29580 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ,- BUILDING.-ELECTRICAL PERMITNO.2(] t,.��O
BUILDING DIVISION APPLICATIONIPF.RMIT PLUMBING-MECHANICAL J
BUILDING P41OJECT IIIENTIFICAJ'ION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
r0 NER:S NAME:d -TIC.+CT TJ PHONE: fltlC , ACIDR'S NAME' LIC NO'.
_ NIC CONTROLp
ts LA M 10
RC ECT NITER: LTCN A ESS: ❑
C1ONTACT (C' 1e V� Q(� HONE: ee BU ILDING PERMIT INFO
e �V �n ^'••�Z�� �wu ❑ Consultant Fees Paid by Applicant(Initial) BLnG ELECT PLUMB MIiCH
I � 1
LICENSED CONIRAC I'ORIS DECLARA ION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(Ammtencing JOB DESCRIPTION
o�z wnhs«Edo]moo)drinwxmn3anneBaaine.xawProre.,ronscme.andrmyueenaeia
FOO in full Three and effect. PERMIT ISSUANCE
W^ :h WL ❑KITCHEN REMODEL
F�F..UV License Clan Lica APPLIANCES-RESIDENTIAL ADDITION ❑I'I.UMBING RE PIPE
tn<W Dam Comrm:mrr
g,pt� ARCHITECTS DECLARATION PANELS MULTI-UNIT ❑STRUCTURAL
Z O m Z I understand on,plans shall be used os public record, MODIFICATION
OZ-o UP TO 200 AMPS C1 INTERIOR C1 CHIMNEY REPAIR
F�.F-W Licemetl Professional 201-10D)AMPS IMPROVEMENT
�z= OWNER-BUILDERDECLARATIONOVER1003AMPS ❑BATH REMODEUREPAIR.❑DEMOLITION
6 I hereby affirm that I.m exempt from the Contractors Licence Law for the
Lyix�S O L U Inllowing reason.(Section]031.5,Ha,mr,,and Pnlessions Code:Any cit,nr I'm.,, SIGNS ELECTRICAL EJ OTHER
W LL 1,i-
which requires a permit to ome net,aloft improve,demolish,or repair any structure
1"
poor prior to its issuance.also.,at.,theap .is plicien,for such pc.io file.signed stammer, SPECIAL CIRCUITIMISC, n _
}
the,hei.s licereedpursnnm to the I vimons of the Contractor s License Law(Chapter 9eaofcsiv {�
�0 (commencing with Section AM)of Division lot the Ruslns and Prnm CnJe)or TAMP.METER OR POLE INST. y
L y o C that he is exempt therefrom and the buffs for the alleged exemption.Any violation of ❑NE WI BLDG/ADDITION ElDEMOLITION
>LLCl 4•
Section 7031.5 by any applican,for apennitsubjcets the applicant m a civil penalty of POWER DEVICES ❑TENANTV. VUf L1l1 El FOOD SERVICE
n more than rive hundred dollars($500),
S W IMMING POOL ELECTRIC IMPROVEMENT
I,as owner of the propeny.or my empinyccs with wages as their sole compensation,
� O will doth,work,aodthesaam shut intendedorof(ereer
d forsale(S .]0¢4.B.6tre. ❑OTHER
h-
W 3 m and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
propeny who build,nr improves thereon,and who does such work himself or through
his awn employers,provided that.such improvements are not intended o oflercJ for NEW RESIDENTIAL 171 ECI'R SQ IT.
sale.If.however,the building or improvement issold withinonse year ofcompletion.the 1 SQ.FT.PLOORAREA Vs Q.EF.
caner-builder will have the burden ofproving that he did no,build or improve for pur- e
po,e of sole.).
0 1,as owner of The property,.,it exclusively contracting with licensed contractors to
construct the project(Sec.]BW,Business and Professihns Code:)The Contractors Li. Zs7 .1S
.
c e Law does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE Vim+ �Y L.
who connects for such projects with a contractor(s)licensed pursuant to the Conmecler's
License Low. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
0 Date -
WORKERS COMPENSATIONDECLARATION HACK FLOW PROTECT.DEVICE / I ���
• I hereby affirm mile,pennhy of pr6m,one of the following declamtions: J C..
I have and will maintain a Certificate of Consent to self-insure for Worker's Comped- DRAINS-FLOOR,ROOF,AREA,COND,
STORIES TYP[CONSTRUCTION
work
as pn h thi for by Ss issued.
J](g)hl The Lab or Gdc,for the perfonn.ncc of the
work far which this maintain
is issued. FIXTURES-PER TRAP
CJ 1 have ami will maintain Workers Compensation te ak far hi h squired by Section
JAp of the L.M1nrCodefor, the perfomrance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4OUTLETS OCC.GROUP AVN
My Worker's Compensation Insurance cmrientnd Policy ntanecr arc:
Carrier: Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE.01'EXEMPTION FROM WORKERS' GREASF/INUUSTRL WASTE IM'f:RCEPfOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(ThisseOrn need not beaanplmedd the permit is roore hundred dollar,it 1 Old GREASE TRAP
or less.) PLANCHECK FEE �0
I certify that in the performanceofthe work far whichthis permit is issued,lc hall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so m to become.subject to the Workers'Comped- ENERGY FEE
O Z .cation laws of California.Dam WA'I'T7R HEATER WIVENTIELEC'IR GRADING FEE
Z Applicant
N NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/1'REATING
s ; become subject to the Worker,Compensation provisions of the Labor Code,you must SOUS FEE
forthwith comply with such provisions or permit shall be dcemud revoked WATER SERVICE
7Z CONSTRUCTION NEW RESIDPNTIALPIbfB. SQ.FT. PAID Dam Receipts
V Ihcreby off rn
nbar there ianconswction lending agency for the perfnmmnce of
F' the work for which this permit is Issued(See.903],Civ.C.)
Da Leaders Name ll)TAL:
yr. V Lenders Address TOTAL: 4 J.
I real fy That 1 have read this application and state that the above infonamiaaka
an is �� BUILDING P!E
N correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby dmhodzerepreuntatives ofthis city mender upon the SEISMIC FEE
above-mentioned propeny for inspection purposes. PERMIT ISSUANCE �/�
(We)agree to sive,indufy ad nkeep hannlcus the City of Cupertino.gainer ELECTRIC FEC
utmAu s'y 1
Imbilities,judgments.costn and expenses which may in any way itemeagairst otid City ALT ER OR ADD TO MECH. /^g
in consequence of the granting ofthis permit. PLUMBING PEG ` n'1
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AI NO '-POINT AIR HANDLING UNIT(TO TO,=)CFM) A
SOUR( REGULA'T INS. MECHANICAL FEE Y
AIR HANDLING UNIT(OVER 1(1,1X10 CFM) CONSTRUCTION TAX
Signature hf Appfcmt,Co uacha ate EXHAUST HOOD(WR)UC7D HOUSING MITIGATION FEE
HA RDOIIS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle h.zmdous material HEATING UNIT(TO 100.010 BTU)
as definad by the Cupertino Municipal Code,Chapter 9.12,and the Health.ad Safety
Code,Section 25532(.)] HEATING UNIT(OVER IOn"BTU)
[:J Ye" F1 No, VENTILATION FAN(SINGLE RESID) PATO Date Receipts
Will the applicam or future building hesupant use equipment or device,which BOILER-COM11P(JHP OR I W.qU BTU)
mhwardous air carman.mme as defined by the Buy Area Air Quality Management TOTAL:
Di,it ki! BOILER-COMP(OVER I00,IX(1 BTU)
❑Yes f-1 No
I have read the haeardauc materials requirement,under Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fismia Health&Safely Code,Sections 25585,25533 and 25534.I understand that if the NEW RESIDEN'T'IAL MECH. SQ.Er.
building does ma currently have a tenant,that it is my responsibility to notify the occupant
of the requirement'which must be met prior,.issuu.ce of a Certificate of Occupancy.
Owner or authorized agent Date `IDTAL: 141 I ISSUED BY:
OFFICE
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