S 1327 (2) i
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
1J GITY OF CUPERTINO BUILDING-ELECTRICAL PEIy11T"° 1327
BUILDING DIVISION APPLICATION/PERMIT PLUMBNG.MECHANICAL.
BUILDING PROJECT IDEN'TIF'ICATION
BUILDING ADDH \ - ` ` � SANBI'ARY NO. APPI,ICATION SUBMITTAL])ATI
OW 'NA ? H•aWN�I°\jaw^�■I NTRAC ORIS NAME: LIC NO: �
`00 N O,7 N/C CONGROL#
CH TECT'NGINEER: LIC NO, 3 FSS: - ❑
OV 14f
CONTACT; , PIIUy`�J(I / BUILDING PERMIT INFO
2S /•^ &33 ❑ Con mI not Fees Poid by Applicant(Initial) BLDG ELECT PLUMB STiCH
❑ ❑ VAC ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm That I am liceaod under provisions of Chapter 9(commencing JOB DESCRIPTION
"Zth SectionlOWaf Doisinn3ofthe ltosinessand I-odesduns Code.amdnry licensers RESIDENTIAL:
100 wit PERMIT ISSUANCE
W• in full force and eRe1y. ❑SFDWL [I KITCHEN KITCHEN REMODEL
FZU License Class
`�3� CLicontactor APPLIANCES-RESIDENTIAL ❑ADDITION �YLUMBING RE-PIPE
m [I MULTI-UNIT ((( ❑___STRUCTURAL
�tI N HI'1'F.C'I'S])EChAHAIION PANELS
F- MODIFICATION
Z O Z I understand my plain shall be used as public records
OZ—� UI'T02(NIAMPS El INTERIOR ❑CHIMNEY REPAIR
F-4f''WLicensed Pmtasional 4111-1000AMPS IMPROVEMENT SWIMMING POOLS
..I OWNER-HUILDER DECLARATION OVER 1000 AMPS
BATH REMODEUREPAIR C1 DEMOLITION
Lp. WEl
6 I hereby affirm that I um exempt from the Crot.lue,License Law for ,
X36, following rancor.(Section T03 15,Business and Professions Codc:Any city or county SIGNS ELECTRICAL - 130THER
llilil u. which requires a permit an construct,alar,impmsc,demolish,or repair any structure
prior o its issuance.also requires the applicant for such pennitto life a signed smantent SPECIAL CIRCUITIMISC.
pN.. that he is licensed parsu:muo the provision.softhe Contractor's License law fChapar9
(commencing with Sermon 7000)of Division 3 ofthe Business and Professions Code)or 'TEMP.ME'T'ER OR IMI 1NST COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption Any violation of ❑NIiW BLDG/ADDITION [I DEMOLITION
^� Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOODSURVICE
^ Qnot more than five Imndmd dollars(5500). IMI'ftOVEMENT
Losowncrufthe n SWIMMING FOOL ELECTRIC
0 prose ctur is of intended with wages astheirsme c01Business ❑OTHER
wdl dothework,and themmcareisnuti License
aaw it .,not a(SaJPW,Business
am and Professions Code Theoves taenia Licenselawdoesnotapply self rowner throuof OU'fl.l!TS-SWITf.HES-FIXTUR'S
property who builds or improves thsuch i and who docs such,intk himselftu through
his own empinyres,provided thin such improvements are not intended or of(ereJ for NEW RESIDENTIAL 131.EC:rR FE
sale.If,however,the building or impnwemeat is sold within one year ofcomplction,the �SQ.FT.FLOOR ARG SItiQ.FT.
p:wer-builder will have the burden of pnwing that he did not build or improve far pun PAID I D
ofsnle.). 1 P M
1,.owner of the property,um exclusively convecting with licensed cimpactors'. TOTAL: ✓Q
construct the project(See.7044,Business and Professions Code:)The Cmdracmis Li- v _
cense Law does not apply to an owner o(pmpcmy who builds or imreand
proves theon. . QTY. PLUMBING PERMIT FEE R 5An
who contracts for such pmjays with u conameau(s)licensed pursuant m the Con scar's
License latw. PERMIT ISSUANCE CITY Ur (aU
I mm exempt under Stt. .B&1'C fur this reason V
ALTER-DRAIN&VENT-WATER(EA) VALUATION
r Data
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby allium under penalty onflvvjury enc of the following dmlunnioms.
- Ihave and will amintin a Cenificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOK AREA,COND. STORIES TYPEC(INSTRUCT10h
Wain.as provided for by Section 37M of the labor Code,for the pemirmance of the
work far whaft this permit is Issued. FIXTURES-PER TRAP
❑1 have and will mainmin Worker's Compensation Insurance,as required by Section
3]OUofthe laborCale.for thepMlrtmarecofthewalk Pnwhich this permit is issued GAS-EA.SYSTEM-I INC.4 OUT OCC.GROUP APN
Worker's rylen 9n bin, ace comm an l Policy nu n
Caprice -r eat ! o cc Policy No.: �����t�7�'� GAS-EA.SYSTEMOVER 4(E
CERTIFICATE OP EXEMPTION FROM WORKERS' GRCASIIINDUS'1'RL WASTE I 'ER
COMPENSATION INSURANCE. BUILDING DIVISION FEES
lTRissection need ala lie completed if the Baon
Permit is re hundred dollars ISISo GREASETRAP
or less.) PGNCHECK IEE
califythatintheperformnnce of the work for whichthispemsia isissued,Ishall SEWER-SANITARY-STORM G.200FT.
` not employ any person in any manner so as become suhject to the Warkers'Compen- ENERGY FEE
saran tawsof California.Data WATER HEATER WNENTR?LECI'R
Z� Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Canifieme of Exemption,you should WATER SYS'I EMOREAI'ING
L✓ become subject m the Workers Compensation provisions of the LnMn Cade,you most
SOILS FEE
forthwith comply with such provisions or this permit shall he devoted revoked. WATER SERVICE
Q
CONSI RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
L1 C) I herehyaRrm that them is o construction lending agency for the perourmentaid
;Dam
t
Ne work for which his permit is issued(Sec.3099,Civ.C.)
UTAI:
0 U Lenders Name
} Lenders Address L'
I ramify that 1 have real this application and stat that the above infonnuomt is BUILDING F
contact.I agree w comply with aB city sad county imbalances and ,are laws relating m QTY. MECHANICAL PERMIT FEE
V building construction,and hereby balance mpresentativesofthis city teenerapon the SEISMIC FEE
above-mentioned property far inspection Imposes. PERMITISSUANCE
(Wc)agme m save,indemnify and keep harmfecs the City mf Cupertino against IiLECTRIC PL
Imbiliaies,judgments,contained expenses which may in any wtyacerueagaim,said City ALTER OR ADD TO MUCH,
PLUMBING FE
in consequence of the gaming of This permit.
A PPLICANT(IN DE RS"BANDS AND WILL COMPLY W ITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00 CI'M)
M[CHANICA 1'eE
S ORCF RF.GDLA'TIONS.
(�� AIR HANDLING UNIT(OVER 10.fM%1 CFM) CONSTRUCT NTA%
Signature of Applicvm/Cammcar Data EXHAUST I IOOD(W/DUCT) HOUSING TIGATION PER
HAZARDOUS MATER1Al- CLOSURE
Widtheapplicantor fumre building occupantsave or hondle hamNonus material HEATING UNITTO I00,000 BI T)
as defined by the Cupertino Municipal Cale.Chapter 9.12.and the Health and Safety
Coca.Section 25532w)I HEATING UNIT(OVER 101.08(1 BTU)
❑Yes C]No VENTILATION FAN(SINGLE RESID) PAID
Da Receipt M
Will the applicant at Ponve himli ing occupant uta cquipmem ar devices which BOILER-COMP THE OR Ifp.010 BlL]
nit hazardous air contaminants as defined by the Bay Arca Air Qualify Management TOTAL:
svicf! BOILER-COMP(OVER 100,0%1 IT❑Yes El No
I have mad the hazardous materials as,dramcros antler Chupaffi95 oftla Cali- AIRCONDITIONER ISSUANCE�P�t
fomiu II.Im&Safety Crate,Sections 25505.25533 a 12.1534,1 understand thin if the NEW RESIDENTIAL MEC I. SQ.FL /✓/
building does no currently have a tenant,that it is my responsibility to notify the ceeupant
of Ne requirements which must be met prior to issuance of a Cemilic,aa all Occupatmy.
Owner or authorized agent Date TOTAL.:. ISSUED BY'.
OFFICE