S 0650 (2) APPLICANTTO FILL IN INFORMATION WITHIN REI)LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NII
BUILDING DIVISION It APIa1.ICATION/PERMIT PING FROG CU IVENNIFic S _ 0650
IIUII,UINI:I'ROJf:CI'IDEN'1'IPICA'DON
BUILDING ADDRESS: - SAN]I'ARY NO. APPLICATION SUBMITTAL DATE
1123' Kentwood Ave. . s- 2 Ai
OWNER'S NAME. PHONE: -� O C 'tRACTOkSNM rs LIC NO NIC 'OKBOLR
• 294
ARC :N E.Arew .IC NO', A DRHSS: S ❑
COKTACE PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by.Applicant(Initial) BLDG ELECT I'LuMH . ME
LICENSED CONTRACT'OR'S DELLA ATION QTY ELECTRIC PERMIT 17EE
I herehy affirm that I am licensed under provisions of Chapter 9(Commencing JOB DESCRIPTION
'OaZ tb Section 700X)off),,Nion 3afthe Briman,sand[statesman,Cude,undmy license is R I
uF100 wt PERMIT ISSUANCE FlI ❑KITCHEN REMODEL
In full farce and a et.
f<UU LicenseC ss�-- —Lisp sm APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPIT
VI
Zed
DatC can RetOr
Is
ARCLIITEC'I'SDECLARAI'10 ❑MULTI UNIT ❑STRUCI'URAI,
Z O Z I andetsnmd my plans shall he used as public eveor s I'ANTH.S MODIIHCATION
OZ-0 UPTO200AMPS [I INTERIOR [3 CHIMNEY REPAIR
F-�Ful Licensed Professional 201-II0NIAMPS IMPROVF1dF:NT SWIMMING I'OOIS
qY , OWNER-BUILDI!R DECLARATION OVER lots)AMPS
❑BATH RBMODELIREPA1R 0DEMOLII'ION
re
�•CL a I hehy affirm that 1 cin exmnpt farm the C..nation ,License Law or the
b 0 L U following reason.(Section 7031.5,Business and Professions Cale:Any city or countySIGNS ELECfRICAI. ❑OI'HF.R
t++3 LL in which requires a permit to cannmct,alcor.improve,demolish,or repair amy sr¢fure
f'�-0� pinnoit iouantt,mso rcquireslhe applicant fnnuch)eat+iuofleusigned xmtcmem SPECIAL CIRCUCOMISC. ��
that lie is licensed pummonno the provisions of the Comrtctors license Law(Chapter 9 / U"'NV D
r+0C be, mention with Section]gN)of Divimon lulmeHminese and l'rdcasions Cade)or TEMRMIOER ORPOLE INS'1. UUU��`������I'"""' "`"'"
6 o C that he is exempt therefrom and the basis for the alleged exemption.Any smimion of \ ❑NEW BLDG/ADDITION ❑DEMOLITION
^,LL Scction7031.5byany applicantorapernit.mbjacts thcapplicamtoa civil ped.Ity.f POWER DEVICES C1 TENANT ❑FOOD SERVICE
Qt more than five hundred dollar,($500).
I,ns ownendthe rt,nnn con tlu ccs with wu¢s as tbuirxrle cam tion, SWIMMINGPOOLELECTRIC IMPROVEMENT
0 ❑ )rope Y Y I Y 6 )ensu
will do the work.and the structure is not intended orof sed for sale(Sra.9614,Business ❑OTHI?R
0i.3as and Pmfess!ons Code:The Contractors License Law it.not apply as an owner of OUTLIHb-SWITCHES-FIXTURES 40
propcny who builds or improves thereon,and who does such work himself(it through
his own empinyms,Provided that such bnpmvemonts am not intendant or offered for NEW RESIDENTIAL FLECI R SQ IT -
sale.If,however,the building or improvement is sold within one year ufeempletion,the SQ IT.FLOOR AREA $6Q.FT.
owner Wilder will have the burden of proving that he did not build or improve for pur-
p+nc ofsale.L
1,as owner of Ore property,am exclusively contractingwith licensed contractors to TOIA
msuuet the protect(Sec 7844,Btemneix and profession,Cams:)Lie Contractor's Li-
cense Law does not apply to an owner of proporty who Miles at improves flosecon.and
i-censeLowdoesnmapplytoonownerofpropertywhoMilesarimprovesthereon.and QTY. P MBING PERMIT FEE
who Contracts for such pmjens with a contmnons)licensed la romal to the Contmetnrs
License law. PERM( ANC(! ..
I in.exempt und"Sec. .B&P C(..Ibis rcumn
ALTER AARAillIgge VENT-WATER IEA) VALUATION
Owner Data
WORKER'S COMPENSATION Df CLARATION BACK FLOWZR EVI '.
I hereby upon under penallyte perjuryone ofthe fnsureor decWorkers
ou
❑Those and will muinmina Cenllica¢of Consennnmll-InsoreTor Workers G+mLmen- DRAINS-1; 0 )P, ,COND. STORIES TYPE CONSTRUCTION
salon,its provided for by Section 37W of the Labor Code,for the performance of the
h�str which this permit is issued. FIXTURES-PERT I'
�fhave and will maintain Worker's Compensation Insurance,us required by Section '
3700 mf the Labor Code,for the performance(if the work for which dais permit is issued GAS-PA.SYSTEM.I INCOCC.GROUT' 'AIN
My Wor n e satin mmnre crone,and Policy�nym��bC�J�- ,,````
Camcr:�ani Policy blo,i 1. ZL45`1V1 GAS-FA.SYSTEM.OVBk4(CA)
CERTIF CATP.O' XEMPf1ON FROM WORKERS' ORF.ASI'JINDUS'I'RI.WASTE INTIiNCF.YfOIt
COMPENSATION INSURANCE BUILDING DIVISION FEES
('L'hkaectionreW not Mcompleteed lfthepermit is l intone hundreddollars(SI00) GREASE'I'RAV
or leas.) PIANCHI!CK FEF.
renifythat in the performance offle work forwhich this permit is issued,l shall SEWER-SANITARY STORM HA.20f IT.
not employ any person in any manner ma as m become subject tat the Workers'Concen- ENERGY 142E
Z nation Laws ofcaliforme,Dane WATER((EATER WNEKf/ELECTR
z Applicant s GRADING PEE.
NOlican TO APPLICANT.If,a0er making this Certificate of Exemption.you should WATER SYSTEM/I'RI:ArTNG SOILS FEE /
her nom subject to the Workers Compemmina provisions of the Lubar Code,you must
Wfon hwim comply with such Los klonsor thispermit Its 11 M damned revoked. WATER SERVICE
Q
z CONSTRUCTION LENDING AGENCY NEW RISIDI!NTIAI.PLA1B/ SQ.FC PAID Dam
UD. rFt1-.t rirhi thmthcre!saco nknCiagrncy frn the lmerfumwnce of ce
N
'he work
for whichM1lspermiis issued(So,,3W7,Cis.
C.) - TOTAL:
U Lender's Name
O Lender's Address TOTAL:
} _ IIUILDING PT:
CL, 1 certify Jr.,I have read this applirvtinn and nam That the uMwc information is
IrN7 coral.l agree to comply with all citymid county robot and ame lawsrelating to QTY. MECHANICAL PER MIT FEE
UG Willing commutation,cant hereby authorize represenmtives of this city m enter mprlie SEISMICIN
abuse-menti oned property for inspection Parin . PERMIT ISSUANCE ELECfRICF E
(We)agree m saverm
,indemnify and keep haless the City of Cupcninn.,art f
Iiabilitics,judgmens,costs and expenses which may in any way acme againstsaid City ALTER OR ADD TO MECH. ,
In ameequenceof t he gtaningofthie permit I'LUMBINGP C
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO 10,000 CFM)
SOURCE E L• TION. MI!CHANICAL E
AIR HANDLING UNIT(OVER 11,011()CPM) A6CHON TAX
M � �
SI not of AppiaaoUContrcmr Data EXHAUSTIIOOD(W/DUCT) HOUSIN 1 TION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Ecin,licnmmfntare buildingoecupate stmemimadlehanardausmamnal HEATING Uslr(T0100,000 BTU) '
as defined by me Cupertino Municipal Code.Chapter 9.12,indite,Heal and Safety
Code.Section 25532(0)9 I IP.ATINf,IJNIT(OVI!R 100.000 HI U)
❑Yes r7 No /s u.J
VENDULAT10N FAN(SINGLE RESID) CI VI PMH(Lfu
Will the applicant or future building occupant use equipment or devices which Date Rce" t N
a MOILER-COMPAHP QR 10(1,0(111 BTU).
I !emit District? ou;air cnnmminomx ns dofinM Try the Bey Areu Air Qnnllty Manngeme(n ,1 L
Disuin9
❑Yea ❑Nn BOILER-COMP(OVER I0113 1 U)
I M1ave read the M1arrdnus materials requirement AIR CONDITIONER under Chapter fi.95 of the Cal � ISSUANCE DAT/E�
hada Health&Safety Cada,Sectors 25505,25533 and 25534.1 understand that If the NEW RESIDENTIAL MECH. SQ.IT. /I -18
Q
buildingdces not currently haveomnant tM1m it is my responsibility mnotify the acupmt L O 1 (J
of the regmimrmms which roan M1e met prim m izsuantt of a CeniOrate of tXcupamy. L
Owner or authorized agent - Data Tat ISSUED BY:
OFFICE