S 1636 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Mit IT NO. 1636
BUILDING DIVISION APPLICATION(PERMIT PLUMBING.MECHANICAL. `V
BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Z 8 4,1414 y CN ^ 0
'R'1'NAME: PHONE: h' C-pORS AME IFK� z;; /S N/C CONFROLM
• ARCHITECT/EN'GINEBR: LIC NO: (DRESS: �lA ❑
3 s til � E.. S _
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELL
PLUMB MEC
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ Iyr��t
1 hereby armor that load licensed coder Provisinds ofchapter 9(commencing JOB DESCRIPTION
F1�OW CZ) with Seet1on7000hof Division 3.fthe Busidaward Professions Cade,andmyl'mcnec is RESIDENTIAL:
full I...d and effect PERMIT ISSUANCE
IN F i i C1,v�` ?6/GG 9 ❑SFDWL ❑KITCHEN REMODEL
y,s Lrenxe Conn ,AJU0T� APPLIANCES—RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
arc Connector
ARCHITECT'S DECLARATION PANELS F1 MULTI-UNIT ❑STRUCTURAL
Z O r�h 1 understand my plans shall be used as public records
P MODIFICATION
O Z.l UP TO 200 AMPS
F"Il—
W Licensed Professional ❑INTERIOR. El CHIMNEY REPAIR
OWNER-BUILDER DECLARATION 2111-IIXI0AMPS IMPROVEMENT SWIMMING POOLS
Q 1 hereby.(See hat I um exempt sem the Cessions or License Law for the OVER 1000AMPS ❑BATH RNMOpBUREPAIR DEMOLITION
d U fallowing reason.(Section 903L$B,alters and improve,
de Professions Cade Any city.,county SIGNS ELP.CTRICAL DOTTER --I/�✓,l_x_l
3 m F whleb requires n permit re quire the
aha,improve,aeermit t or repair any umearem _
prior to t '.: I' q ' m applicant for such permit fl god xlutement SPECIAL CIRCUIT/MISC. 1
WWGAthat he limnwdp tt m provisionoofthe Contractor License LwlChapler9
(commencing withSection 7000)afDav,mp3 ofthe Business andP f::ons Cnle)or TEMP.METER OR POLE INST. COMMERCIALi
that he,.,exempt therefrom and the basis far the alleged exemmiola
ptn.Any vtion nr ❑NEW BLDG/ADD4040;��
IE^y Section 7lHLS by any appliaum fora permit suhjecs theapplfcanfmocivilpenxltyof POWER DEVICES
not more than live hundred dollars ❑'TF.NAMT ICE
� Q ❑ 1.as ownerof hopropengur any employees with w,use,dur r sole compemalion, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended or drama fertile(Sur 7044,Business ❑OTHER
and Professions Cede:Tho Contractors,License Law docs not apply h,an owner of OUTLETS—SWITCHES—FIXTURES
A' property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am oat intended or offered for NEW RES I DENT IAL ELECTR SQ Ft. in
sale.If.how even the building or improvement is sold within one year of complaion,the SQqT. RAREA $/SQ.FT.
pesor-builder will hove the burden of proving that he did not build or improve for par- A`w1 D
of sale).
❑I,as owner of the property,am exclusively contracting with licensed contractors to TO'T'AL. 8 V
anstmctthe project(Sec.7044,Business and Professions Codicil The Compecmr's Li-
topic Lew does not apply loan owner()I property who builds or improves therem,,and QTY. PLUMBING PERMIT FEE
wltnconwcK forsuch projects with aumvacuous)licensed pursuonnnt .Convector's .�f
C]
License Law' PERMIT ISSUANCE ``1\x yr
I am exempt under Sec. ,B&PCforthisrwson
Deana Dale - ALTER—DRAIN&VENT—WATER EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of Perjury one of the following declampomo
❑ IM1ave unJ will maintains Cenificule of Consenuo self-insure ihr Worker's Comped- DRAINS—FLOOR,ROOF,AREA,CONI(. STORIES TYPE CONSTRUCTION
sound,un provided,fnr by Section 3700 of the labor Code,for the port ormance of the
work for which his permit is issued. FIXTURES—PER TRAP
❑1 have and will Indian Worker's Compensation Imported,as required by Sweat
170 of the Labor Code,for the per'fmmuneo.fine work forwhich this Penni,is issued. GAS—EA.SYSTEMT INC.4OUTLETS OCC CROUP APN
My Work Cape Iion Insyyrrr a merrier and Policy yy� /sell e R
Carries�7f}j�fp✓lJ nc Policy Nn.LpP 7Ll��JII I GAS—EA.SYSTEMOVER4(EA)
CERTIFICATE OF EXEMPTION.MOM WORKERS'
COMPENSATION INSURANCE. GREASFl1NDUSTRL WASTE INTERCEPTOR HIIILDING DIVISION THUS(Thi,ardinnn.eda.(M completed ifthe permit is dome hundred dollars($100) GREASE TRAP
err less.) PLANCHECK FEE
I certify that in the Performance oflhe work forwhich this pariont is issued.l shall SEWER—SANITARY—STORM EA.200 FT
not employ any Prion in any murder A,as to become subject m the Workers'Compea- ENERGY FEE
Z section Laws of California.Drtc
Z O Applicant 1 WATER HEATER WNF.NT/ELECI'R GRADING FEE
vJ
NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTEM/TREAGNG
abecome mhmo to the Worker's C.mparecumn provisions of the Labor Code,you mum SOILS FEE
W forthwith comply with such provisions or permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ff. PAID
UO karwhichm,thomiti isrcens,mcann lending agency rnr thepaE.rmunceor Dam t#
W the wmkfar which his permit is isxueA(Sec.3099,Cr,C)
Q Lend.[', TOTAL:
'Lnnde2s Addm AJdrcss TOTAL -
Icertify that I have read this application arta stem ho the above cos totalling is BUILDING FEE
y e.neat,i ugreemcomply wire all oily arta county omiaattecsew stem laws QTY. MECHANICAL PERMIT FEE
U,7a. idertangc.dsmectiogenJ hereby mape....a prepresenmtives o(mt eitymenter uthon the SEISMIC FEE
nhovo-mer)aed grepropene foremnifyi an keep ec PERMIT ISSUANCE
(We)agree m save indemnify and keep harndas the City of Cupertino against ELECTRIC FEE
IiuM1ililies,juJgmenla,a.su xnA expenses which inay in any way accrue against said Cily
in corocco we of the granting of this permit. ALTER OR ADD TO MECH. PLUMBINGP
AP .ANT UNDERSTANDS AND WILL COMPLY WITII ALL N N-POINT AIR HANDLING UNIT(TO 10,M)CPM)
IIRf : GGULA NS. MECHANIC LFEE
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRU TION TAX
Signamfc of ApplicaMCommodr is Data EXHAUST HOOD(W/DUCT) HOUSING MIT ]ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sore or handle hooddlous material HEATING UNIT(TO 100.000 BTU)
as defined by the Catholic.Meniclpal Code,Chapter 9.12,and the Health and Safety 1^ is
-
Code,Section 25532601 HEAPING UNIT(OVER 110,100 BTU)
❑Yes Fl No - PAID
VBN3'ILATION FAN(SINGLE RESID) Dale R eiptx
Will the applicant orfurore building by the Buse ea AirQuordeviceswhich BOILER—COMP r3HP OR 100.000 BTU)
emit hazardous air cnnmminams as JeyneJ by the Bay Area Air Quality Management TOTAL
Div cfI
El Yes ❑No BOILER—COMP(OVER I(III,INIII BTIO
I have read the hazardous material,necrcancer,uder
nChapter 6.95 f,he Cali- AIR CONDITIONER ISSUANCE DATE
rain Health&Safety Cade,Swions 25505,25533 it 25534.1 undersmdd lhal if the NEW RESIDENTIAL MECH. SQ.Fp.
building does not currently have a tenant,that it is my responsibility to notify the receptor
or the requirements which must be met prior to issuance of v Certificate of( cdpamy.
Owner or universal agent Date TOTAL: ISSUED BY:
OFFICE '