S 1514 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL PER`yI1'f NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL ,
UJ 151
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: 1 SANITARY NO. APPLICATION SUBMITTAL DATE
I (9526 Lo.,na La %e G.�,�r �ho CA 9 '5014- lS9
WNER'$I L��+(5 402.2-51ZNl 4_S^ C$jNTRACTOR'S NAME: LIC NO:
�R Nn1 L_.`r J YY ` / N/C CONTROL#
JW ARCH]I'BCTIENGINEER: LIC NO: ADDRESS: ❑
O wnu 7J-71`44'T
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICFNSED CONTRACTOR'S DECLARATIONQTY ELECTRIC PERMIT PEE T
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
FWOZ with Station 9lNq)of Division3 of[M1C Businesswtd Professions Cuda,andmy license is RESIDENTIAL'
W� in full force and effect. PERMIT ISSUANCE
C
Ll
License El KITCHEN REMODEL
t U Liceusc Class Lia# APPLIANCES-RESIDENTIAL DITION [I PLUMBING RE-PIPE
ycel Date Conmacmr
WWARCH]I ECT'S DECLARATION PANELS ❑MULTI-UNIT ❑59'RUCTURAI.
F5
yOrNjr lunduxumd my plans shell bo used ns public reaprds MODIFICATION
Oz—, UP TO 200 AMPS
�r3.F.47 ❑INTERIOR El CHIMNEY REPAIR
Licensed Pmfessionvl 201-RAOAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
1�] 1 hereby affirm that 1 am exempt from the Conrucmr's License Law for the OVER 1000AMPS ❑BATH REMODE BPAIR` F Al
a L F following reason.(Section"103 L5,Business and Prpfessione Code:Any city pr county SIGNS ELECTRICAL ❑OTHER i� �is
e,4,� which requires a permit tat ennmrard,alter,improve,demolish or repair any structure 010
i-.a,,6 prior to its issuance,also requires the applicant for such permit In rile a signed statement SPECIAL CIRCUIT/M ISC,
¢� Card he rs licensed pursuant.. he provisions of the Commerce's License Law(Chapter9
CD d (cormarcirg with Section 9000)of Division 3 oRho Riamess.nd Professions Code)., TEMP ME'I Erg OR POLE INST. COMMERCIAL'that he is exempt therefrom and the halts far the alleged cemnptird Any violation of [1 NEW BLDG/ADDITION ❑DEMOLITION
wto
Section 7031.5 by any applicant for a permit subjects the applicant to u civil penalty of POWER DEVICES
more than Live hundred dollars 5500). ❑TENANT ❑FOODSERVICE
FZQ
not 1 as owner little property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC le IIMPROVEMENT
!aye'
will dothe work.and the structure is net intended proffered for sale(See.91144,Buslnesv ❑OTHER
¢1 and Professions Cade:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
L property who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements aro not intended or offered for NEW RESIDENTIAL ELECTS SQ Ur Ills
sale.If,lowest,the buildingor lmpmvemert is sold within an yearofcompletion,theO FT FLO RA ^ $/SQ.FT
r-btlmuilder will have burden of proving that be did not build or improve for pnr-
pose o soled. -
❑el as owner of the(Sec.property,,m sines and amtraning with licensed cammrnary m
construct[M1c project(Sec.OM4,Business and Pmfesaionx Cpdu)TM10 Contmcmds
cause Law does not apply to an ownanofpmpeny who builds or lmpruvas(hereon,and QTY. PLUMBINGPERMIT FEE Q),
who contracts for such projects with a eomruemr(x)licensed pursuant to the Conv.eods f (�
License Law. PERMIT ISSUANCE Urr/'f
❑ l am exempt under Sea. ,B A,P C for this reason
1huccern ALTER-DRAIN&VENT-WATER(EA) VALUATION
ole
D V
} WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby.IBnn under penalty of pujury one of the fnllnwmg dedamtions '
❑ IhavmndwlllmainwinaCerlificn[eefConsenuo self-insure fpr Wnrku's Camper- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sstim,as provided for by Section 3900 of Iso Labor Code,for the performance of tae
work for which Chis pemtit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workcf's Compensation Insurance,as required by Section
3900 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OU'LITTS OCC.GROUP APN
My Worker's Compensation Insurance comer and Policy nmnaer am'.
Carrier: Policy No.; GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRI,WASTE INTERCEPTOR
(This section need oat be immpluad it heperuch is fnr)ne hundred done,($100) H_ .DIVISION FEES
less.) GREASETRAP PLANCIIEC P,
I certify Card In the any Performance thee,t work m wake t to permit is issued,I shall
not employ an y SEWER-SANITARY-STORM EA.21N1 PT.
p y y ocean in an manner so as m become subject the Workers'Gumpert- ENERGY
Z
outran Law,of Crinoline.Data
z Applicant WA'lEli f{EATER WIVEN'C/ELBC'!R GRADIN
h
NOTICE PO APPLICANT:If,alter making thio Cenificate of Exemption,you should WATER SYSTEM/TREATING SOIL.
abecome subject 1.the Weaker'.s Compensation provisions of the Lubar Code,you must
Gt1 forthwith comply with such prevision,orthis permit shall be deemed revoked WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDI?N'lIAl.PLMB. SQ.FT. PAID 4.—1c
Receipt#
L) O l her which nm thinpermit i is nal(Sec,
lending agency for the performance pr'
o [hewers for whish this permit is issued(See 3092 Civ.C.) - TOTAL:
Q ULentle(e Name
V4Lender's Address
I certify that 1 have rend this application and state that the above Inf sec atior Is BUILD G PDD
h curtail.I egoism comply all all city tolerantly ordinances and state laws rearing to QTY. MECHANICAL PERMIT FEE -
V Z building conewcllnn,and herchy.mhoriu rcpresenmdves of this city ro enter upon the SITE CITE
.hove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to Isle,indemnify sad keep hairless the City of Carleton.again,[ ELE BICEPS
ludilines,judgments,cost and expenses which may in anyway aecma against said City
in consequence of the granting of this permit, ALTER OR ADD TO MECH. PLO BINGFEE
APPLICANT UNDERSTANDS AND WILL COMPLY W I'ft1 ALL NON-POINT AIR HANDLING UNIT GG 10.000 CFM)
SOURCE
/REGULATIO".. MEC FEE
L*L(Ag AIR HANDLING UNIT(OVER 10,oll CFM) CONSTRUCTION X
SI mof Ap i JCluractp Date EXHAUST HOOD(W/DUCT) HOUSING MITIGA'!I NPEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous material HF.ATI NO UNIT(TO 100,1NN)BTU)
as defined by Che Cupertino Municipal Code,Chapter 9.12,and @e Hee¢.and Safety
Coro,Section 25532(x)1 HEATING UNIT(OVER 100,M)BTU)
❑Yes El No VENTILATION FAN(SINGLE RESHE PAID
Dateeci I#
Will life applicant or furore
building
uhu equipment deviceswhich
emit hazvrdes air as Aimed by the Bay Are.AirQuality Mvnugemnt BOILER-COMP(3HP OR IW,OW BTU)
TOTAL,
Oisbic'?
r-1 Yes No BOILER-COM P(OVER IW,000 BTU)
I have teed the hazardous mamnxls reyuircmemv under Chnpterfi95 of the Cvll- AIRCONDITIONER ISSUANCE DATE
Recent Health&Safety Code Sections 25505,25533 and 25534.1 understand that if tae NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have tenant,that it is my responsibility to many the occupant
of the rameirunents whish na,lb,me,prier to issuanee of a C nlficac or Oe uparmy.
Owcarorau labnoed agent - Date L. ISSUED BY:
OFFICE l