S0001C0426 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BAL OINT PEN ONLY
CITY OF CUPERTINO BDILDINC. F.LECTRICAh PF . f N$0426 0 4 2 6
BUILDING DIVISION APPLICATION/PERMIT I'LUMn NG-MECHANICAL ;T7
.
HIBLDING PROJECT IDEN'1'IPICATION
1141K� RHSS:P 4
�4.. AI ION IDBM�AL DATE
OWNER'S NAME: HONE: NIRACfOR'S NAMIi:.IefD � ONTROLp
ARCHITECI'/ENGINIi R: X-�Va LIC NO: UHE S: � zs S `
CONTACT: PHONE, IW1 L BUILDING PERMIT INFO
❑ Consultant Etc..,Paid by Applicant(Initial) P'Un ELECT PDM MECH
I I ❑ ❑
LICENSED CONTRACTOR'S DIiCLARA'1'ION QTY ELECTRIC PERMIT FEE
I hereby affirm that I um licensed under provisions of Chapter 9lconowne"g JOB DESCRIPTION
Z with Section](NXB of Division lid Businessland Pmfes,inn, 'ccnw is RESIDENTIAL'
IAO ,/n� PERMI"1'ISSUANCE RESIDENTIAL
� in toll limeanJ cll'ec pq I ❑SPDWI. ❑KI"ICHIiN RCh10Dli1.
<UU Liven.+e lass Lica 1 APPLIANCES-RESIDENT IAL ❑ADDITION ❑PLUMBING RE-PIPE
�Q,6 Dale ARCIIITECI"S IDECLAHATION ❑MULTI-UNCI' ❑STRUCTURAL
F N Z 1 unJcrsmnJ m l I II h mcJ as hlic rea,Ns PANELS MODIFICATION'
OZN— YPan+sm Pu UP'10200 AMPS
❑INTERIOR ❑CHIMNEY REPAIR
FyFy�j Licensed Pmfv,,mml 201-I000AMPS IMPROVEMENT E)SWIMMING POOLS
OWNER-BUILDER DECLARATION
,� OVER 1000AMl'S ❑tlATH RE!vIODE1lRL'PAIR ❑DI?MOLITION
C C Q 1 hereby affirm that 1 con exempt Irom the Cnntraclnr's License Law fur Ibe ❑ .TIER jC
K OaU following....(Section 9031.5.Business and Professions Cock:Any city ne county SIGNS ELECTRICAL
W 311,y¢ whim requires a permit to ttmeaum,alcor,Improve.demolish,or repair any.uumme MC
O.i prioto itsmance al,.requires mcapprcamlo -,licmdt In lilcasisned.latemnn SPECIAL.CIRCDI OMISC.
f,Wy thin rte ix licensed pur+uam m the provisions of the Contrecu,r's License low Chapter COMMERCIAL'
�lyp0
(commencing with Section 7000)of Division]ofthe Business
and Professions CuJe)or TEM1tI'.METER ON POLT:INST.
tY y o rG Ihln ne i.+"evempt Ihcrcfmm and me basis for the alleged excmpean.Any violation of C3 NEW BLDG/ADDITION ❑DEMOLITION
W—y
Seen m170315 by any np,Iuma tar a pennit'object'the applicant 10 it civil penalty of POWER DEVICES ❑lENANT C1 1700D S17RVICE
not mote than five hundred dollars F$500). IMPROVEMI1I
�=QO [11,co.n,marofthe Noun,or my employees with wages as their role compensation. SWIMMING M%)L ELECTRIC ElOl'HER
E. will do do,work unit tnatmcuuc is not inerdedor.Hered fn ,ale(See.]Ulg.Bovines
I.�l—m and Pmlcsaians Cale The Commcn,r'.+License Law does sol apply to an owner of OU'I'I.GI'S-SWI'T'CHES-PI%TURKS
a3— properly who builds or unfurlthereon.and who Jens such work himself or through NEW RESIDENTIAL ELfiCI'R
his own employes,provided that such Improvements are not intended or offered for SV. .FLOOR A
sown,,,nowcv will have
th ng m en of proving that h da ,u build
r improve
ar-
rMuildcr will have the burden of proving Ism he did na M1uiIJ or improve for par- r'I ELT
pssc of xTOTAL
Pa owner
U D
1,as owner of the prolcnY'•um exclu+ively contracting with licensed contractors to
mshom he pmjccl ISec.9014,Businc,s and Profession,Code.)Tim Contractor's 1_i-
xlawdoesnolapplytoanownerolpropertywhobuildsorimprovesthercon,and QTY. PLUMBING PERMIT FEE JUL
who contracts for such projects with a cnmractod0licensed purmantto the Contractors
Liccnsc Law. PERMIT ISSUANCE
[ I ant exempt under Sm. .H&P C total,reason
ALTER-DRAIN&VENT-WAIEH(FA) V LUATION
Owner Dale
WORKEH:SCOMI'IiNSA'TION DECLARATION BACK PLOW PROTECT'.DEVICE O
,,,,",.,So
herehy afSo under penalty of perjury one of me following declarations: X
❑Ihavu and will muintaina Ccnifia¢of Conscmm selfLinsurelor Workers Compen- DRAINS-FLOOR,ROOF.AHE\,CORD. STORIES '1'YPIi CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,Iia the performance of the
work for which this pmund Is issued. FI%ILNES-E'ER TRAP
1 have and will maintain Workers Compensation Insurance,us required by Section
t]glof]heed CINe,fonhe performance afore work fur which oris pennilrsiss.c GAS-EA.SYSTEM-1 INC.3OUTLETS (KC.GROUP AYN
My Warks ,m t1`Ylti�und Policy
Carrier. IVzVV Policy No.: CAS-GA.SVSTF,M-OVI?R4(EA)
CIiRTIFICA'I'T:OF E%IiMPTTON ICOM WORKERS' GRP,ASEIINDIISTRL WASTE INTIiRCEPNR
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(Ellis acadnn need not b:ulntpletcJ ifthc permit is iia nncnmulrcJ dollars($IqB GREASL'"TRAP
1'hANCI IECK IEE
.a less]
I anify morin the pertormancrofthe work for which this p:mtil isisucd.l shall SEWER-SANITARY-STORM IiA.200 FT. ENERGY FEII
nnl enlploy.ny Anaxon in any munncr su os to bm:omc subjget to the Workers'Compcn-
Oz smion la�syySSWyV'Coll)ym DatF'll_ WAI'IiR HEATER WNIiNI'IELEC'TIt GRADING I'TH '
z O APPlicankJ'/ U�
NOTICE TOA 1'LICANT:If,af¢r making oris Ccnificme of Exempuom you should WATER SYSTISM?BEATING SOILS FEE
F c will compWurh Nevis
in did provisions of the Labor C�Ne,yon moot
1 � fnnM1wit6 comply with such provisiomor]hie pennil shut]Mdevoted revoked. WAI'IiH SERVICE
(]
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLFIB, SV.fT. PAID Data Receipt
Vz I herehyulTrm tha Tien ixui tare,tin t1craingagency[.r Ill perfnnnunve.f
the warkfor which oris permit is ixwN(Sec.3110,Civ.CJ 'TOTAL:
0Imdur,Name Tt
V Lender,Addrcu
>" (1.1 1 ccnilY that 1 novo rad this applicmi.n unit slam that thu nhavc to m atiun is BUILDING PHIL
F' 4' R QTY. MECHANICAL PERMIT FEE
0. mares.]agree thcomplywithallcityandnsuntydstalet and vac lows refining m SEISMIC FEE
U IZ building construction.and hereby authorize representatives of this city to enter upon the
ahovenuentioned proper y for inspection Impows, PERMIT ISS DANCE
ELECTRIC
(We)ugmc v,mvc,indemnify and keep harmless the y ac ons,lag cxlm,id City
liabilities,judgmcros.c dom expanses which may in any way accrue against aid City ALTER OR ADD TO MECH. PLUMBING FE
in nm,nluenee of the nmin sFlhh permit.
APPLICANT'UN's NS')�S ANU I�{'f. .C(1 IPLY WITH ALL NON-POINT AIR HANDLING UNIT(to IUIXXICFM) MIiCHANIC .FEE
SOURCE TI fkl
AIR HANDLING UNIT(OVER H).000CFM) CONSTRUMI TAX
Sig roolApplic' tmemr Druce EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIAE S DISCLOSURE
Will be applicant or future Wilding occupant smarm handle hmzaN.uzmnterml HEATING UNIT(TO IN)."BTU)
as defined by the Cupenina Mnnicipul Coda,Chanter 9.12,and the Haulm and Safety HI'AI.TNG UNIT(OVER 100.000 BIT)
Cute.Section 25552(.)4 ,,II���
DYe, MV�I�TIOI[NN(SINGLE RESID) PAID
Date Rceript a
Am I WiII Incuppliaut or future building occupant use apipmm�t or devices which (3HP OR I(N%000 BTU)
emit barnocim,air emourairems as defined by the Bay Arca Air Quality hlenag normDistrict? (OVER KILW0 BTU)Ye, ZkNo
1have reu{{me hmardous mamr.1uan".ulalerChalon695oftheCali- ER ISSUANCIi DAl'F,fnmia HcaRh fc e,Scn, 505.2$lJ unJ 25533.I undcrstanJ mm if the I.MECH. SQ.FT. �� / (7!�cjll I Irmo thalllpomihillay amntify the occupumIInlo hallponihiGly 1.notify me occupant�m p' ni eolaCcnlicaleo(Icu�iout o zed agent UulcTOTAL: ISSUED BY:
OFFICE