S 3155 (2) --APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING-ELECTRICAL PF. IT NO, 3155
mow rr
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. J K 1 55
BUILDING PROJECT IDENTIFICATION- v 111 v v
BUILDING ADDRESS: SANITARY NO. APPLICATIONS MITTALD TE
fo
Grp cPa': o? 608) Qo/i»ser e-ji-no too 9So/y �
OWNER'S NAME: PHONE: _ CONTRACTOR'S NAME: LIC NO:
110925A -3 S O I NIC CONTROL If
. ARCHITECT/ENGINEER: LIC NO: - ADDRESS: - '❑
corvTncr: PHONE: BUILDING PERMIT INFO
❑ Consultant F¢¢S Paid by Applicant(Initial) BLDG ELECT/PLUMB SPEED
ED ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that[.it,licamretl under provisions.f Chaplet 9(commencing JOB DESCRIPTION
ODOZ with Section 7fN10).fDivision3 oflM1e Business and Pmfessiov in fall force and effect. Cmlc,and my license is PERMIT ISSUANCF. RESIDENTIAL'
WUU License Class Lie# ❑SFDWL [_1 KITCHEN REMODEL
h,'y
/ 'W Dale Contractor APPLIANCES-RESIDENTIAL ❑ADDIIION [I PLUMBING REPIPE
ARCHITECT'S DECLARATION PANELS MULTI-UNIT ❑STRUCTURAL
Z O y Z 1 understand my [.asshallhe used vs public rcCoNn MODIFICATION
O'-'"C UP TO 20n AMPS Z C/
eP^Fp.W Licensed Profession.] El INTERIOR El CHIMNEY REPAIR
W2,,.1 OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT El SWIMMING POOLS
yy 0.'W 6 I hereby affirm that I am exempt from the Codirector',License Law for rbc OVER IOOOAMPS ❑BATH RHMODEUREPAIR ❑DEMO ITION
D 3 LL Fq following reds...(Section 7031.5.Business and Pro&ssione Code:Any city or county SIGNS h;LECTRICAL ❑OTHER T g t
F I�O� which..quires a permit to conamcl,til ler,Improve,de...h,h,r repair any armar,
fn prior m its issuance,also requires the applicant for such permit file a sig anneement SPECIAL CIRCUIT/MISC.
Appp a. that he is licensed pu.aanno the provisions of the Contractor's License Law(Chapter 9
OHO (commencing with Sechum700p)of Division 3 of the Business and Professions Code)lar TEMP.METER OR POLE INIJ COMMERCIAL
'0.q oCL Nat he is exempt inere[mm and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION El DEMOLITION
iLLCI trN.
Section 703 l S by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES Ir
F Z} not more than five hundred della.($500). ❑TENANT ❑FOOD SERVICE
yq ❑Las owner of the Amp ny,or my employees wish wages ns theirsole comp nsatinn. SWIMMING POOL ELFCTRIC IMPROVEMENT
1" will do the work,and the structure is not ntended or oRemd for sale(See.7044.Business ❑OTHER
ILL m and Pomerania Code:Tire Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
CC properly who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ IT.
sale.IL however,the building or improvement is sold within one yoarof complelionthe SQ.FT.FLOOR'AREA $/SQ.Fh
owner-bander will have the burden of proving Ill.,he did not build er Improve for Pur-
pose of sale.). - -
❑ 1,as owner of the property,am exclusively contracting with licensed contractors it)
construct theproject(Sec.70,14,Business and Profession,Code:)Ile C.mmdors Li-
cause Law does not apply drnnowner ofproperty who Talks or improves thereon,and QTY. PLUMBINOPERMIT FEE
Who Contracts for such pmjecls With a commumr(s)licensed pursonnao the Grammar's
License haw.
I]'lc ex ntler Sec}x1 �T'� ,B&P C for this reason PERMIT ISSUANCE
�' Dram ALTER-BRAIN&VENT-WATER(EA) VALUATION
. Ow(" WOR C .NSA'FION DECLARATION BACK FLOW PROTECT'DEVICE
1 hereby alfirn under penalty of Petra,one of the following declaration,
❑ I have and will maintain a Cenifcan of Consent to,elf-insure for Workers Carman- DRAINS-FLOOR,ROOF,AREA,COND STORIES TYPE CONSTRUCTION
ration,as provided for by Section 3900 of the Labor Loam.for the performance of the
work for which this permit is issued. FIXTURES-P • RAP
I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Cale,for the performance of the work for which this permit is issued, G ASY, ZINC.4 OUTLETS OCC.GROUP AIN
My Wurkeek Compensmion Insurance carrier and Policy number are:
Gisler Pit I icy Nn.: GAS\E .SYS ER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKF:NS'
COMPENSATION INSURANCE •REASE9ND T 'TE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed if the permit is forone to do, (SHM
or less) R g
PLANCHECK IEE
Icenify that in the performance of the work for which this permit is i. shall ,EWER-
notern 10 any c -SANITARY MEA.200FT
employ y person in any nernner so as to become subjecial Workec ,y ENERGY FEE
O z ration Luwa of California.Dote WATER HEATE fPl'/ELECTR
z O Applicant GRADINGFEE
sy ti NOTICE TO APPLICANT.If,after m.king this Certificate of Exempinn,you uld WAT EMTREATING SOILS FEE
aThermal subject to the Worker's Compensation provisions of the Labor Codq yo mal2t
aQ forthwith comply with such provisions or this permit shell no deemed revoke.). V <1 ER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.UP.. PAID in
L) 0 I hereby niton that there is a construction lending agency for they pformanca of Receipt#
the work for which this permit is issued(Sec.3097,Civ.C.)
U Lender's Name TOTAL:
LendossAddres, - TOTAL:
a1 ceniry that 1 have read do,apploplam and side that the above rm
infoalion Is BUT'
00 coalm,1 agree to comply with all city and eo.nty.rdinanw,and mate laws.claim,to QT V MECHANICAL PERMIT FEE
U ,Z building construction,and hereby authorize represematives of this city to enter upontbc SEISMIC PEE
ab.vamentioned progeny for inspection purposes. PERMIT ISSUANCE PLECfRICFr
(We)agree m save,indemnity and keep harmless the City of(mimmno against
liabilities,judgments,costs and expenses which may many way acem,against said City ALTER OR ADD TO MECH. PLUMBING FEE
inco41E ]
e grming of this permit.
A FPERSTANUS D pLl.CO lPLY WITH LL NON-POINT AIR HANDLING UNIT(TO IOp00 CPM)
SOUERSTA♦ MHCfIANICALIuG
AIR HANDLING GET r(OVER 111.(100 CFM) CONSTRUCTION TAX
Sign. nVCommctor Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION NBH
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,003 BTU)
as delfned by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,00!1 BTU)
F1 Yes ❑No VENTILATION FAN(SINGLE RHSID) PAID --
,. - Date Receipt# -
Will the applicant or future defined by the B use equipment or devices which
anilhmardous air conmrninams as defined by lM1e Boy Aro.Air Qmdily Management BOILHR-COMP(:iHPOR 100,000 BTU!
District?
❑Yes 7 N BOILER-COME(OVER I01,00 BTU) 07
I lmverwd thembandous alit,mahmdirements under Chapmr6.95 offie Cali- AIR CONDITIONER !SSUONCE DATE
Pornin Health&Safety Code,Sections 25505,25533 and 8534.I understand 0.1 ff the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a lcnunt.Mm
at it is my resparmility to notify the cepnnl _
of the regnircnamr which ma.be.11 mono isuanee of Certificate of Oecupvncy. -
Owner or authorized agent Dare TOTAL: ISSUED BY:
OFFICE