S 2388 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLOMBING-MI?CHANIC L
BUILDING PROJECT IDENTIF'ICA'TION
I
PERMIT NO.
(N n Q
S L o
BUILDING ADDRESS�O/�O La -r-
t
SANITARY NO.
APPLICATION SUBMITTAL DATE
(16—(9
OWkJ[RN�W&;
��JJ77 88 NN
Se I'I{IINLU-.0o�
CONTRACTOR'S NAME: LIC NO:
NIC
❑
CONTNIILM
• ARCHI I CCUENGINEHR: LIC NO:
ADDRESS:
CONTACT. PHONE
V/(9 'I �� 4 _ Ii g
❑ Consultant Fees Paid by Applicant (Initial)
Bl11LDING I'HRMIT INFO
BIXU ELECT PLUMB MECH
11 ElII,� ❑
LICENSED CONTRACTOR'S DECLARATION
I harchy alErm ilial I len licensed under provisions of chapter 9 anmmeneing
QTY HLECTRICPERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
with Section /(00) of Division 3 of the Business and Professions Cada, and my license is
in full force and cheap.
RESIDENTIAL:
El SECANT. ❑ KITCHEN REMODEL
APPLIANCES - RESIDENTIAI,
Dem Coptfu
])aireClass Cour'
El ADDITION El PLUMBING RI PIPE
❑h1ULTl-UNIT ❑STRUCTURAL
MODIFICATION
❑ INTER [OR ❑ Cl II M NF.Y R EPA IR
IMPROVEMENT SWIMMING POOLS
DECLARATION
ARCHThe,
1 understand my plans shallll be usul as public records
PANELS
UP TO 200 AMPS
Licensed Professional
201-1000AMPS
OWNER -BUILDER DECLARATION
I hereby affirm The, I an exempt from the Contractor', License Law for the
following reason (Section 7031.5, Business and Pmfesurar, Crack Any city or comply
❑BATH REMODI:IJREPAIR C1 DEMOLITION
❑ OTHER X17 J�
OVER IBfI(IAh1P5
SIGNS ELEM RICAI.
which requires u permit to consumer. tiller, impowe, demolish, or repair fury sleuaum
SPECIAL. CIRCUITIMISC
6 O �—
' A 3
Run, m it, isx...rare, also require, the applicant Torsuch pennh to lileasignnl atarement
that heislicensed pursdannotheprovisionsoftheContmemr's license Law (Chapter 9
(commencing with Section 7000) of Di vision Sof the Business and Professions Code) or
1 17 E METER OR POLE INST
I
COMMERCIAL:
thin he k esadpt thamfnaat and tae basis for the alleged excmptind. Any violation of
Ll NEW BLDG/ADDI'TICS ❑ DEMOLITION
Section 7031.5 by any applicant for a pannit subjects the applicant to a civil penalty of
POWER DEVICES
❑TENANT [I FOOD SERVICE
no, marc Nan five hundred dollars (55(0).
I, us owner of the pmpcny,mmY ampinyees with wagesmtheir sale uampansatinn,
will do the work und the sunemre is nil intended proffered rustic (Sea. 9(04, Business
IMPROVEMENT
El OTI IIiR
SWIMMING POOL ELECTRIC {
OUTLETS - SWITCHES - !INTO S
mol Profession, Cale: The Commemr'n Licema Law data not apply to nn owner if
NEW RESIDENTIAL I?L1!CIR S
pmPeny who builds or improve, Neuron, and who Aces each work himself or through
his, wn employees, provided ohm .such impmvemm�ts are nil Warded cr offered for
sale.It'.how."'. the huildn"or impmvensmnlsuald w'hhninmm ye are contplaion, Ilia
owner -builder wit r butdepngingthtll'�yynintbuildorimprnveforpur-
f
SQ. Ef.IL(IOR AREA
S/SQ. Ef
TOTAL:
rnhe
c of sale.). . ct a_r,/
Darner of they pen, xclusively convecting wit- hTicelced eonturemnm
o,,dsoum the ptupal (Sea. 9(D4, Bre nese and Professions Cavle:) The Connect s J -
cause Law does not apply dim owner of Property who builds (it improves thereon, unit
QTY PLUMBING PERMIT FEF,
,
who contracts for such pmjecta with u cnmractur s) licensed pursuant o the Contractors
License law.
❑lumestan ncr Sec. ,B& P C for Ibis ret wan
1'IiliMlt'ISSUANCE 3Q
OwALTER-
DRAIN &VENT- WATER ([iA)
VALUATION
WORKER'S COMPENSATION DECLARA N
BACK FLOW PROTECT, IIEVICE
' Ihcrchy uffvm under penally til lxrjnry num of the failu inK Aedumtiuns:
❑ I have and will maintain a Cenificem of Consent o self -Insure for Worker's Compen-
smion, as peavided for by Section 3700 of the Labor Cade, for ilia performance of the
DRAINS-FhOOR,ROOEAREA,COND.
STORIES
TYPE CONSTRUC`T'ION
work for which this .it is issuask
FIXTURES - PER TRAP
❑ I have and will maintain Worker's Compensation Insurance, its raluiral by Section
3700of Ne LaMar Cals, hathe performancemthc work Buwhich this permit is issued.
GAS -EA. SYS "GEM- I INC. 4 OUT LETS
ICC. GROUP
APN
My Workers Compcnsminn Insurance carrier and Policy nun ltenare:
Cartier. Policy No.:
CA.-s.SYSTEh- WA)Fj
CERTIIICA'I'li OF EXEMPTION PROM WORKERS
COMPENSATION INSURANCE
GRI NIAP ItCWA LINT FJI'fl
BUILDING DIVISION 14?IS
(Thisseetinn needoot hecomplmal lfthe,rent isfarone hundreddallars(SIIO)
or Ices.)
GR k
PIANC11IiCK FLE
I cenify that in the performance til the work lin whichthixpcdnit is issued, I shall
subjec,, the Workers' Compen"
not employ troy person in nay manner so us,, heamm t
SMSA -. Yl M ❑'.
ENERGY 17EE
WA . HEATER WNr.NT/ELHCTR
GRADING ILE
vtian Laos of California. Date
Applicant
NOTICIi TO AI'1'LICANI`.I[afler mukinK this Cenilicare til lixcmptinn, you should
become subject or The Worker's Compensation provisions of the Lotaa Code you at I
WA Ta S'I'IiMORHA11NG
SOILS FIJI
fnnhwith comply with such pmvisimro, this permit shall ha devoted revoked.
WATER SERVICE
NEW RESIDE:NDAL PLMEL SQ. Irl'.
CONS, RULTION LENDING AGENCY
here�y:Jllrm thm Amro isuaamwminn lcmalnsagency fnrtheperlbrmnocent
PAID
Date cce"d#
the work far which this permit is issued (See. 3097, Civ, CJ
Lender's Name
y 'TOTAL:
Lender's Addreax
T
BUILDING PEE
I certify that I have wait this application and .state Ilial the above information is
nen. I agree to comply with all city and county onlinancea and state laws miningm
building commoners and hereby authorize representatives of this city m enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC PER
PERMIT ISSUANCEi
1H-EC'I RIC FEE
above-mentioned pmpeny fur inspection phpsi
(We) name as save, indemnify und keep handless the Cay of Cupertino against
IEE
D
may inanywayac[me against vialCity
liabilities,judgments. costs and expenses whichPLUMBING
in consequence of IM1e granting of Nis Pamir.
ACI Eft OR AUDIO MECH.
AIR HANDLING ONI'I' ('IO H1, df CFM)
MECIIANICALIIT
APPLICANT UNDERSTANDS AND WIL" C PLY WITH ALL NON -POINT
SOURCEIL A'I'ION5.
AIR HANDLING UNIT (OVER 10.(00CFM)
CONSTRUCTION TAX
J/I
/ ! O
J
is amre of ApplicanVConwtlnr Date
HAZARDOUS MA'ILRIAI S Is LL USE
EXHAUST HOOD(WIDOC)
HOUSING MG[GAT ION FEE
BEATING ONE "1'(TO W,(g0 BTU)
Walltheapplicant orfuture boildmgoacdpenlstorearhandle hadrohm,material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
DEALING ONI'1' (OVER Ulb" It TU)
E]. Yes No
� Will the applicant or future building occupant use equipment or devices which
!'AID
VEN'T'ILATION PAN (SINGLH RES ID)
Date Receipt a
Kit hazmdous air eonmminatne as defied by the tray Arca Air Quality Management
Disnicf)
E] yes r7 No
BOILER-COMPQHPOR 10BODITU)
T
BOILER-COME(OVER 100,000111u)100,000111u)
AIR CONDI1'IONER
I have Toad the humnloun materials requiremcros under Chapter 6.95 ofthe Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. ET.
fa nia Ilaalth & Salley Cuda. Scotia., 2550.5, 25533 und 25534. 1 understand That If tire
building Jas not currently have itenant, that it is my responsihility to notify the occupant
of the requiernaents which must he met prior to issuance are Ceniticete of Occupancy.
ISSUED BY:
TOTAL:
Conon andannieed ascan Dale
OFFICE