S 0854 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
[_: N
Y OF CUPERTINO JUHLDIND-ELECTRICAL PI54"NO. 0854
ILDING DIVISIOAPr1.lOATtON/IxF.RMIT I•LIIMBINC.-M1IECIIANICAL
BUILDING PROJECT IDENTIFICATION
DING ADDRP SANITARY NO. APLICATION SI111MITTAI.DATIiWNER'S NAM Pi Nil 19¢ CONTRA R' NI•ME: _ ,S 1 NO -��
n p Q((�J LJ
/W/1i�✓4 _( ��^a/ N/C CONTROL N
LIC NO: AL ) /� ❑
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CONTACE /O PHON . 3?,&,// DUILUING I'ERMI'I'INPO
h ITL ✓7S.0 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB IF H
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEC
1 hereby uin.Nat 1 um licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
00 th Senian]Iq(p of Uivision3of Ne Business and l'ndessina ale and my license is NE IDS FNTIAI_
w0 PERMITISSUANCE
nfull lisrceond ❑SFDWL ❑KITCHEN REMODEL
Nu Licrnm bass Llc.e ApP1.lANCGS-RESIDFMIAL ❑ADDITION El PLUMBING RE-PIPE:
F W Dam Contractor
in p' ARCHITECTS DECLARATION [1 MULTI ❑S1'RUCfURAL
ZC) Iundersand myplamshall bemesim,abfic records PANELS MODIFICATION
cz-, UlIT02MAMPS [I INTERIOR C3 CHIMNEY REPAIR
r.,4 t M Licensed Pmfassionai 201-IIX0(1AMPS IMPROVEMENT E)SWIMMING POOLS
OWNER-BUILDER DECLARATIONOVER I(0(IAMI'S ❑BATH RFMODEVREPAIR 0DEMOLITION
1 hereby nfnrin that I am exempt from the Contractor's License Law for the
O a V following mason.(Section 7031.5.Business and PrOussionv Coale:Any clay m county SIGNS ELECTRICAL [I%q ER _
3 LL which requires o permit to conslrun,altar,improve,demolish,or repair any slmeture / y
E'�C pdnnn its issuance,also onanoeslheapplicant ka,lonpennit m tfleasignedshnemeit SPECIAL CIRCUIT/MISC.
�} that he is licensed pursuanrto the provisions of a he Communal,license Luw(Chapter 9
(commencing with Sect ion 7")of Division 3 of the Business and Professions Calk)or TEMP.SIFTER OR POLE INST. COMMERCIAL
that he is candid therefrom and the basis for the alleged exemption.Any violatinn of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^LLN,
Section]031.5 by any applicant for a permit subjects the applicant to u civil penally of POWER DEVICES []TENANT ❑1'001)SERVICE.
Z} not more than five handled dollars(S500). IMPROVEMENT
in
C]1,as owner of the pmpeny,or my empinyee.e with wages us mairsole compensation. SWIMMING POOL ELECTRIC ❑OTHER
will dothe work,and the someone is not intended or oRerW formla(Sec.71144,Business
Wand Professions Coda The Contractor's License law docs not apply to an owner of OUTLETS-SWITCHES-F1%'1'ORE%
prnpeny who builds or improves therom,and who does such work himself or hrough
his own employees,provided that such improvements am not inmaded or offered for NEW RESIDENTIAL ELUCTR SQ P.
sale.If.however.the lambing or improvement is sold within one year of canpletinm,the - SQ.FL FLOOR AREA VSQ.FT.
nerbuilder will have the burden of proving that he did not holder imposes lot pur-
poseof sole J.
E]1,os owner of the property,am exclusively contracting with licensed comments an TOTAL:
construct the project(Sea 7044.Business and Professions Code:)The ComracnAs li-
censeLaw deals nor apply utanowner of pmNny who holds or improves Thereon,and QTY, LUMBLNG PERM IT FEE
who contracts for such projects with a comreemrfs)licensed pursuant o the Coolorlers
Licence Law. PER
I am exempt under Sec. .H&I'C for this«axon
Owner Date ALT[R I N V -WATER D!A) LU�10^_
WORKERS COMPENSATION DECLARATION BACK FLOW ITR li 1 .
` 1Jt herhimaunalal'nf perlurY one of the fallowin6 Jalaratione
a,p Il farbine_mdi700 of Consenvo Cadcnsor the Wnrkrrs Ce of the MIS-IrL00R,1200E AREA.COND. STORIES TYPfi CONS'fRI1CT10N
suti k f us which
thi for mi Section 3]IXl of the IaMn Cale,for the ferinrmance of the
w ---
kfit, and thin permit is issued. PI%'IVR:. -
1 Love and will maintain Worker's Compensation Insurance,m myvirW by Section
g0 3700of Carzicrnh u it le,formnthe firman if d palm for whi htf h'n Hpermit is J. GAS-FA.SYS'IF.M-I INC.40l1TLITS OCC.GROUP
APN
Nw: /�� GAS-PA.SYS'IBM OVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WOR KERSGREASOINDUSTRL WASTE INTERCEPTDR
COMPENSATION INSURANCE BUILDING DIVISION PEES
is weapon wee not he complcaW lithe permit is forsme hundrW dollarsMM(SIM)or less.)(ThGRT4uT P PLANCHECK FF.Ii
I certify That in the Performance of the work forwhich this permit is issued,l shall SIT - 1'I'ARY-STORMEA.2(OIT.
not mapiny any person in any omnner so as to become subject to the Workers'Compery ENIeNGY IIiC
QZ sntion Lows of OJifornia.Date WA LIR HEATER / CTR GRADING FEE
Z 0 Applicant
ti
NOT ICH TO APPLICANT:If,otter making anis Certificate of Exemption,you should WATER SYS'I NBC
(✓ became subject m the Worker's Cnmpensmimn pmvisinm of the Lahtr Cattle,you must SOILS ITT:
Is+ fnnhwith enmply wish such proviumne,,rthis permit shall bedecend necked. WATER SERVICE
UO CONSTRUCTION I.ENDINGAGENCY NEW 0.ISIDI?MIIALPLMB. SQ.IT PAID Date sun
1 hereby affirm that there is n canamninn lending agency for the Performance of
( mit the work for which this pctis sued(Sec.3097,Civ.C.)
Landers Name TOTAL:
WLenders Address 'TOTAL:
y I certify but 1 have read this application and,note that the above information is
BUILDING THE
TA correct.l agree to comply with all city and county nnlimmces and sum law,relating to QTY. MECHANICAL PERMIT FEE
V 4 building crontmction,and lmrchyamhorive representatives ofthis city taunter upon the SEISMIC FEE
abastcmenaioned pw,dy for inspection purposes. PERMIT ISSUANCE V
(We)agree n indemnify and keep harmless abe City of Cupcnino against F.LIiCTRIC FEEsame,
Iiahilities,judgmems,costs and expenses which may in any wayaccom aguinst said City ALTER ORADD1'0 MECH.
I.conencf Ne gaming of Nis permit. PLUMBING FEE
seque o
APPLICANT UND QTA ' S AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT'(T'O I LM0CFNU MECHANICAL FEE
SOURM12�tc, /p/k ,��
L/ AIR HANDLING UNIT(OVER IO,(NMI CPAP) CONSTRUCTION TAX
Signature of Ary licvm Commnor Dote EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle Im saunas material IWAIT NG UNIT(TO Em(XNI RID)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the IIcahn and Safety
Calc,Station 25532(x)] IMATING UNIT(OVER 100,00(1 a To)
Yes ❑No
VT:MIhATION FAN(SINGLE N[is ID) PAID
Date Rcwipt p
f ' I the• 'cam or future building occupant use equipment or devices which BOILER_COMP 3HP OR IMOW BTU) O
or' ami�ts as defined by the Bay Area Air Quality Management ( TOfA1..
IN,rira7
QYes FIN. BOILER BOILER-COMP(OVER 100.0BTID
AIR CONDITIONER
Ihath readh
ehacsrd S materialsrequirements actin Chapter
nlaofthe if he ISSUANCP. ATE
fomia Health&Saate,S pprions 25505,2553]and 25534.1 nnJctxmnJ that if the NEW RESIDENTIAL SUCH. SQ.IT.
M1uildiag d,a,, h Ymnam.Nat it is myresponabiliry mnotif the -.,am
of she h Tsth n t rimmiummieofa Ceni11 PY14 ,.,/r
Owae a rta Dam TOTAL: ISSUE BY:
OFFICE