30566 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO - BUILD INO-ELECTRICAL' PERMITN0, /� O5
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING,.MECHANICAL. J J
66
BUILDING PROJEta'IDENTFIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTAL DATE
2'7LS1,0 z2s3o PHONE'K: , d c+ q V-7-fie
hs� ,• 1A0 A, LlD1^c7 fl -
�Z CONTRACI'OR:S NAMI?: - LIC NO: NIC CONTROL#
RCHI T/P.NGINEER: ITGLICNO16�"L: ADDRESS: ❑
A nOLJ h SM
. CONT PHONE: BUILDING PERMIT INFO
AULRa ;WICA5s 4a8-�`IG•-
I� 'y 1�o ❑ Consultant F<t5 Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CfI
V ❑ ❑ . ❑
,. LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
C0Z
1 hereby affirm firm I am licensed under pmion
visa o(Chapter 9(commencing JOB DESCRIPTION
with Section]IMXIIofDivieion htfthe Husineas and Professiem CMe,and mylicenu is PERMIT ISSUANCB
aWP is full rid effect. RESIDENTIAL:
Q U Lice Cl o s M C SFDWL _r C KITCHEN REMODEL:
LLJ� APPLIANCES-RESIDENTIAL
vac []ADDITION ❑PLUMPING RE-PIPE
ZO 7�. AR 1ITE SD ON PANELS [IMULTbUNIT ❑STRUCTURAL
lundcamnd lens sir s r recn - L,aMODIFICATION
OZ Q - UPI0200 AMPS' ❑INTERIOR IL'cHIMNEY REPAIR
t 't Yrnfcxsionn 201-100JAMPS (IMPROVEMENT
r¢� OWNER-BUILDERmthe ON
<
hereby effimt)hat 1 am exempt Trent the Contractor's License Law for the OVER INN)AMPS '❑BATH RF.MODF.IIREPAIR ❑DEMOLITION
Nato f.1 0 tg reason.(Section 7031.5,]in info and Profession•Code:Any city or county C OTHER
SIGNS I!LGCTItICAI.
F• yQ which its ieaa v permit us Consvun;alter,improve,h pear it.fi repair any swnurc
yyHJ Ila,brslicluad,marao rtq.irea Emoistlicant for sochperminoicenslt.e gnedsm¢mem SPECIAL CIRCUIT/MISC.
y�•�• i• that he is licensed pumuam mNe pmmivisio.(the eBusin ss License Law(Chopmr9 _
I+I q 0 0 (enmmencisc whir SeCfunction
and the
Division for the
theeged exe and on.Anions Cnde)or TEMP.METER OR PULL INS F. COMMERCIAL: '
M C.eC ohm he is exempt therelmm and the hmis for the alleged exemption.Any violation of C NEW BLDO/ADDITION C DEMOLITION
N
Section 1011.1 M11uny applicant fare permit.aM1jttts the applbalm no a civil penalty of POWER DEVICES
a mom than fisc hundred dollars($500).
[]TENANT ❑FOODSERVICE
Q [:] I,us owner nllhe pmpeny,or my mnployee.a with wngea ria their sole cnmpenamion. SWIMMING POOL ELECT RIC -IMPROVEMENIT
will do the work,and the mmme,is nut intended proffered far all(Sec.7014,Business C OTHER
n'3C4 and em(essions Cash:The Comment's License Law docs vat apply to an owner of OUTLF.IS-SWITCIIPS-P U
property who builds or improves thereon,and who does such work himself or through
his own employees,provided ohm such impr.vanems arc not intended m offered fur NEW RESIDENTIAL.ELE SQ R.
agile.If,however,the building or improvement is sold within one yearorcompletion,the SQ.IT.FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pun •u,
Pat ofalle.). TOTAL:
,as owner of the pmlcny,am exclusively contracting with Ihensed contmetoa mcen _
t ve Law a es not apply
to an Business and rty who
CMe:)The Comranon.and
Q $E I7 7 lex96
ac lswd.esnotchPlymas with
of enamemrty whoseiWsoriml andrehereun.enJ Try, PLOh1I3ING 1'IiRMIT FEE Q r / •`1y
wheral La. Nrsuch pmjrcts with acnmmemr(a)Iiceused pumuam tmhe Cnnuannr's
Literal ae Law, PERMIT'ISSUANCE
(]civm exentptu ,H&PCfar thio ream.
ALTER-DRAIN&VENT-WATER IEA) VALUATION
s n
/ 'WOiK1iRtS❑OMI'CNSATION UECLAItATION BACK R.OW PROTECT.DEVICE S
I hereby ufhnn under pearly of perjury one of the following declamtiom: _ sa
❑I have and will maintain a Certificate ofComentto self-insure for Worker's Compel- DRAINS-FLOOR,ROOF,AREA.GOND.
•seine,as provided for by Senlon 3900 of the tabor Codc,for,the puformm�ce of Lha S'D)RIES 'TYPE CONSTRUCTION
work for which this peonil is issued FINC IT ES-PER TRAP
C I have and will maintain Worker's Compensation Insurance,as rtquired by Section _
3700of OC LeMv Code,for the perfmasomeeofthe work for which this permit is ixsuCIL GAS-EA.SYSTEM+I INC.4 OUTLETS
AI'N
My Workers Compenaatinn Insurance carrier vd h
nPolicy numeOCC.GROUPr arc: '
' Currier: Policy No.; GAS-EA.9YSTEM-OVEft4(EA) '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASrANDU BUILDING DIVISION FEES
(This section need not he cmnplmed iffle permit is for one hundred dollars($HMO STRL WASR?INTERCEITOR .
' ar Iw.a.) GREASE'1'RAP."
PLANCHECK FEE
Loy any Oat inthe in Perany marianeeof the astotrrkfnrwhije this the it is Workeued,I rs'Counter.
SEWER-SANITARY-STORM EA.2W IT.
not employ any person in any rrmnner m un to hecome subject fire WnrkerT Compere ENERGY PER
Applicant
of Culif.miu,llatc
�O Applicant - _ -. WATER BEATER WNENT/ELIiCTR GRADING FEE
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/1'REATING
F become MhjCO m isio
the Worker's Compelled..pmvna of the Labor Code, oil moot SOILS FEE
forthwith comply with such pmviniom or this permitshall he deemed revoked Wp'fEµSI!ItVICE
Or (�
oz CONST'RUCTION LENDING AGENCY NEWRESLDENTIALPIAB. SQ.FT. PAID
. IherebyaHrradadscreistt e... etion lending agency for the perf.rmance of Date Reccipftl
� � the work for which this permit is,issunl(Sec.3TN],Civ.C.j •
O U Lender's Name TOTAL:
Lender's Address TOTAL:
y I enmity that I have rend This application and main that die above idmoral inn is BUILOINGFER
V) correct,Iagree It)Comply with all city and County ordinances unit state low a relating m. QTY, MECHANICAL PERMIT FEE
G buildingeonstrunion,and hereby Maharani represenmivesof this city menter upon the SEISMIC FEE
abos6mentioned property for inspection purposes.
(We)agree to save,indemnify and keep hared.,the City of CLpcnino named PERMIT ISSUANCE ELECTRIC FEE
livbilltics,judgnstion,costs and expenses which may in any way accom against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND,WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CTO 10,0X1 CFM(
SOURCE REGULATIONS, MECHANICAL FEE
t ' AIR HANDLING UNI T` 10,00)CFM) CONSTRUCTION TAX
Signature of ApplicanVCommnor 4 Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future holding occupant store or handle hazardous mnarial HEATING ONE'f(10100.000 HT'U) '
as defined by the Cupertino Municipal Cade,Chapter 9.12,amt the Health and Safety
CMe,Section 25532ND IIEATING UNIT(OVER I W."BLV)
❑Yes tC No I . - r.
VEWILA'HON.PAN(SINGLE RESID) PAID
Will Ne applicant or future building occupant use equipments devices which Date knetipt g
L• mit hmnrdous air contaminants as definnd by the Buy Arta Air Quality Management BOILER-COME(3HP OR 100,01)BTU)
District? .. • TOTAL:
❑Yee. ❑No If OILER-COMP(OVER I06,000 HTU) -
I have teed But examines materialsrequirements under ChapterAIR CONDITIONER
forma Henan&Safety Code,Sections 235(15,25577 mal 25534.1 understand that if of Cali. ISSUANCE DATE the NI!W kPSIDI?NTIAL MF.CfI. SQ:FT.
building does not currently have o tenant.that it is my responsibility to notipa
Mary the cocunt
of the requirements which must Ise met prior to issuance of a Ccrtificme of Occupamy. s
Ownsoramhonreingeur Ilam TOTAL: .
ISSUED BY:=aN_ '
OFFICE