B 0445 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO =1DFAT1,1,1N
ELECTRICAL 1 PERMIT NO�0 4 4 5
BUILDING DIVISION APPLICATIONIPERMIT ICII SOOO1
BUIICATION
BUILDING ADDRESS: nn"_ SANITARY NO. APPLICAq'ION SUHMITI'Al.DATI
Q/OS e! TOA SS L
OWN�R'NAME: J:jI CONTRACTOR'S NLWNNO',
ONIC CONTROL p
7Smfion7�3
CfIENGINEER: LIC NO: A NES ` ❑
: PHONE: s BUILDING PERMIT INFO
❑'Consultant Fees Paid by Applicant(Initial) BLDG ELECT PgtM1)It MUCH
❑ ❑ CWy! ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
ereby alfiam Nat 1 am licev(enmtnetaing JOB DESCRIPTION
un]fNgJ of Division 3ofNe Business and Profesions Co c.and mylicense isPERMIT ISSUANCE.mtmd eR«t SFDWL ❑KITCHEN REMODEL
Is Lic.p pPPL1ANCIS-RCSIDENTIAL ❑ADDITION ❑PLUMBING RF.-PIPITCast 'to
�7y ARCHITECTS DECLARATION ❑MULTI-UNIT El STRUCTURAL
PANELS MODIFICATION
Z 0 Z T undersand my plans shall be used as public records
_ UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F.Vl {wsl Licensed Professional 201-11000AMPS IMPROVEMENT SWIMMING POOLS
A;2� OWNER-BUILDER DECLARATION OVER 1000 AMPS El BATH REMOWUREPAIR D�EI10LIT�OQN
C C a 1 hereby affirm that I am exempt from the Cmiestame,License Law for the Kjf.TAP/C A�/s
a,�d Cel,6 V following reason.(Section]031.5.Business and Professions Code:Any city or emody SIGNS CLFCfRICAI. 9UTHF.R
"O y which requires a permit in construct,alter improve,demolish,or repair any structure .4k4Z6 r
dH1 prior in its issuance,also acquires the applicant for such permit a file a signed mes
namn SPECIAL CIRCUIT/MISC.
6� that he is licensed pursuant o the provisions ofshe Contractors Limove Law(Chupar9
OC (commencing with Section]IMY.I'Dilkiom 3ofdre Bmxiness and Profession.Curator TEMP PO
M13TR OR LE INST. COMMERCIAL:
ca that he is exempt Nerefmm and the basis for the alleged exemption.Any violation of [I NEW BLDGIADDITION [I DEMOLITION
Section 7031.5 by any applicant bar a Permit subjects the-optician to a civil penalty of POWER DEV ICES ❑TENANT ❑FOOD SERVICE
rn nm more Nun five hundred dollars($500).
FQp Q , IMPROVEMENT
❑ SWIMMING POOL ELECTRIC
[]OTHER
i III Jo lhewons and the structure is Cols tended License Law
not apply to an cosi
if
ij � and Profession Code:The Contractors License Law does not apply m on owner of OUTLETS-SWITCHES-PIXTURf:S
L3.. property who builds or improves thereon,and who does such work himself or through NEW NESIDEN'fIAL ELECfR SQ FT.
his own employees,provided!Oaat such impmvemems me not intended or offered for SQ.Fr.FLOOR AREA EISQ.FT.
side.if.however the building or improvement is sold within one year nTmmplednn,the
owner-builder will have the burden of proving that he did not build or improve for For-
pos¢nf cafe). TOTAL:
1,as owner of the pmpetsy,am exclusively commeting with licensed maimumes m
construct the pnsjeut(S«.7044,Business mail Professions Code:)The Cnntmemr's Li-
mnse law does not applyu,an owner of property who hokix or improves thereon and QTY PLUMBING PERMIT FEE
who contracts for such projects with a contractor(s)licensed Pursued to the Contractor's
License law. PERMIT ISSUANCC S. 5o
I am exempt under S«. ,B&PCfm this remun
ALTER-DRAIN&VENT-WA)P.R(EA) VALUATION
Owner Dam l
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DI?VICE $b U
1 hereby affirm under Penalty of Perjury one of the following declarations:
I have and will maintain a Cerificxm of Consent to sdFimure for Workers Compcn- DRAINS-FLOOR,ROOK AREA,COND. SMR1IS TYPE CONSTRUCI'10
guru.,m provided Why Section 3700 of Ne W1mr CMe,far rhe performance of the
work for which this perm it is issued. FIXTURES-PER TRAP
have and will maintain Workers Compensation Insurance,as required by Section
is)of me
Labor CCeocke,for he performance of the work for
which
}t9his p�e.itit7ispisaaul. GAS-EA.SYSTEM-1 INC.SOUTLM, OCG.GROUP APN
My Wr(k Ij ryrCllR�noG yNaoY/lS.L OAS-CA.SYSTEM-OVI?RA(BA)
Caron( T ,�/
CERTIFICATE OF EXEMPTION FROM WORKERS' GRPASIIINDUSTRi.WASTEIMTRCFPT(sR
COMPENSATION INSURANCE BUILDING DIVISION TEL'S
(This section pend out be completed if the permit is for one hundred dollars($100) GREASE TRAP
does) PLANE i' FTC
I certify that in the performance of the work for which this pemsit is issued,i shall SEWER-SANITARY-STORM EA.No Ef.
nor employ any person in any manner so as to become subject m the Workers'Carmen- F.NER
Z ouirm Laws of CaliRtmia.Data WATER BEATER WIVEN'f/171.12 R �eD GRAD iF.
z0 Applicant 1
h
NOTICE TO APPLICANT:If,e0er making this Cmifleate of Exemption,You should WATER SYSIEM/1'RF.ATING SOILS F.
become subject to the Workers Compensation provisions of the Labor Cade.you must
res forthwlda comply with such provisions or this pefmir shall be deemed revpked. WATER SERVICE (✓
CONSTRUCTION LENDING AGENCY NEW RCSIDENTIAL PE-MR.MR. SQ.FT' Rceeipa p
U 0 Ifor which
permit
isacnmtruc.ionlending agency for the performance of
� (~ the work for which this permit is issue)(Sec.3097,Civ.C.) TOTAL:
0 U Lenders Name TOTAL: r 5o
r U Lender's Addass BUILDING FGF
1 certify Nm I have read this application and state that the above iofommion is
sF.V�1 cnrect.I agramcomPly with all city and county ordinances and state laws relining to QTY. MECHANICAL PFRMIT FF3E SEISMIC ECF.
U z building construction,and hereby audience representatives of this city to enter upon the
above-mentioned pmperty for inspection purports. PERMIT ISSUANCE ELFCI'RIC
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmena.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MSCI I. PLUMBIN E.
in csmaegter.of she panting of this perms.
APPLICANT UNDERSTANDS AND WILL COMPLY W I'TH AL1.NON-POINT' AIR HANDLING UNIT(TO Ig000 CFM) MECH CA 'E
SOU ' TIONS.
C AIR HANDLING UNIT(OVER 10,000CFM) CONSTRU NTA%
tug store of Appld'ma Comractm Date EXHAUSTHOOD(WIOUCT) HOUSING 1'11GATIONFCE
HAZARDOUS MATERIALS DISCLOSURE
Wall the applicant or future building mcupam store or handle hazardous material HEATING UNIT 00 NM,g10 BTU)
as deRned by the Cupertino Municipal Code @anter 9.12,and the Health not Safety HEATING UNIT(OVER IIX1,OW PTU)
Code.Section 25532(a)'!
❑Yes ❑No VENTILATION FAN(SINGLE BESIDE PAID Dam Receipt Jr
Will the applicant or fumm building uscupant use equipmentor devices which BOILER-COMP QHP OR 100.00c)BTU)
emit haaNnus air contaminamx ns defnN by the Bay Arca Air Quality Managemem TOTAL:
District? BOILER-COMP(OVER HM,00D BESQ.
❑Yes ❑No
AIR CONDITIONER IISUA CE DATE
I have ,S the hazmdnus ma¢r155 requirements under Chapter 6.95 of at Cali-
' 1'omu Health A,Safety Calc,See uo�k�25505.25533 aaW 25534.1 undetxmM No if Nc NIiW RESIDENTIAL MECH. E /yL
building does nor currently at t, eT1 my responsibility wnofify Ne«concent
of the requirements which a�a tet -nnoi smnce oft Certificate of Occupancy.
Owner¢r aadismized spam pace L: ISSUED EY:
OFFICE