29909 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
CITY OF CUPERTINO - BUILDING ELECTRICAL PERMIT NO. w O
BUILDING DIVISION APPLICATIONIPERMIT PING PROJECT IDENTIFICATION
�JJ JV
' BUILDING PROJECT IDFMIF'ICA'TION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
OWN R'S AME: a PHUNIJ- CONTRACTOR'S NAME LIC NO:
C�'g S7dq!I NIC CONTROL
n
ftCHITECT NGER: � LIC NO:
ADDRP.SS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
6r-yam �11 I/a.L�'f/l,�Ga`ia/) ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
WNL Y` \1�f/ �"1 J1 V� �a j .
LICENSED CON IR'S DECLARATION QTY ELECTRIC PERMIT FEE �6s�
I hereby affirm Nal 1 sm lice®ed under provisions of Chapter 9(commencing JOB DESCRIPTION
Oo'Z with Section 700)mf Division 3aflhe Business end Pnfeasions Code,and my hismae is RESIDENTIAL:
X00 PERMIT ISSUANCE
C W m full force wJ effect. ElSFDWL ❑KITCHEN REMODEL
a Vl,,) License Class Lic.0 - APPLIANCES—RPSIDENDAL ❑ADDITION El PLUMBING RE-PIPE
yZ Dem Contractor
m stm ARCHITECT'S DECLARATION PANELS El MULTI-UNIT ❑ L.
STRUCTURA
z O ret Z 1 understand my plans shall he used as public records MODIFICATION
Oz�- UP TO 200 AMPS C1 INTERIOR El CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER]Pon AMPS ❑BATH REMODEL/REPAIR El DEMOLITION
Ise� 1 hereby affirm that 1 am exempt Irons the Contractors Licence Law Int rM1e
d U followingmrssm.(Section 7031.5,Business and Pmfessions Cole:Any city orcountySIGNS ELECTRICAL
❑❑OTHER
FF which rcyuircs n permit re conswn,ohee improve,demolish,or repair any tamdure
that heor to
p also requires the pavisilicvof for such Contrarmiuoicensle ae ned Law
SPECIAL CIRCUITIMISC.
} Not he is licensed pursuant to provisions of the Commcrnr's License Law(Cbapmr9
Gx (commencingwith Section 7")of Division 3 of the Business and Professions Code or COMMERCIAL:
wi ) TEMP METER OR POLE,INST.
a 0 0OC Natis exempt therefrom and the basis for the alleged exemptin
o .Any violation of [IITI
NEW BLDG/ADDON [IDEMOLITION
LL•
Section 7071.5 by any applicant for a permit subj¢n the applicant to e civil penalty of POWER DEVICES
not more than five hundred dollars(55W). ❑I ❑FOODSERVICE
^Zi IMPROVEMENT
❑Lmbasoro,Ne property,or myemployeeswiN cared far ar to IS..
compensation, SWIMMING POOL ELECTRIC
al wdl dothewmk, it the no turelenoaLicense Law
argSecA044.Business _ []OTHER .
nod Profusions Cole:The wv n p rso License Low does not apply s if owner of OUTLETS—SWITCHES—FIXTURES
0.13$ progeny who employees,
or improves thereon,and who fines such work himself or through
his own employees,provided that such mens is old w arc on intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however,the building or improvement is roll within one yemof completion,the SQ.FIT.FLOOR AREA S/SQ.R.
owneolmilder will have the burden of proving that he did not build or improve ho par
ElEromet,
nwnerafla property.am exclusively contracting with licensedcontrucmrsm TOTAL:
ct the project(Sec.]044,Business end Professions Cole:)The Cometh or's Lk
w does not apply to an owner of Impiety who builds or improves thereon,and QTY. PLUMBING PERMIT FEE AY U0 forsuch Proja1s witha commcums)licensed pursuanuo the Cmntracmrs 1996
License Law, PERMITCE 's�J
I]I nm exempt un er Se B&P C far Nis reason j
OwnerA R DRAT VENT—WATER(EiO f�llt v. 4s�s LI I I HkrLVALUATION
_ ��Dart
V and 'S co01"11115L
ATIOPS N DECLARATION ACK W PROTEGE DEVICE
1 hereby affirm under penal f perjury one of the following dedmations:
I have and will maintain a Cenificme of Consentto self-insure for Workers Compen- DRAINS—FL :22FAIUIA,COND. STORK TYPE CONSTRUCTION
cation,as provided for by Section 3900 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES—PER P
I] I have and will maintain Worker's Conformation hu,mance,as required on
by Secti
3700 of the Latour Code,lot the performance of the work for which this permit is issued GAS—EA.SYSTEM-IIre: TLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number a - 1
Cimm,: Policy No.: GAS—PA.SYSTEM-OVER 4(EA) '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR BUIVAG Dly SION FEES
(Thissecrionneed aotbecomplered ea,permit is foronehundreddollazs(5100) GREASETRAP
or IesnJ PLANCHECK '
I unify dust in the pedcamunce of she work for which Nis permit is issued,Imail SEWER—SANITARY—STORM EA200 FT.
not employ any person in any manner m as to become subject to N .e Worker'Camper- ENERGY FEE
Z ration Laws of California.Data WATER HEATER WNENT/ELF.CIR
O Applicant GRADJeG E
ti NOTICE TO APPLICANT:If,after making this Ce"ificate of Exemption,you should WATER SYSTEMRREVDNG SOILS s
a7 become subject to the Workers Compensmion provisions of the Labor Code,you must
W fonhwith comply with such provisions or this permit shot]be deemed revoked. WATER SERVICE
�^ CONSTRULTION LENDING AGL'NCY NEW RESIDENTIAL PLMB. SQ,FT, PAID
r.1 Z I hereby affirm that is a construction lending agency for the performance of Dem Receipts
U Q the work for which this permit is issued(Sec.NEE,Civ.C.) '
W E" lender's Nanne TOTAL:
L) Lender's Artists. TOTAL:
I canify thus 1 have read this application enJ stare that the above information is BUILDING �+
F•fA cored.I agree to comply with all city end county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V Z building consuuctiomnnd hereby eulhorieetepresemativesa(this city Incinerationthe SEISMICF ' `
ehovemmemimned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hntmlass the City of Cupertino against ELECTRIC - E
liabilities.judgments,costs and expenses which may in any way name against said City ALTER OR ADD TO MECH. PLUMBIN.FEE
in consequence of Ne granting of this permit -
APPLICANTUNDERSTANDSANDWILLCOMPLYWITHALLNON-POINT AIR HANDLING UNIT(TO 10.000CFM) MECHANI LFEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTI TAX
Signature of ApplocatiConuacmr Date EXHAUST HOOD(WMUCI) HOUSING MITIGA ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building metipantstore or handle hazardous material HEATING UNIT(TO IW,M)BTU)
m defined by the Cupertino Municipal Cod,Chapter 9.12.and the Health and Safety
Cade,Section 25532(x)^ HEATING UNIT(OVER 100,0011 BTU)
0 Ye; ❑Nm VENTILATION PAN(SINGLE RESID) PAID Data cciptp
Will Ne applicant or future building rampant use equipment mdevices which
.it hezeNous air comammanu as defined by the Bay Area Air Quality Management BOILER—COMP(3HP OR 100,000 BTU)
TOTAL:
Disaics7
El Yes No
BOILER—COMP(OVER 100,000 BTU)
❑
I have read rise hazardous materials requirements under Chapter 6.95 of the Cah AIR CONDITIONER ISSUANCE DATE
fomiu Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
buildingduea not coreody hase.ta,atn.,,has it kny responsihility tu notify the occupant ,
of the re,mremems which must be mea Prior to issvanm of a CcniOcam of Ocmpnncy.
Owner ter uurhorizW vgets Date - TOTAL: ISSUED BY:
OFFICE