Irl: FLOORAREA
$/SQ. FI'.
owner -builder will have the burden of proving mat he did not build or improve for per-
,od of sale.).
❑ I, as mead, of the property, am exclusively contor,drg with licensed mmractors 1,
construct the project (Sec 7044, Business and Professions Codc) The Conlracn+r's Li-
cense Law does not apply to an owner of property whit builds or improves IhemmO and
i
TOTAL,
QTY. PLUMBING PERMIT FEE
who contracts for such projects with a connotations) licensed pursuant to the Contractors
PERMITISSUANCE
License Law.
❑ I am exempt under Sec. , B A, P C mrthis reason
F
Owner Date
AITER-DRAIN & VENT - WATER (EA)
VALUATION
OOO
WORKER'S COMPENSATION DECLARATION
BACK FLOW PRO'T'ECT. DEVICE
I barely affirm under penalty of perjury of the fellowhng d
a
enc
fir-WorkerCo
Don, as andpillfor bynaCion 3700 of Consents self-insnre for Worker's Courtier-
¢edea, as for by Section 37rN1 of the Labor Cada, for the performance of the
DRAINS - FLOOR, ROOF, AREA, GOND. -
STORIES
TYPE CION
which this issued.
this
work have
FI%TURES -PF.R TRAP
'
and maintain Insurance, required Section
1 have and will maintain W
'
ante oftthi w
work for whichthis permit is issued.
performance h a i
of the bot Code.fonthsurance
GAS -F.A. SYSTEM -1 INC .40U'fLETS
OCC. GROUP
APN
cancer and
My
Cm Worker's Compensation Insurance carrier and Policy number are:
Cartier Policy Nn:
GAS - EA. SYSTEM -OVER 4 (I:A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be complaedrobe pent["[ is foronehundred Jnllurs($I W)
or less.)
GREASE)INDUSTRI. WASTE INTERCEPTOR
ab DING DIVISION FEES
PLAPVH^
GREASE TRAP
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to
a
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Icettify than inthe perforarmr. rho ork rot which his Permit is issued, Isha11
not employ any parson In nay inner so as m become strip m me mwr,
satins Laws of Califs 1e "'n
Applicant t
SEWER -SANITARY -STORM EA. 2W Ff.
'
WATER HEATER W/VENT/ELECTR
NOTICE TO APPL A ,after ma n61bi T ttn x,mption, you should
becoma,nbjeet to the Wor errs Compensation provisions of rhe lahor Cnde, you musty
forthwimcomplywithmchp... amrsa,,his permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby stfirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Ste. 3097, Civ. CJ
Lender's Name
Lender's Address '
WA'TERSYSTEMOREATING
WATER SERVICE _
_-
'_
PAID Data Receipt#
NEW RESIDENTIAL FUME. SQ. FT
TOTAL:
TOTAL /
BUILDING FEE
rectify that I have ad this application and scare that the shave information is
1 certm
correct. I ngree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE AA
Vi ST
PERMIT ISSUANCE
ALTER OR ADD TO MECH.0
ELECTRIC IBE
PLUMBING FEE
.Move-mearion<d property for inspection Purposes.
(We) agree In save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way atom, against said City
asequence afro¢ minga(th'npermit.
AIR HANDLING UNIT(TO 10,1100 CFM)Q
MECHANICAL PEE �
APPLICANT UN _STANDS AND WILL C YWITH ALL NON -POINT
SOURCE RE ATIONS.
../�
AIR HANDLING UNIT (OVER BLIND CFM)
CONSTRUCTION TAX
Signa/ rdA at/Comracto Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNTI'(TO 100,000 RTU)
-
Will the applicant or future building occupant, stare or handle hazardous materiel
as defined by the Cupenino Municipal Code, Chapter 9.12, and the Health and Safety
Code ,Section 25532pq?
HEATING UNIT (OVER 100,IN)O BTU)
[_1 Yes E] No
Will rho applicant or future building txcepant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Man agement
PAI Ume Rewipt#
VENTILATION FAN (SINGLE RESID)
-
_OILERCOMP f-3HP OR 100,000 BTU)
TOfAI
District
❑Yes- 7 N
BOILER - COMP (OVER I1gko d B'TU)
AIRCONDITIONER
I have read the hazardous materials requirements under Chapter 6.95 of the Cal i-
ANCF. DATE
NEW RESIDENTIAL MECIL
gamin Health A, Safety C . Sections 25505, 25533 and 255 4 1 understand that if the
bui lding dtretratcu yh' tewnr t My,,,, 1Stoorld'yth,mcupnt
tlo
or rvyuire hichmumbeme i isxum ,nificarc of/Jcc�yuy�
w/iii / /Aw r dd
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OFFICE