S 0074 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING-F.LECTRIL'AI. - PERMITN
O.
tlU1LDINCDIVISION APPLICATIONMERMIT PLDMBInc'-MF.exANICAL
BUILDING PR(IJECT IDENTIFICATION
Ii J1 ZG AfIORIiSS: SANITARY NO. APPLICATION SUBMITTAL DATE
10`3. G oN G3q
OWNER'S NAME: QPHONE: CONTRA OR'. NAME: IC NO:
NIC CON TRUL p
ARC ITECT/C•NGINEEft: LICN ADDRESS: l 1 ❑
CONTACT: PHONE: 1 IL-ia' 6UILDING'PERMIT INFO
Cl Consultant Fees Paid by Applicant(Initial) - RI. ELI: PLU MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 herchy ahem that I am licensed under provisions of Chapter 9(commencing
AaZ with Section 7")ofDivision 3 ofthe Business and Professions Code,and my license is RES ID
W 00 w PERMIT ISSUANCE
m full inward c c ❑SFDWL (]KITCHEN REMODEL
QVV
License Class - Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
F.Z yl Date Con rvvtnr
i/lQd ❑MULTI-UNIT ❑STRULTURAL
g,7rn AR'HITECTS DECLARATION PANELS
a+Z Iunde land yplanss 11 his used as public records MODIFICATION
C)Z�a UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Pmfe%sumal 201-I01CAMP$ J�IPROVEMIiNT SWIMMING POOLS
Q 2-J OWNER-BUILDER DECLARATION OVER 10010 AMPS �-(`TH REMODELfREPA1R [IDFMOLITION
a
1 hereby affirm that I am exempt from the Cmnrac,.r'%License Law for the
'ad0 a, following reason.(Section 7031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
1+13 C h¢ which requires a Permit to construct.alter,improve,demolish,or repair any structure
�mJ prior,.its issuance,els.requires, tit,dicmt(mouth permit,.film oigncd,niument SPECIAL CIRCUIT/MISC.
Hg;0000CCCC W�!�y that he is licensed pursuit w the pmvismacs'the C.nvucmrs License Law(Chapter 9 OMMFR IA x
(eommencmng with Seainn 7lKKB.f Division3 of,he Business end l'nNessionsCMe)nr TEMP.METER OR POLE INST.
that he is exenmt therefrom and the basis for the alleged exemption Any vicliamn of ❑NEW BLDG/ADDITION ❑DEMOLITION
4N. Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of POWER DEV ICES ❑TENANT ❑Tom SERVICE
a more than five hundred dollars(5500). IMPROVEMENT
F'=o 01,as ownerofthe property,or my employees with wages as theirsole mmpcnssion, SWIMMING POOL ELECTRIC
pQ�F. will do the work,and@eswcareo,am intended m.ffcred for sale(SeeIDN,Rosiness ❑OTHER
LL] m and Professions Cafe:The Contractors License Law docs not apply,o m owner of OVI'LMS-SWITCHES-11KTl1RES
,,.Peery who builds or improves thereon,and who does such work hint or through
hi%own employees,provided that such irmrewound%we not intended nr offered for .NEW RESIDENTIAL.ELECTR SQ P.. � gk q1
sale.If,however,the building or improvement is sold within.nm
eyevfc.mplefind.dle SQ.FF.
FLr RNRI D VSQ;FT.
owner-b milder will have the burden of proving that he did not build or improve for pun- r M
pose of sale.). TOTAL: Q
1,as owner of the property,am exclusively contracting with licensed contractors to 1, _ u
comtoo,,he pr.jcct(Sec.7044,Business and Professions Code:)no Colossuses LI- /' JUN°
RECI
cense law does not apply in an owner of property,who lumicis or improves thereon,and QTY. P/.UMB OPE IT FEE
who c.ntrans for such projects with a contractors)licensed puramat1.'he Contractors `-6' AfTV rYt �uuL�tl A'
License law. LPERMITANCE _
I am nemil under Soc. ,B&P C for this nea%on
IN&VENT-WATER(EA) VALUATION
Owner Date
WORKERS COMPENSATION DECLARATION PROTECT.DEVICE1 hereby allirtn under penalty of erjury one of the following doelwa,ions: (I��❑Thous and wilhneimeinaCenif¢ant of Consent to self-insure for Wakcrs Compel- 00R,BOOR AREA.GOND. STORIES TYPE CONSTRUCTIOI
sound,as provided for by Section 37M of the Labor Cotte,for the performance of the
work for which this Permit is issued. PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as requited by Section37Mor the labor CMc,for the performance of the work for which this permit is issuod. STEM-I INC.40lOTTIS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Coact: Policy Na: GAS-EA.SYSTEMOVER 4 MA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION IRES
(Thi%sectionneNnm becompleted ifibe permit is havoc handled dollars($100) GREASETRAP
or less) PLANCHI?CK FEE
I certify that in theperf. tOn, ofthework orwhich this Perna is issued,l shall SEWER-SANITARY-STORM EA.2M FT.
no,employ uny pe us i m one v s to co a gdlrj ct to the Workers'Cnmpen- ENERGY FEE
0 ,z cation Laws of Ca'to IT c WATER HEATER WNENTIELGCTR GRADING
z 0 APPlicdm r
On NOTICE, 'OAP T. .'Ir C555555rtificme of OR caption,you should WATER SYSTEMITREATING SOILS FEE
F hc.mc suhject t the- nor G not on vi ions ,he labor Code,you must
f� forthwith comply with such provi.ions or this permit hall bre deemed revoked. WATER SERVICE
WQ
n' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID Receipts
L) 0 Iherebyielirm that there isaronstmcti.n lendmg agency Pathe pertorman¢.f
the walk for which this Permit i%issued(Sec.3092 Cie C.) TOTAL:
U Lenders Name
} W Leadees Acidness TOTAL.
f.y I certify that 1 hove real this application eM sate that the shove information ie BUILDING Fie
loot earl concct.I apee,ocomply withall city and county ordinances and state law%nlming,. QTY, MECHANICAL PERMIT FEE SEISMIC FE
V ,z building conduction.and hereby amhorive rcpresenmuves of this city to enter upon me
ra abovcmentioned property for inspection purposes. M01M,0W
ANCE ELECTRIC HE
(We)agree m save,indemnify and keep harmless,he City of Cupertino against
liabilities,judgments.costs and expenses which may in my way accuse against said CityDD TO MECH. PLUMBI ,FEE
in consequence of the granting of thi%Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTNG UNIT 10.000 CFM) MECHA [CAL FEE
SOURCE REGULATIONS,
NG UNIT IB,OOB CPM) CONST UCI'IONTA
Signature of Applicam/Contnt,.r DowOOD(W/DUCO HOUSI GMITIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will intipplicam.r fu a.building oe,madd,,.re or handle huaurdous materialIT 0101M,0W BTU)as defined by the Cupertino Muicipal CMc.Chapter 9.12,and the HeMN unci Safe,yHEATING UNIT(OVER 100,000 BTU)
Cale,Section 25532001 _
II
El Yes ON. VENTILATION FAN(SINGLE RFSID) PAID to Recciptp
Will the applicant or future building oecupant use equipment or dmices which BOILER-COMP(3f IP OR IIX1,0W BTU) qs�j
emi,jaccom.us ser contaminants as defined by the Boy Area Air Quality Monugcmenl TOTAL:
Mimi? BOILER-COMP(OVER 100.800 BTU)
❑Yes ONO
I heave mad the hsanrd.us nmtedalsmem%under Chapter u,95 oftha Cull- AIR CONDITIONER ISSUANCE DATE
ryuin 40
bidding
Health&Safety Code,Sonans 25505,is my and nchil I to may a thin if,he NEW RESIDENTIAL MECH. SQ.FT.
of theng does ono currently hose a,are,that o is my ce mit Corti tomayOv i Ball
of the requirement%which most Mme,prior to issuance ofa CenilicmmfOccupancy. .�•'�• (�
Ownernr umhoriaed agent Date TOTAL ISSUED BY:
OFFICE