31214 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO21
. 31214
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J 1 L LF
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
/1
OWNER AME PHONE: CONTRACTORS NAME: LIC NO: CJ
_ O/ ? i/ �u ` O NIC CONTROL p
RCHITF.CT/ENGINF.ER: LIC NO: J ADDRESS: "'/ J ❑
Eem ~6L 4ro' CT se
CONTACT: ' - PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ULW ELECT PLO B ME
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT PER I hemby affirm that I sm licensed under provisions or Chapter 9(commencing JOB DESCRIPTION
oZ wit Sain,70IX0)of Divinon 3 ofthe Business and Professions Cod,and my liccnsc is RESIDENTIAL
O .n ' PERMIT ISSUANCE
t full force and eBea.� k.5'B5,F14 -7 ❑SFOWL ❑KITCHEN REMODEL
UW License Clas Lic.M
N<Il Dam �� Cnnw••�• - - r.J APPI-LANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ZC un my,ARCHITECPS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
1 u nand lans shall consoles public normals -MODIFICATION
OZ-� noUP'10200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
[.. LiccnsW Professional 201-IqW AMPS PROVEMENT
�4` OWNER-BUILDER DECLARATION
k�d ��', 1 hereby affirm that 1 am exempt from the Contractors License Law for the OVER91xx1AMPgss` TH REMODEI/RF.PAIR DEMOLITION
W O y U following reason.(Section 703 L5,Business and Professions Cade:Any city or coumy gIGNg IiLECfRICAL ❑OTHER
3 0Fa which requires a permit to contact,after,improve,demolish,or repair any acture
�S,�vy.i prior m its issuance,lso requires theupplietat fur such Permit nm Oleasigned statement SPECIAL CIRCUITYMISC.
Seca�W{1,r that he is licensed pursuanrto the provisions ofthe Cuntmctors license Law(Chapter 9
y�CpO (commencing with Section 700H Of Division 3 ofthe Business and Professions Cashier TEMP.METER OR POLE INST. COMMERCIAL:
LLLLLqx o�' that he is exempt themfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W^H Section 7031.5 by any applicant lot apermit subjects the applicant in a civil penalty of POWER DEVICES TENANT ❑FOODSERVICE
I- not mom than five hundred dollars(g50H. IMPROVEMENT
2�� ❑ 1,as owner ofthe property,.r my employees with wages as their sale compensation, SWIMMING POOL ELECfRIC []OTHER +
will do the work,and the structure is not intended oroffemal foreale(Sec.70sq Business -
W and Pmfess'ions Cock:The
Contractor's License law does nm apply to an owner of OUTLETS-SWITCHFS-
�'a property who builds Or improves thereon,and who does such work himself or through
his own employees,provided that such improvements um not intended or offered for NEW RESIDENTIAL ELE SQ Ef.
sale.If,however.the building or improvement is sold within one yemofcompletion,the -cakS'Oy FT.FLOOR AREA FJSQ.ET.
ner-builder will have the burden of proving that he did not build or improve far Pur. f 1b
E]61 of Fels.). d� u
❑ I,asownerofthe proSee 704, B sines exclusively contacting With:)canedcontractors - L' 'a/ /^//_,n
construct La the project(sec.o an Business and Professions Cade:) pMe roves Chemo t.LL All ' 8
cense Lawlaenot th rojees lith.owner ofpropeny who
sed ...m r.dsthereom,and QTY. PLUMBING PER FEE ` krov
who emnuab for such projects wird a mnrucmr(s)licensed Purnuanu.the C.mraa.r'n
License Law. PERMIT ISSUANCEU/-
❑I am exempt under Sec. ,B&P C for this mason LLrE is _
Owve (late ALTER-DRAIN&VENT-WATER(BA) /^/ O
m N
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE "I
I hereby affirunder Penalty of perjury one of the following decimations: 111......
I haveand will maintains Csrffiamonf Conxns toxlf-ineure fm Workoes Compen- DRAINS-FLOOR,ROOF,AREA,CONI. STORIES TYPE CONSTRUCTION
cation,ma provided for by Section 3700 of the Labor Code,fear the Performance of the -
work for which this Permit isissued. FIXTURES-PER TRAP
.5I 3')0 -
have and will maintain Workers Compensation Insurance,as trainload by Section
0of the labor Core,fmthe poformance of Nessmk for which this permit is ismed. GAS INC.4 OUTLETS OCGGROUP APN
My Workers Compensation lasuancycurti.1 and Policyngmf$LD�e ,+q
Carrier.ffATF L//A// P.Iicy No.:"fa.]�B�.�i —1 / GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' _
COMPENSATION INSURANCE GREASIVINDUSTRI,WASTE,POERCEPfOR
BUILDING DIVISION FEES
(Tbisxation xetl not bec.mplaed if the penitis is Perone hundred dollars 181IXq GREASE TRAP
or Ie6sJ PLANCNECK FC•E
(certify thmin the pcnnrmmse nlhe work for which chis permit is issud,lshell SEWER-SANITARY-STORM EA.200 PT.
not employ any person in any manner sec as m become subject m she Worker'Comphd-' ENERGY FEE
Z rasion Laws of California.Date WATER HEATER WIVENTBeLECTR
Q Applicant GRADING FEE
VJ NOTICE TO APPLICANT:If,after making his Certificate of Exemption,you should WATER SYSTEM?REATING
become subject to the WOders Compensation provisions of the labor Cole,you most SOILS FEE
Ik1 forthwith comply with such previsions or this permit shall be deemed evoked. WATER SERVICE
a �
i7. z CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT. ,AID Dat R ipso
V p l herebyaffirmthi that then iss issued
lending agency for Pertmmantt of
the work(or which this,hectic is ixsuW(Sec.309],Co.C.) -
G" (~ Lemlcls Name � TOTAL:
o Lenders Address - TOTAL: BUILDING FEE
FFFf+++ 1 cenify that 1 have read this application and state that the above information is
IA correct.I agree to comply with all city and coumy ordinatu'es and state laws islands to QTY, MECHANICAL PERMIT FEE
V building construction,and hereby muthodm representatives Of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT'ISSUANCE
(We)agree to save,indemnify and keep hamless the City of Cupertino against ELECTRIC FEE
liabilitier,judgments,costs end expenses which nay in any way accrue againu aid Ciry ALTERORADDTOMECH.
in consequence of the granting of this permit. PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICA FEE
SOURCE EGULATIONS.
AIR HANDLING UNIT(OVER 10,00D CFM) CONSTRUCT NTAX
Signamm of ApplicanUCommem V Date EXHAUST HOOD(WMUC11 HOUSING MI ATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thtapplicam or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as do in by the Cupertino Municipal Code,Chapter 9.t2.and she Health and Safety
Cale,Section 25532(.)? HEATING UNIT(OVER 100.00)BTT))
(]Yes ❑No VENTILATION FAN(SINGLE R[SID) PAID
Will the applicant or furore building oceupam me equipment or devices which Date Receipt H
emit hazmadaus air comminams as definal by the Bay Area Air Quality Management BOILER-COMP(THP OR 100,000 BTU)
DlsuinTTOTA
❑Yes 0N • BOILER-COMP(OVER 1011,gN1 BTU)
1 have read the hazvdoas materials requirements under Chapter 6.95 of the Cali- ' AIR CONDITIONER ISSUANCE DATE
fonds HuW&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently haat a met that.itmyeeof.Certifi to notifythe occupant 1
of Ne rtquirememswhich must a tmet Prion ti isemyrepnCertificatetf Qcuparap -
Owner or onzed agent Date TOTAL: ISSUED BY:
auN
OFFICE