S 1386 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PE8dp1T NO 13 Q86
BWLDINC DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. V
(TUI LIIINO I'ROJ F.C'I IDF.N'1'IFICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
BUILDING ADDRESS:
I i b -Av-* �Sv of
OWNJER:S NAME: 0 0�.� NONE: CONTRACTOR'S NAME: LIC NO: NIC CONTROL.
\HCHITGCI'IENGIN PER: LIC NO ADDRESS: ❑
CONTgC: PHONE: H ILDING PERMIT INFO
S Er 0'"a ��# 9�3 9 y�� EJCOnsullanl Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEGA
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby aftlrm That I ancens
t lied wader provisions ofCh,u 9(..annineir,
aaZ with Secniun]OOOI of Division Lal the Rosiness vnd Professions CodgandmylimmeiaRESIDENTIAL
MITISSUANCE
Fly m full force and effect. ❑SFDWL ❑KITCHEN REMODEL
aUfj License Class Lic.# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
vFiGW Date CoM."I'r ❑MULTI-UNIT 1-1 STRUCTURAL
ARCHITECTSDECLARATION PANELS MODIFICATION
ZOyqlundersmnd my plan stroll be used as public record
OZ-, UPT02AMPS ❑INTERIOR ❑CHIMNEY REPAIR
I H`n.,tWq W
Licensed l'ndessionul 201-I0N10AMPS IMPROVEMENT ❑SWIMMING POOLS
se E� OWNER-RUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
C tY Q I hereby affirm that 1 am exempt form the Contractors License law Iia the ❑OTHER
o W U followingea
rson(Section 7031.5,Business and Profession.Code:Any city o,county SIGNS ELECTRICAL
.136-Lv-"� which requires a permil w construct,alter,improve,demolish,or repair any structure
1Ij priono us issuance.alotuauiresthe applicant lirsuchpernitln rile a signed statement SPECIAL CIRCU Tf/MISC.
�y mat he is licensed pursoamtothepmvisionuf heConvechorsLkx,-Lew(Chapter 9
�aOC (commencing with Section 7000)of Division 3ofnhe Business and Professions Crdc)or TEMP.METER OR POLE INST. COMMERCIAL:
a Ke y mat he k exempt mererrnm and ibe basis rine the alleged exemption.Any viola, 0 of ❑NEW BLDG/ADDITION ❑DEMOLITION
all Section 7031.5 by any applicant lir a Permit subjects the applicant to a civil penally of PO 714 DEVICES ❑TENANT ❑17001)SERVICE
m more than five hundred dollars(8500), IMPROVEMENT
ZG
E] 1,as Owner of the property or my employees with wages as their sole compensation, 'IMMINGPOOLELECTRIC
❑OTHER
will do the work,aend thmracwm Is not intended or offered for sale(Sao.7044,Business
IW O and Professions Cloth:e:TCMnmmors License Low docs not vpply to an owner o1' '1'. SW ITCHES-FIXTURES
6 3 property who builds(Or improves thereon,and who does such work himself or through
his own employees,provided that such improvtmenu am not intended or offered for NEW RES ELECTR SQ ET.
talIf',however,theb.Ildingrrimpmm
vecnt,,told wiminoao yeurrf evmplminn,the SQFT.FLOOR AREA USQ.F1'.
.
e.
cr-bollder will have the burden of proving that he did not build or improve for pur-
v
portrt tank.), TOTAL:
s owner of One prrpcny,um exclusively convecting with licensed contractom to
construct the prnject(Sec.7044,Business?mit Professions Code:)The Comectods 1-i-
terese Law does not apply men Owner at profterty who builds or improves therein,and QTY. PLUMBING PERMIT FEE
who contmetx for such projects with ro ommusemr(s)licensed punuam home Contractors
License Law. PERMIT ISSUANCE
lam excmpltmdcr See. ,B&P C for thilecOeon
AC]17R-DRAIN.@ VENT-WATER(EA) VALUA'1'IUN
Owner Dote
WORKER'S )MPENSATIONDECLARATION BACK FLOW PROTEGE DEVICE
1 hereby ufOnn under penalty of perjuryone of the following declaradnne
I have and will maintain a Cenificamin Coleco(ou9f-insure(,Or Worker's Cn open- DRAINS-FLOOR,ROLE,AREA,COND. STORIES TYPE CONSTRUCTION
station,as provided for by Section 3700 of the Labor Code.for the pedrnnance of the
work for which this permit is issued. FIXTURES-PGR TRAP
Fl 1 have and will maintain Worker's Com lroation Insurance,as requited by Scetion
37M of the Labor Code,toy he performance of the work(or which this permit is issued. GAS-EA.SYS TEM-I INC.40V1'LhIS OCC GROUP APN
My Workers Compensation Insurance carrier and Policy number am:
Carlen Policy Nu.: GAS-OA-SYS'T'EM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKIiRS GREASFANDUSTRL WASTE I NTIIRCEPTOR
COMPENSA'I ION INSURANCE B1111.DINC DIVISION FEES
(1Bis section nadnot he completed if the permil is nambothmNreddollms D](0) GREASETRAP
or less) PLANCHECK FEE
y ed,I shall SHWER-SANITARY-S'IORM EA.IIx)FT'.
I certify per o the any man n r ofthe work foe which this ffic W m tat,' ENERGY PF.E
not employ any Mann in any manner so as m become subject m the Wnrkegt'Compen-
Z sada.laws of California.Date WATER HEATER WNENT/ELECTR GRADING FEE
z Applicant
NOTICE TO APPLICANT:If,after staking this Cendicme of F.xempnion,you should WATER SYS'fliM1l/fREATISO SOILS FEG
Fbecome suhjecuo the Workers Compensmion pmvisinreof the Lmerr Code,yam most
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY N EWRESIDEM'IALPLMR, SQ.FC JAIO
Z Ihereby radou"hanhem lsaconamctioa lendin,moncy l'Or thepertnnnunce Of Recelpt#
fU
0 me work for which this permit is issued(Sec.3197.Civ.C.) TOTAL:
Q U Clarice,Namc
Lcndcr's Address TOTAL.
Iia 1 cenify that I have read]his application and state that the above information Is g py wi yam yr g QTY. MECHANICAL PERMIT FEEto coaem.le rtetc curl neblemol deount Ninoncesand ata aroma refrain to L17a. buildmgconmmad,,,layherebyau]honzcront,i, arrivesofthis city toenmrupon thetrove-mentioned property fnr inspection keep hs. PERMIT ISSUANCE(We)agrees,save,indemnity end keep harmless the CityoI Cupertino against eDinconsiequenc oft he granting expenxsmit. may in any way ucemeagainsl sail Ciry ALTER OR AUU 10 MIiCPI. Easequence NDEgranting Sthisp WILAPPLICANT UNUfiRSTANOS AND WILh COMPLY WITH ALL NON-POINT' q1µHANDLING UNIT(IU IO(Xx)CFM) PEIiSOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,X10 CFM) WIAIfITtI
Signnmre of APNievnOCantmcwr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willdeapplicant orfumm building oecopamemreor handle hozadouvmamnW HEATING UNIT(TO 101,00 BTU)
as defined by thc Cupenino Municipal Call,Chapter 9.12,vad the Health and Safety HEATING UNIT(OVER IDIOM)B'fU)
Cade,Scctirm 25532(.)! _
❑Yes ON. V ENTILA'I'ION FAN ISI SOLE RI?SID) PAID Dam Rcvcipt#
Will the applicant or future building Occupant use equipment or devices which BOILER-COMP OHP OR IOO,000 BTU)
mit bv.vrdrus air,amouninan,as dot by the Bay Are.AU Qmdity Management TOTAL:
District? BOILER-COMP(OVER 1(10(10)BTU)
❑Yes ON.
I have read the haz:udons malinols requirements under Chapter 6.95 Of the Cali- AIR CONDITIONER �i ISSUANCE DATE:
fomiu llgafth&Safety Code,Sections 25505,25533 and 2594.1 understand that if the NEW RESIDI?NTIAL MECH. SQ.FT.
Wilding does not urrently have a tenant.this it is my responsibility to notify the omapunn ✓ ( ( fit
of the mquireroend which must W met prior to issuance of a Certificate of Occupancy. , )1 Q CAJS
OwnclMimhorited a gent Date TOTAL: .ISSUED BY: JOR On [l
OFFICE