S 0711 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ 111111.D1NG-ELECTRICAL - PERMIT NO,
IIUII.DING DIVISION APPLICSFIONMERMIT PLUMBING-MECIIANICAL S 0711 11
BUILDING PROJEC`f 1U1?NTIFICATION T
BUILDING ADDRESS: ^^ SANITARY NO. APPLICATION SUBMITAL UATIi
ve
GW EWS NAME: ' PHONE: CONTRACTOR'S NAME: LIC NO: _
G e• `-1 n` sC r 1 NIC CONTROLX
ARCHITECT/HNGINEIiR; LIC NO: ADDRESS-
It"ii5a F-
C ❑
- Ifo . 0`Q-
CONTACT: PHONE: - BUILDING PERMIT INTO
❑"Consultant Fees Paid by Applicant(Initial) BI.Dr, ELECT PLUMB . MECH
LICENSED CONTRACTOR'S DECLARATION ' QTY ELIiCTRICPERMIT FEE JOB DESCR1Pl'ION
I herchY uffrm thin I um licensed under provisions of CLapmr 9(conhmencing
P.1to 0O with Section Titan of Division 3 ofthe Business and Professions Cole,andmy license is ' RESIDENTIAL;
��.. PERMIT ISSUANCE.
Cut' intoll and c+Ten. UL ❑SFDWL ❑KITCfiEN RIiA10DE1.
mut' Lmcns Clan LIC,N APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING R&PIPE
L. W ❑me Cnmmaor
ARC]11 AH( ❑MULThI1NI'1' ❑S'Ik CICATI.
p.,pm PANIBS IFICATION
ZOZ lundersmnd my phma shall M1e uscA a.PUM1lic records UI'TO 2W AMPS t
OZ—� ❑INTERIOR CIiIMNEY REPAIR
I-�R-LL Licensed Professional 201.1110AMPS IMPROVEMENT . 0SWIMMING POOLS
OWNFR-BUILDER DECLARATIONOVER 1(%XIAMI'S' ❑BATH RE ODEjjREPAIR ❑DEMOLITION
W W I hereby uffrm that I sen exempt from the Contractors License Law Term
'ay�OtYU follwing reason,Section 7031.5.Business and Professions Cae:Any city or county SIGNS ELECTRICAL El OTHER
tel�+LL y which requires u permit to construct,alter.improve,demolish,mor repair any structure
�
_ O�' Climb,its isxvnncc,alrorcqui res the applicanlfurauoh peril
mit to l ea signed statement SPEC I A I.C IRC11 i"T/M ISC
uthat he is focused monano the Provisions of the Contractors Liccnm Law(Chemor9
W SCO (commencing with SectionT10(nof Division 3 ofthe Businessand Isafoaiens Code)or TEMP.METER OR POLE.INS r.
COMMERCIAL,
d y o¢• that he a exempt therefrom and the basis far the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
LLX7 {z• Sectnn70311 by any applicant far v permit subjects i homm1hcnni me eivllpcnalty of POWER DEVICES ❑'I73NANT' ❑FOOD SERVIC1i
to nounare than live hundred dollars ESSEX)). IMPROVEMENT
fZC ❑I,ns ownendhM1e propcny.mor my empinyeeswith wagesaztheirmlecnmpcnsminn, SWIMMING POOL ELECTRIC
W emwill do the wank,and the st exam,is nut intended nndferad for sole(Sec.7044,Business El OTHER
W ame and Professions Code:no Con mcmr's License Law ices not OPPIY nh an nwnegof OU'11.fT5-SW'ITCHFS-F1XT S
em. prolerty who builds or hnproves theram,and who does_such work himself or through
his own employees,provided that such improvements am net intended or offered for NIiW RFSIUENTIAL ELIiCIR
sale.If,however.the building or improvement is sold within one year ofcomplction.the A 3 Q.f[
owmerhuilden will have the burden of proving this he did not build or improve for bur-
01,it DEC 0 41997
1,its owner mol the property,am exclusively contracting with licensed contractors AL'
construct the project(Sec.AXht,Business and Professions Code:)The Caricatures Li. - -
censeLawdoesnotapplytoonownerof Property who builds or improves themon,and QTY, PLUMBING PERMIT EF.
who contracts lit such projects with a ammncmr(s)licensed paramount m the Cnnn o nr's t' is DV s
License Law. PERMIT ISSUANCE JJ 1
❑1 min exempt under Sec. .0&P C for this Mason
ALTER-DRAIN&VENT-WATER(lit) VALUATION
Owner Date
WORKEEP'S COM ofiNtpor,. DECLARATION BACK FLOW I'HOTECI'.DEVICE L
1 hereby l l mai under penalty of perjury ane mol the following declarations:
Ihvve and will mbimaine Certificate of Consent self-insure for Workers Compcn- DRAINS-FLOOk,ROOF,AREA,COND. STORKS T'YI'H CONSTRUCTION
section,as provided!for by Sermon 37M of the Labor Code,fur the performance of the
work for which ilia permit is issued
FIX'I'l1RES-I'Ek'1'RAP
1 have and will maintain Workers Compensation Insurance,as required by Seeman.
30(10 of Ne Labor Cale,fur the performance of the work for which this permit is iswrost GAS-EA.SYSTEMb IINC.4 OUTLETS OCC.GROUP AI'N
My Workers Compensation Insurance carrier and Policy number are: ,
Cinder: Policy Na,: GAS-EA.SYSTEM-OVER 4(EA) -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASI%INUUSTRL WASTE.INTERCEPIY]R
COMPENSATION INSURANCE BUILDING DIVISION FENS
(This section need not he,completed Hine Permit is torose hundred dollars(&HIO) GRrASETRAi'
mor ins,) 11 PIANCIiPAK FHL:
I Certify that in the performanccoftbe work liter which this permit is issued,limit SEWER-SANITARY-STORM EA.21X1 FT.
not emPlmy any pcnon in ony manner in' u 1 ochre". Workers'Compen- ENERGY FEE
,� ami no Lows of Colifomiv. WAI'17 t BEAT ER W/VENT/ELIeCR
0 Applicant
GRADING PIiIi
r) NOTICETO AI'I'LIC 'f:11, mKn this Cenifcatea Exemption,you should WA'I'1iR SYSTEM/TREATING
became subject ns the Workers er pe. sen provisions of the Labor Code,you must SOILS FEB
forthwith comply wit xtreh powisionsorshis famhit shall he demned revoked. WATER SERVICE
n, 0
¢ CONSTRUCTION LENDING AGENCY NEW RESIDEN'I'IADPLMB, SQ.FT. PAID
UOI hereby ofperformancen that them is a construction lending agency for the performance of Dem tptp
f+ the work for which this permit is issued(Sec.3891.Civ.CJ
O U Lenders Name TOTAL:
W I.crderx Addmcv TOTAL:
y 1 cenify that I have mad this application and state that the above information is DING PEI3
to correct.I agree to comply with an city and county mationers and state laws relating ,, QTY. MECIIANICAL.PERMIT FEL?
U buildingennswaion.and morhy nothorim representatives ofthiscity to emerciam the SHISMICFEE
alloo-nhemioral property far inspection Purposes, PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities.judgments,casxicad expeoses which my intnyway acerae against said City ALTER OR ADD TO MECH. PLUMBING FEE s
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT'(1010.00007M) MECHANICAL FEE,
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.1)(11 CPM) CONSTRUCTION TAX
Signature of'Applicant/Cnotmcmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sore or handle hazardous material (((HATING UNIT(TO I0g1XXl BTU)
as defined by the Cupeniah Municipal Core,Umpmr 9.12,and the Health and Safety
Code,Section 2.5532(a)1 HEATING UNI'('(OVER 1010X)BTU)
❑Yes 0 N VENTILATION PAN(SINGLE RESIDE PAID
Dam Receipt X
Will the applicant or future building by.theoccupant use aAirequipment or devices which
emit hazardous air contaminants as defncAh.the Bn Area Air lit Mann einem 8011,1:R-COMI'(311P OR 1(X1,(100 NTIJ) .
Y Y Quality g TOTAL:
District Yes ON. BOILER-COMP(OVER 10.1110 BTU)
❑ '
I have read the hazardous mnteriahrequirements under Clopier 6.95ofthe Cali- AIR CONDITIONER ISSUANCE DATE
romla Health ,let,Cale,Sectima 255115.25533 and 25534.I undeneand shut If the NEW RESIDENT IAL MECIL SQ.FT.
E,
t eurren0yhaveatreaot,thmmurn, spomihiftyuntotifythc avupant / 21—
ofthe '`menuwhich most t nfaCenifease of up:
O r amhnr eJa at - me 'TOTAL: ISSUED BY:
OFFICE