S 3817 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPF.RMIT PLUMBING-.MECHANICAL 8 1 C O '1
BUILDING PROJECT IDF.NTIF-ICATION J
BUILDINGADDRfSS: SANITARY NO. APPLICATION SUBMITTAL DATE
e .f < 5'
OW 'S ME: PIIONE: C RACTOR'S NAME: LIC NO',
,(� ZE-1 N/c coN'raDl.0
ARCH TECT/ENGINEER: LIC NO A)fJd�C CMFE-i l N�•� O l ❑
CONTACT: PHONE: •//l BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ E?� ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
09Z1 hereby affirm that turn licensed under provisions rf chapter 9(commencing ( JOB DESCRIPTION
'00 111hS dint, 00(b.1 Division 3ofthc Btuinessand Prufr_vvi mCusle,andri ceus is PERMIT ISSUANCE. RESIDENTIAL:
�1 _ in
�I t ❑SFDWL ❑KITCHEN REMODEL
auu Liccnsc Chis Lich — APPLIANCES-RfSIDEN'I IAL El ADDITION [I PLUMBING RE-PIPE
IF a W Dae contra.�. J•1�'i(
F>,� ARCHI'IFCPS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
Z C)y Z I understand any plans shall be usedas public records MODIFICATION
pZ-0 UP'10200 AMPS
[I INTERIOR El CHIMNEY REPAIR
W Liccnwd Prufm.iaml 201-IWANIPS IMPROVEMENT SWIMMING POOLS
•xp+�C G I hereby Ahm that that eNER xempt Rom he C ntruaurx License Law for the OVER 1 WO AMPS ❑BATH REMODEI/REPAIR ❑DEMOLITION
ac 3 A.U following reason.(Section 9031.5,Business and Professions Cale:Any city or comay SIGNS ELECTRICAL El OTHER
nl W N which requires a auras,In roh,dmrt,all,,,imprnve.Jcm.lish,nr repair any amcmre � O
prior o its issuance,also requires the applicant for such permit to file a signed statement 1 SPECIAL CIRCUIT/MI SC.
f,�ytbutheishantredpursuanttothepruvisionsoftheContractor'sLicenseLa.(Chapter9
W5oC, (commencing with Section I(Mbyf Division 3.fthe Ineinexsand Professions Cnde)nr TEMP.METER OR POLI INST. COMMERCIAL'
Q.a cC that he is erempl therefrom and the basis for the alleged exemption.Any victim..of ❑NEW BLDG/ADDITION ❑DEMOLITION
W_N Section 90315 by any applicant for a Permit subjects the applicant n a civil penalty of POWER DEVICES Ll TENANT ❑FOOD SERVICE
not mom than five hundred dollars($5(10).
F.Z Y IMPROVEMENT
_< wiLo the work,
the pand estruc.i myemployees with ed ordered fosale(Sec.compensation, SWIMMING POOL ELECTRIC at�p.,-2 will do essions Cudc: he Cont la tors License La dos not apply 90Aa,Busowner of ❑OTHER
L w m and I'm whore Cede:The improve,
t Contractors License Law, m,not apply m an owner of OUTLETS-SWITCHES_pt,%TURF,$
In,o ny who builds or,,id,d es thcrchn,and who does on eh work deed o himself...thnmgh
his own employees e proldan, That such Imprrve.bI w arc nut mammae or offered for NEW RESIUEN'1'IAI.IiLIiC'TR SQ F1'.
sole If.howeveq the huilAing nrimpnrvemhnt is rold within one yenr.f completion,IM1e SQ.PI'.FLOOR AREA QSQ.Fn
owncolnuilder will have the burden of proving that he did not Saild or improve for par-
prove ofsals.). _
L as owner of the Property,am exclusively contracting with licensed contractors to T
construct the Pracer(Sec.7044,Business and Profession,C,de:)The Carriacou's Li-
screw law does net apply to an owner of poi who builds or improves thereon.and QTY, PLUMBING PERMIT y FEE II !tel] `J
who contracts for such projects with a emutictor(,)Iicenwd pursuant to the Contractor's
License Law. PERMIT ISSUANCd
I am caempt under See ,B A,P C far thii;mi 999
AIaIiR-URA
IN VIiN'1 1'BR BBA)
Owner Dale
I VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. 1
I hereby affirm under penalty of perjury one of he following declarations:
I have and will harindlnaCenificmeof Commat towlf-insure mrWorkers Compere- DRAINS-FLOOR.ROOK AREA.CON . L, INSTRUCTION
cation,as provided for by Section 3700 of the Labor Gale,for he Performance of Ne --�•
work for which Nis permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
391X1 ofthc Labor CeM1e,for he perhrnance afhe work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker s Compensation Insurance carrier and Policy number are
Caner; Policy No.: I GAS-P.A.SYSTEM OVER 4IEA)
GERTII'IGSTIi OI+EXEMITION PROM WORKIiRS GRIiASF/INIIDSTRL WASTE IN'TERCEI'TOR
COMP.NSATION INSURANCI! BUILDING DIVISION PEES
(This seclinnne t te contplGed if the permit lx Ra ane hundrcJ Jnlian($IW) GREASE TRAP
nr less.) PLANCHECK FEB
Iccrify 4inth )t fthe work for which his mail is issued,Ixhall SEWER-SANITARY-STORM EA.200 FT.
nm employ an lea b to the Workers Co.,.- ENERGY FEE
Z satin.Laws nfC r .�fir t yp r�py•ILM�Ieq WATER HEATER WNENT/ELECTR
zQ Applicants -lLID 7 __ GRADING FEE
NOTICE TOA PUCANT:It after making this Certificate of Exemption,you should WATER SYSTEMOREATING.
h 5: become subject to he Worker's Cnnpensation provixinrvs of the Labor Code,you mast, SOILS Fri.
tv
dna 1'onhwith amply wuh.such po—kiotennhix permit shall bodecmW rev.ked. WATERSHRVICB
0. Q CONS isac .. LENDING AG IiNCY NEW ftFS11JEYTIAh PLMB. SQ.FT. PAID
V 0 Ihcreby off rn that there isaconstrvction lending agency for he performance of I tic Rcceiptp
F'D. the work fur which this permit is icmcd(See 3099.Civ.C.) TOTAL
C) Undcrs Name .
ULetalce,Address TOTAL:
y 1 certify that 1 have mad this application and sure that the above inf.mtmirn is BUILDI EIII
F(n cutmm.I agree m comply with all city and county ordinance.and store laws miming to QTY. MECHANICAL PERMIT FEE
L) Z makfing eon 'o and hereby actinium mpresentntivcs ofthis city 10 enter upon the SEISMIC PEL
abovue toned In my for inipemion purPascc l PERMIT ISSUANCE ELECTRIC
(Wc)agree t s indenmlfy unJ keep harmless the Chy of Cupcnino ag+tin.,, ELECTRIC P
liubik1A
dgm �ntsmW cxpcns 'hich may in any way accrue againsuuiJCity At,]17R OR ADD 10 MIiClI.
in f gruntingof tti pc it.Pe" FR.0 NDS ND IL COMPLY WITH ALL NON-POINT AIR HANDLIeNG UNIT(TO 10.OtIDCFM).C, AT N. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000CFSD CONSTRUCTION TAX
Sig mm mApplicanUCnmmnnr Dare EXHAUST FOOD(W/DUCT) HOUSINGMITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle M1mard.uamrtenal HEATING ON[-[(TO 100,000 BTU)
as defined by]he Chardon Municipal Colo.Chapter 9,12,and the Health and Safety
Cuda,Section 25532(x)'! HE
A'TING UNIT(OVER HML(MM1 BTU)
Ycs 0 No
VENTILATION PAN(SINGLE RESID) PAID Dam Receipt e
. Will the applicant or fumrc building occupant use equipment or devices which
emit hazardous air contaminants a defined by the Bay Arca Air Quality Management TOTAL:(3HP OR IW.000 BTU) .
TOTAL
Distract? BOILER-COMP(OVER 100.000 BTU)
❑No
go
Ahhe,ardou led requirements under Chapter 6.95 ofthe Culi. AIR CONDO[ONF.R ISSUANCE DATE
foury Cnlc, coli t s 55115,8533 anJ 25514.1 unJeestrd Nm it the NIiW'RESIDENTIAL MliCll. SQ.FT.buil •allyl ve n1.Nm hiss myrespnn,ih llty to nalfy the...... nofhich aPl4• uamis enfa Ceniticaterf OccupancY.
O.—caamhoremd agent Date T 1- ISSUEDBY:
I Is
OFFICE