S 2010 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL VES
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BOILnING DIVISION APPLICATION/PERMIT PLUXIIIING MECIIANICAI- �J 2010
BUILDING I'ROJI!M'IDENTIFICATION
BUILDING ADDRESS: r SANITARY NO. APPLICATION SUBMITTAL DATE
a/s33 -��
•OWN R:S NpME; PHONE: COND/jT)iRjLj$A/�`IrR�'SS�'-1NA,_tE�_ �//�1 LICN 111 N/C CONTROL#
'A CHITELT/ENGINEER: LIC N OW , / `^�/�a 1 l W ❑
CONTACT PHONE: BUILDING PE fjM ff INTO
D �� ��� ❑ Consultant Fres Paid by Applicant(Initial) BLD ' ELECT PLO B MOIL
LICENSE[)CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I am licemesl under provisions of Chapter 9(commencing
01L'Z� with Section TNID)of Division 3"fine Business and Pndcusions Cale.audnry license is RESIDENTIAL:s100 PERMIT ISSUANCE
C W F in full force and e ElSFDW I, El KITCHEN REMODEL.
QUU L¢cnse Clasyi4 Lie..# APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING ftE-PIPE
FZW pate—�jf Conarron
IaQ0. ARCIIIII'L 'DECLARA'TION [I MULTI-UNIT ❑STRUCTURAL
X O'= 1 undmmnd my plans shall be coed as public records PANELS L� MODIFICATION
OZ`30 UP T02ro)AMPS L Z ❑INTERIOR ❑CHIMNEY REPAIR
F�_W Licensed Pronssinn.I 201-ItlX1AMP$ IMPROVEMENT SWIMMING POOLS
�Y£-4 OWNER-BUILDER DFCLARAI'ION OVER 109)0 AMPS 11 RATE REMODF EPAIR ❑DEMOLITION
C Cu]Q I hereby affirm that I am exempt from the Commcer'a License Law for the
ig50 0.0 following reason(Section 7031.5,Btidnes and Prnfessine,Code:Any city nr ovunty SIGNS ELECTRICAL (]OTHER _
which requires a permit to construct,alcor,improve,demolish,or repair anystructure O ,
I�"u'0 prionoits
y issuance.also rcquircs the epplicam l'or such permino 0lnasigncd nameme.( SPECIALCIRCUIT/MISC.
� (hal he is mm
theprovisionsoflheComcrdLi
scenseLaw(Chaper9
W2i00 (commencing with Section 7(X1))Of Division 301da Buxinessand Professions Gxl0or 'f imp.METER OR('OLE INST. COMMERCIAL
d y o y that he Is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4%1 LLww• Section 7031.5 by any applicant for apermit xubjats the appllcanno acivil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
zy not nunethm fivehundreddollan($500) IMPROVEMENT
C ❑l,m"wner of the pmpeny,onny employees with wages nn RM1eirsnle ahmpensation, SWIMMING POOL ELI' RIC
will do the work,and thesmmture in not intended m offered for sale(Sec.AH4.Business ❑OTHER
W`m and Pmfessint,CMe:The Contractors License"W does our apply to ea"wall"f OlfFLIUS-SWITCH - ' TURES
lk a^ property who builds or improve,the ran,and who does such work himself or Through
his own employees provided ma such improvements ore not intended or o0kred for NEW RESIDENTIAL ELECT S FT
site.lL howeve,the hnildingar improvement is wild within nneyear Ofcnmpletian,the SQ.FT.FLOOR AREA $/SQ.FT.
ow -builder will have the burden of proving that he did nm(wild or improve for pur-
Pase of wile.).
❑1,as owner of the property,am exclusively contracting with licensed conuvcom to
contract the project(Sec.7194,Ifusiness and Prdexsinn.s Conic)'Ihe Conracmr's Li-
censeLawdoesnotapplymanownerofpmpenywhobuilds"r improves thereon,and QTY PLUMBING PERMIT FEE
who contmns for such projects wish a fnmractons)licensed pursuanl to the Cnntlnemrs
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. .B&P C fit'his ive'do
• Owner Date ALTER-DRAIN&VENT-WATER(HAL VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
hereby affirm under penalty"(perjury one of the following de,-Uli"ns.
I have lmdwill maintain aCenifcmmfComeln toself-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES 'yYPIi CONSTRUCTION
cation,as provided for by lection 3700 of the habit,Code,for the performance of the
u rkfor which this permit is issued. Fl%TURFS-PER TRAP
have cad will maintain Worker's Ccmpenmti"n Insumncc,as required by Section
.700 Of the labor Cale,for the performanec oftho work for which this parntil is issued. GAS-EA.SYSTI?M-I INC.4 OUTLET OCC.GROUP APN
My Work r' CamlhcE�?I m scarier and pdw ambo p �� � G
Carrico /L3 Policy No(i0s/YXl!3 / GAS-ISA.SYSTEM-OVER 4 1 F)
CERTIFICATE OF EXEMPI[ON FROM WORKERS' GRFAS&INDUSTRL WASTE IN'FERCEPIUR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissectionneednnthecomplelrsl iffhepemhit isfornaehundurldollars($IW) GREASETRAP
nr les) .ANCHECK FEE
I cenify that in Rhe performerncenDhe work far which this permit is issued,(shall SEWI2R-SANITARY-STORM EA.200F'
not enhploy any pelsm in shy m:maer us us to became subject a the Workers'Compen- E - Y FEE
O z sato.Laws of Califomia.Date WATER HEATER WNENT/ELECTR
z Applicant GRAD( .E
I. FN-m
NOR ICE TO APPLICANT.If,after making this Cenificate of Exemption,you should WATER SYSTEMaREATING SOILS FEE
f~ became subject to the Workers Compensation provisions of the Lida.Cnde,you must
m'7y forthwith comply with such pervisionsoT this permit shall be deemed invoked WATER SERVICE w
Im ,LLT
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIi SQ.PC a xiptp
U 'z (hereby storm lhatthee it.immanactin.lcisingagency for the perfuntram.0
k for which his permit is issued(Sec.3097,Civ.CJ TOTAL:
O U Lender's Name 'TOTAL:
U Lender's Address
>s I rectify that I have read this application and sane(hat the above maturation is LNG FEE
it�.m V0.1 cancer.l agree to comply with all city and county ordinances and state laws relmingto QTY. MECHANICAL PERMIT FEE S ISMICFEH
LJ z building construction,and hereby authorize representatives of this city to enter upon the
above-me,inned popery for Inspectina purposes. PERMIT ISSUANCEEL[CTItIC FEE
o
(We)agree ns save,indemnify and keep hamilcss the Ci(y of Cupertino against f
Iiabililiesjudgmenls,coos and expenses which nay in any wayucclueagamloid City ALTER OR ADD TO MESH. PLUMBING FEE
in consequence of(he granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO III CFM) MECHANICAL FEE
SOURCE REG LAT s —17
// AIR HANDLING UNIT(OVER 10d000CFM) CONSTRUCTION TAX
Signature of ApplFo C"nracoo �— EXHAUS'T HOOD(W/DUCT) HOUSINGMITIOATION FEE
HAZARDOUS MA'ITR1ALS DISCLOSURE
Will theapplicam or future building occupant sore nr handle h:rard"us material HEATING UNIT TO 1100,000 BTU)
as defined by the Cupertino Municipal Cede.Clu pinr 9.12,and the Hcahh and Safely
Cale,Section 25532[x)'1 HEATING UNIT'(OVER 100,(011 BTU)
❑Yes ❑Nn VENTILATION FAN(SINGLE RESID) PAID Dam Recciplp
Will the applies,or future building occapem use equipment or devices which BOILER-COMP IMF OR 100.00f)BTU)
emhave
it rdca s air commandants as defined by the Bay Area Air Quality Management TOTA .
District i BOILER-COMP(OVER 1011,00 BTU)
E3 Yes Fl No
I have read Rhe bmaNnus materials requitemen¢under Chapter 6.95 of the Call- AIR CONDITIONER ISSUANCE.DATE
fomia I Icahh&Snfmy Code,Sections 25505,25533 and 25534.I understand that H the NEW RESIDENTIAL MECH. SQ.
buildingdues not urrently have a reason.that it is my responsibility to notify the occupant I D
of the Nqui¢ments which must he"het prior to issuance of a Cenificute of 0crupancy.
Owner or au(horiuJ agentDate TOTAL: ISSUED BY: v v
OFFICE