31369 (2) AAPPPLIICCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C� ITY 4,CUPERTINO BUILDING.ELECTRICAL PERMIT NO. ^ � ^ k6 N9^/�
BUILDING DIVISION APPLICATIONIPERNUT PLUMBING-MECHANICAL "3 3
BUILDING PROJECT IDENTIFICATION
WW.OING ADDRESS: SANITARY NO. APPLICATION SUBMITfALDATF
as3 kr- qso o "1-9 Ci �
R'S NA15
/s �g� _C ONTRACTOR'SNAME: LIC NO: NIC CONTROLp
%R HITECT/ENGINE R: LICNO: V ADDRESS: 0 ❑
CONTACT PHONE: - BUILDING PERMIT INFO
❑ Consultant Fors Paid by Applicanl(Initial) IILpG ELECT PLUMB ' M
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby afficn Bad I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
DMZ with Section]000)ofDivisian3ofNe Business ens Professions Cale,and mylicemeis G RESIDENTIAL:
�IO in PERMIT ISSUANCE S ❑SFDWL ITCHEN REMODEL
full forte and effect
�UF License Class Con N' APPLIANCES-RESIDENTIAL []ADDITION LJ PLUMBWG RE-PIPE
<a Date TS Contractor— 2
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
PANELS
Z O r�Z 1 understand my plum shall be used as public rtcords � � MODIFICATION
OZ UPTO200AMPS El INTERIOR [I CHIMNEY REPAIR
C•-H,�t�i Licensed Profesimm 201-1000AMPS IMPROVEMENT
Sp"y� OWNER-BUILDER DECLARATION
�GYY7.2 OVER I�I(I(IAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
W I�6 1 hereby affirm Not 1 am exempt from the Cnnvacmr's License Law far the
06 V following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL / ❑OTHER
Oy which require a pcmdt m emixtown.alter,improve,demolish,m repair any svumure
prior to its issuance,also requires the applicant for such Permit o file a signed statementSPECIAL CIRCUIT/MISC.
} that he is licensed pursuant to the previsions of the Convector's License Law(Chapter 9
<� (commencing with Seint..7100)of Division 3 ofthe Busime.and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
d%e a this he is exempt themfmm and the basis for the alleged exeinption.Any violadannf ❑NEW BLDG/ADDITION ❑DEMOLITION
m Senior ID3 LS by any upplicani for a permit subjens the applicant ns a civil penally of POWER DEVICES
} ❑TENANT ❑FOOD SERVICE
nounme than five hundred dollars(3500),
0I,as owner of the property,or my employers with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
e will do the work,and Ne structure is not intended moffcred fnrsale(See.]0/4,Business TIP HER
Wand Professions Code:The Comments Lirense Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
�' .. property who builds or improves thcre.n,end who does such work himself or through
his awn employees,providM Nut such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ Cr.
sale.IL however,the building or improvement issold within one year ofcompletion,the S .FTs EA 3/SQ.FT.
ownenbt ilder will have the burden of proving that be did not build or improve far pur-
pnxenfsaln.). CT 281oo
❑ I,as awns of the property,am exclmively contracting with licemodcanv..I to TOTAL: 'I V V�
c.mvum the project(Sec 7W,Business and Professions Code:)The Comractor's Li-
cense Law does not apply to an owner of property who buildx or improves thereon,and QTY. PLUMBING PERMIT FEF. CITYuI-
whocontracts for each projects with a contractors)licensed pursuant to Ne Contractors V(Jf—HI JIVu
Li ansa Lnw. PERMIT ISSUANCE
d rSe PEA A, B P
Owner D eALTER-DRAW&VENT-WATER(EA) VALUATION
^I
WORKERS COMPENSATION O LARAT[ONBACK FLOW PROTECT.DEVICE v
I,]hereby affirm under penalty of pry erjuone of be fnilawing dedara imia V
r I have and will maintain a Certificate of Conwinto self-insure 6r Worker's Cmmper- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPECONSTRUCfION
.alio.,as provided for by Section 3700 of the Luber Code,for the perfnmurea crime
work for which this permit u issued. FIXTURES-PER TRAP
El I have and will maintain Worker's Compensation Insurance.as required by.Section '
37M or the Labor Code.for the perf...reof the work for which this permit is issued. GAS-EA,SYSTEM-1 INCA OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASPANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FLIS
(Thissectionneednorbecompleted ifthepermon
it isforehundreddo]lars(S100) GREASETRAP
orhow) PLANCHECK FEE
Ittnifythmintheperformance ofthcworkfawhichthispermit isissied,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner an as to became sabjeaua the Worker%Compen- ENERGY FEE
oz cation Laws of Califomia.Date WATER HEATER WNENT/ELECTR
O Applicant GRADING FEE
to NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
a ^ become subject m the Workees Compensation provisions of the Labor Code.you must SOILS FEE
LL7 forthwith comply with such previsions an this permit shall be deemed revoked. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMO. SQ.FT. PAID
U.Q l for which diuhoubere is a ed(Seetiu0i Cing agency for performance of Date c pt N
U. the work for which this permit is issued(Sec.JfN],Ci,CJ
Lenders Name TOTAL.
Lvi1 Lenders Address TOTAL:
1 certify this I have read this application and stem that the shove information is BUILDING '
FN correct l agree to comply withal]city and county ordinances and state laws rc]ating it, QTY, MECHANICAL PERMIT FEE
U �, building amswction,and hereby amhodae rcprcseWillnmtives of this city mentor upon the SEISMIC
above-mentioned progeny far inspection proposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
n consequence of Ne grunting nRhis permit PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.01()CFM) MECHANICAL FIE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,IX0 CFM) CONSTRUCTION AX
Signature of Applicanl/Contraclor Date EXHAUST HOOD(W/DUCID HOUSINGMITI NFEE
HAZARDOUS MATERIALS DISCLOSURE,
Will the applicant or future building recupum store or handle baaa.lnus material HEATING UNIT TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safcty,
Code,Satin.255320)? HEATING UNIT(OVER 100,000 BTU)
[I Yes [I No PAID
VENTILATION FAN(SINGER RISID)
I the applicant or future building occupant use equipment or devices which Date Raeip •,
_i 11, allom air contaminants as defined by the Bay,Ama Air Quality Management BOILER-COMP(DHP OR 100,000 BTU)
TOTAL:
y d)istdct?
I]Yes ❑Nn BOILER-COMP(OVER 100,000 BTU)
(have read the hamrdmu mweriala mluircmrnis under Cbepter fi.95 nftM Cali- AIRCONDITIONER ISSUANCE DATE
ramie Health&Safety Code.Sections 23505,25533 and 25534.1 tandco and that if be NEW RESIDENTIAL MECH. SQ.PT.
building does not currently havea tenant.that it is my responsibility m notify the occupant
of the requirements which must be met prior to issuance of a CeruRcate of Occupancy.
Owner or authorized agent" Date TOTAL: ISSUED BY:
OFFICE _
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