99080115 (2) "19
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY U 11 7-
CITY OF CU'ERTINO BUILDING-ELECTRICAL PER ITN
RUII,I;INC.DIVISION APPLICATION/PERMIT ILUMBINC,-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS I SANITARY NO, LDATE.
5 0,Q C
I 'NL 'S NAME: PH NE: . O CTOR'S N E: LIC NO:
_ NIC COIL.M
1
L BTEC, GINEER: kj LIC NO 'ADDRESS ❑
CON PACT: PHONE: BUILDING PERMIT INFO
❑ Consutant lFeu cant(Initial) BCH
Paid by Applicant ELECT PLUMB ME
73 � � IDEl❑ [�
LICENSED CONTRAC FOR:S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OWC8Z with Seed-7OWIof Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
�W� in tall farce and etlbct. 6D5S//.a PERMIT ISSUANCE 0SmWL ❑KITCHEN REMODEL
aVV L¢emo Clank LieN �/ / APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
ya i Dna Conn-aa or -
ARCHITHC'I'S DECIARATION ❑MULTI-UNIT ❑STRUCTURAL
I understand my plans shall he used a public records PANELS MODIFICATION
Z p h Z
OZ—M UPTO200AMPS [I INTERIOR El CHIMNEY REPAIR
a4tW 4censed Professional 201-101JAMPS IMPROVEMENT SWIMMING POOLS
WY' - OWNER-BUILDER DECLARATION OVER 1001 AMPS ❑BATH REMODEI/REPAIR ❑DEMOLITION
WQ I hereby affirm that 1 am exempt from the Contractors License Law for the
3 LLU following reason.(Section 7031.5,Business and Professions Code'.Any city or county SIGNS ELECTRICAL. ❑OTHER
an which requires a permit to construct.alter,improve,demolish,or repair any structure
6 prioro its issuance.also requites Nproof m
e applicant for such pof file a signed statement SPECIAL CIRCUIT/MISC, /
�IyY, drat he is licensed pursuant to the proviso sof the Contmmoex License Law(Chapter 9
led 00 (commencing with Section]WU)of Division 3 of the Business and Professions Code)or TEMP METER OR POLE INST. COMMERCIAL:
CG dthat he Is exempt therefrom and he basis for de uliegcd exemption.Any viontlon of [3 NEW BLDG/ADDITION L3 DEMOLITION
X^_T Section]031.5 by any applicant fora permit subjeco the applicant III mutt pcoulty of POWER DEVICES
W rn nmm...iman five hundred doll...($510). []TENANT El FOOD SERVICE=�
FlLa.owneraf the propcny,or my employees wiNwagesz theinole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
p. will dothework,and Nesaucm¢saint"ntendcdoroffIned Annaba(See.7044.Business ❑OTHER
Wm and Protestors Code. fhe Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-RXT
L 3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are,not intended or offered for NEW RESIDENTIAL ELECTR 5
side.If,howevm,the building or improvement issold within one ydorofmarpletion.the SQ.IT FLOOR AREA $/SQ_ET.
cr-hudder will have the burden of proving that he did not build or improve for pur-
ryxaf sale J.
F-] 1,;is owner of the property,um exclusively contracting with licensed contractors to TOTAL:
construct the project(Seen 704,1,Bminess and Professions Cod,)The Comment i s L,
oca,c Law docs not apply It an owner of property who builds or improves them..,and QTY, PI,UMBINO PERMIT FEE
who contracts for such projecu witha contracmr(s)licensed pure am m Ne Cmadozo r'x
License Law. PERMIT ISSUANCE
1 am exe......der Sec. ,B&P C for this reason
Date (E
AU ER-ORAIN&VENT-WATER A) VALUATION
xner WOR KEE'S COMPENSATION DECLARA PION BACK FLOW affirm PROTECT.DEVICE O O
1 hereby arm under penalty of perjury one of the following declarations:
Fl I have and will maintain a Certificate of Consent o sd6fasure for Workers Cooper- DRAINS-FLOOR,ROOF.ARE A.COND. STORI TYPE CONSTRUCTION
,tion,fe provided for by Section 37W of Ne labor Cede,for the performance of rhe
work for which this permif is issued. FIXTURES-PER TRAP
❑ I have and will mandemn Worker's ComNa...son Immance,us required by Section
31110 of the l.ehor Cede,for the pcAomence of Nc work for which this Namit is issued. GAS-F-A.SYSTEM-d INC.4 OUTLET'S OCC.CROUP
My Waded,Compcmmion unmnumb,
lasee c.trier and Policy are `J,�C�t AP�Lo
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) /J I
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRPASEBNDUSTRL WASTE INTERCEPTOR
fThis ncetion need not bexnmpletW ifthc permit is mronc hundred dollua($I WBUILDING DIVISION TEES)
or less.) GREASETRAP
PfANCHECK FEE
I mnify fM1m in the perfonnnncn of the wad forwhich Ninpemrit is—wed lshall SEWER-SANITARY-STORM EA. FT.
n..employ any Person' anymann r beta }1bjecun Ne Wudcrs'Compcn- ENERGY FEE
O ,'� satin.laws r{�[4abfnmia.Date -1�I ��Y- WATER HEATER W/V[iNT/ELECTR
Z 0 Applicant k =k1���y� L.L...�i GRADING ME
) NOTICIi TO AP IICCAN'T':IL ofter ranking Nis Cenlfiane of Exentpuon,you should WATER SYSTEMaREATING
Iv come S.b c,f 1. he Worker's Comperoanon provisions of Ne tabor C dx,you must SOILS EEE
forthwith comply wifh,.th pvokica,or Nis Nodi"shall he deemed revoked. \PATER SERVICE 1
DCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ELAI �
U Q IhurefPoby a 'm thanhere ieawnstmcrino lending agencyturn.perliumnc
au of Ree 'ptp \fly
(•' the work for which Nis permit is i.sued(See 301 Civ.C.) '
O U Lenders Name ^ L
ress
LcnderSAddTOTAL:
I eanify that I have rend ads application and urate Nat the above mfmmada.is +L b
Z? correct.l agree m comply with all city and county ordinance,and state laws renting to QTY. MECHANICAL PERMIT FEE
U z building ttmstmction..nd Hereby uuthmize rcpmsomueves of Nin city manferapm the s IC FEE
ahrve-mentioned property for inspection purposes, PERMIT ISSUANCE
(We)agree m save,indemnify unit keep harndess the City of Cupenina against L EL CTRIC FEE
liabilities,judgments,costs and expenses which may in any way accme against said City ALTERORADDTOMECH.
in m�sequensc of Ne martingof Nis prom. THOUSING. TIGATION7FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM)
SOURC;REGULATIONS.L "_ :: AIR HANDLING UNIT(OVER IO.000CFM)Signature ol'AppliaanUGmfroamr '—� ' Date EXHAUST HOOD((/DUCT)
HAlARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oceupnm store or handle hazardousmmerial HP,A'I'ING UNIT(TO 100.000 BTU)
as def ned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Curie,Section 25532(0/ HEATING UNIT(OVER 100,000 BTU)
❑Yes Wo
VEN'FILA'ION FA N IS INGLE R ESI D) PAID pate Receipt Will me applicant or future building duration useequipment ectted equipment or devices which P
"nit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,001 BTU)
Ili."rlet?
❑Yes ya No BOILER-COME B)VER I00.000 BTU)
1 have raced d"c hmallous materials rcquimmcnts under Chapter e.95 of Ne Coli- AIR CONDITIONER
ISSUANCE DA'(/1', �S
Ofoofw rm.. usth&�Sufery Code,Sections .25533 add
25534.I understand thatIt
he NEW RESIDEM'IAL MECH. SQ.building doenot cunemyhaeanuanh,that it is my respnsatonotifyec
meubnmmLIa responsibility
ent aeowouncy,
or
a
r,
It n6^t a C Dam TOTAL: ISSUED BY: �-
OFFICE