S 0935 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO � BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PI,UMHINC-MECHANICAL. S" 0935
BUILDING PROJECT IDENTIFICATION
BUILDINGADDR/ESSSS: f� n SANITARY NO. APPLICATION SUBMITTAL DATE
OW P 'S NAME. PHONE COM'RAC 11R'S NAME'. CND:
Y fy RIC CO TROLM
ARCHITECf/ENGI LFR: - LIC NO: ADDRESSmet t.414#4 �.� ' 4SJ ❑
CONTACT: PHONE: I DING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BL ELECT Z PLUMB MEC
LICENSED me,
CONTRACTOR
once,SDECGRf Chi QTY ELECTRIC.PERMIT FEE
I hereby affirm mr I am licensed underuit Precisof Chapter 9(mmmencing JOB DESCRIPTION
❑0c) wan Sedion7lxxp of DlvlsinnJ Orme Businesseue Professions Code,and mY rcensels
X 0 0 PERMIT ISSUANCE RESIDENTIAL:
F in Poll force and effect. _ ,.,
�UV License Class Lich ❑SFDWL PJJ(TI'CHIiN REMODEL
inZW Dme Connector APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS UMULII UNIT ❑STRUCTURAL
a
F �s
ZO Iunderdnod my plans shall be used as public records MODIFICATION
OZ Q - UPT02MAMPS El INTERIOR UCHIMNEVREPAIR
f
Licensed Proessional 201-10(d AMPS IMPROVEMENT
a `-d ❑SWIMMING POOLS
C' C2G.G.1 that I a -BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEUREPAIR El DEMOLITION
1 hereby.Rion o that 1 1. exempt from the Comite,Co License Law for the
{TLS O L V following reason(Sermon IDndr Business and Professions Code Any city ns amnty SIGNS ELECTRICAL U OTHER
wash requires a permit re cores the alter,improve,demolish,or repair any suucture
w that he slicenedpursu requires lhavisiocanlfar e Coo ermiunicensle e awhChaptem SPECIAL CIRCUITIMISC.
y the!he is licensed porsuammthe provisions of the Contmetor's License Law(CM1apter9
m n0 (armmenciug wlm Serio,7IXNI)af Division3of the Business and Professions Code)of TEMP.METER OR POLE INST.
S c,Y that he is exempt Therefrom and the basis for the alleged exemption Any violation of NEW B G/ADDITION U DEMOLITION
Mo, Section"l031.5 by any applicant for a pernia mhjers dw.pplierm to a civil penalty of POWER DEVICES T � ❑FOOD SERVICE
t more than Five hundred dollars($500). I V MUST
❑ 1,as owner of the grocery,or my employees with wages as their sole compensation; SWIMMING POOL ELECT RIC asti
sea do the work,and the snumpre in pat lmehded omrtered for sale(Seo.]044.Business �)THER
S3 m and Pmfessinns Cade:The Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
propony who build,or improves mereon,and who does such work himself or through —o
his own employees,provided That.such improvements are not intended or offered for NEW RESIDENTIAL FLECTR SQ UP
sale.If,howeveq The building or improvement is sold within one year of completion,the SQ.PT.FLUOR AREA $/SQ.IT.
ser-builder will have the burden of proving that he did not build or improve for pur-
poseofsale.). - -
U h as owner of The property,am exclusively contracting with licensed contractors to TOT
construct The prof a(Sec.7044,Business and Professions Ccd J The Conuacmr's Li-
cense Law does not apply To as owner of property who builds or improves facona,and QTY. PLUMBING PERMIT FEE
whocontracts forsuch Projects with acunhacmr(s)licensed punuard mtti Contmctor'.s I1
License Taw. PERMIT ISSUANCE Q M
❑ 1 am exempt under Sec. ,B&P C for this reason
Owner Dote ALTER-DRAIN&VENT-WATER(EA) e'VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I] 4 CID
1 hereby affirm under penalty of perjury one of the following declarations:
• ❑ (have and will maintain aCenilicam of Cnnsenunsdf-inure for Workers Camper- DRAINS-FLOOR.ROOF AREA.COND.
cation,as provided for by Section 37W of the Labor Code,for The performance of the fiQR V Uf C TYPE CONSTRUCTION
1 s sT sw,
work for which This permit is issued. FIXTURES-PER TRAP
U 1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance currier and Policy number are:
Cartier: Policy No.: GAS-FA.SYSTEM-OVER 4(EA) _
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF:ASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE _r\ BUILDING DIVISION FEES
(Thissoctlonneed not becompleted ifthe permit is borne hundred dollars(sildin GREASETRAP
or less) I PG CH E
I cenify That in the pe Hr ce or the work for h this Fermis i.s Tssucd l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any persPh' neon ^c Silpt�'yTvl�Wnrker,<Compen- ENERGY FEE
z moon Laws dC e
eN
z O APPh..I WATER HEATER W/VENT/ELECfR GRADI Rl NItlV I
Iti ti NOITCE A LIGAN nfler makipgY Cenifcale of Exemption,you should WATER SYSTEMITREATING INSTP`,EC s0 IND
h become so ject to the Worker's Compensation provision,of the Labor Code,you must IN
1 1 Q
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE CITY
Q
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V O Thereby aBirm mat there is acnnvwaion lending agency for the perfonnanoeof Date sips
4, the work for which this permit is issued(See 3097,Civ.CJ
Q Lender's Name TOTAL:
Leader's Address TOTAL:
1 certify that I have read This application and state That the naive information is BUILDING FEE
rr (A forted.l agree womanly with all city and countyundiame.,and slide law,relming To QTY. MECHANICAL PERMIT FEE
Ubuilding construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned properly for inspection Purposes. I - PERMIT ISSUANCE.
- (We)agree weave,indemnify and keep harmless the City of Cupertino against ELECTRIC PCL r
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in onsequence of the granting of this permit. PLUMBING HE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICALFEE
AIR HANDLING UNIT(OVER 1kIX0 CFM) CONSTRUCTION TAX
Signature nApplieunVComractor Date EXHAUST HOOD(WIDUC) HOUSING MITIGATION FEIii
HAZARDOUS MATERIALS DISCLOSURE
Will the applirmt or future building occupant store or handle hazardous material HEATING UNIT(TO 100900 BTU) -
as defined by the Cupertino Manic}}}000uI Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(,)? HEATING UNIT(OVER IS1000 BTO) -
El Yes Na - PAID
VENTILATION PAN(SINGER RESID) Date Receipt#
Will The applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP UR 100.000 BTUI
DidneO TAE:
C]Yes O BOILER-COME(OVER 100,000 BTU)
Ihave readthe hazardous materials mi diremends under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCELDATE
fomlu Health&Safety Code,Section,25585,25533 and 25534.1 understand that If the NEW RESIDENTIAL MECH. SQ.Ff.
buildingdoe of cu unT,tont it is myresponsibilit t notify h occupant' _
of the req net r ono Issuance of o Cen to rd pa
O er oro onaed - s I Date TOTAL ISSUED BY: /' • O
OFFICE