29250 (2) •"APPLICANT TO FILL'IN INFORMATION WITHIN RED LINES--USE BALL POINT PEN ONLY.
CITY OF CUPERTINO , n BUILDING.ELECTRICAL PERMIT NO. O
BUILDINGDIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDRNTIFICATION - - .a t
BUILDINGADDRESS.- - �' - r / ♦ SAM IARY PPLICAI'ION SUBMITTAL DATE
OWN 'S NAME-a P ONE. CON C O SNAME: y�CNO:
CT/` 11GJ �.Al ROLARCHTT.CD INEEB: /ILIC AE
-
CONTACT: PHONE: ' - -
I, BUILDING'PERMIT INFO
n/`, l ^^��S - ❑'Consultant Fees Paid by Applicant(Intnal) BLD ELECT; PLO M_E
GI/ �LfICENSED CONTRACfXORS DECLARA N QTY ELECTRIC PERMIT FEE
1 he by [firm that 1 1'e.e 1 under pmvis ons o[Ch t 9( mmedcing ' JOB-DESCRIPTION_ '
W0 with Section 7000)of Di 3 of the Business and Professhism d yo'else's RR ID .NTIAL
�UVm full force and effect. PERMIT ISSUANCE
License Cl.. Lic,# ❑SFDWI. - '❑KITCHEN REMODEL
I- ❑] Dale APPLIANCES RESIDENTIAL
On L Gmtraomr ❑ADDITION s. ❑PLUMBING,RE-PIPE
ARCHITECT'S DECLARATION PANELS - - ❑MULTI-UNIT
Oy IunderswnJm 1 ❑STRUCTURAL
'Z • Y P ons shall be used as public records - n MODIFICATION
'UP T02f1(lAMPS El�tq�11 Licensed Pmfessional - - ❑CHIMNEY REPAIR
� 2061WOAMPS IMPROVEMENT
Oat I am exempt
from
DECLARATION
.] OVER 101X1AMP5
p� RJ Q .1 learn affirm that I am exempt from mo.Comracmrs License Law form _ ❑BATH REMODEL/REPAIR 0 DEMOLITION_
%�dVr followingr (Sanction?0115 B . dP f. ' CW A t dt
3 f capriole p n i construct, h Y y °y SIGNS ELECTRICAL ❑OTHER
O which p e demolish,h p any i muro
�jy prom teat I. y ' theppT Ife Jap Itis g JCiImem SPECIAL CIRCUIT/MfSC
GOO [hath t 1' dp r.rent theprovisionsItheContractor's I Lew(Ch pmr9
le mal c g thSeeta 7001ry fDiemeni fth Business dliaeons Code),,, '•MP.METER OR POLE INST COMMERCIAL'
fii #1 that he is exempt Iherefmm and the basis for the alleged exemption.Any violation of - . . - N W BLDG/ADDITION ❑DEMOLITION
l",,,j Wy Section 703165 by aal.ppliwnt for a peemit Ni the applicant too civil penalty of PO :R DEVICES,'. s;
N y act mora than rive hundred dollars($500), NANT :O FOOD SERVICE
• CQ ❑I,as owner of the property,or my employees with wages as their sole compensation, SWIM NGPOOLELECTRIC `. I OVEMENT
,C+ wJl do the work add the stmewreisnet intendedmaffered farsala(See 7014,Business ❑OTHgR
3 and Prafessitns•Cnde The Contmcmrs License Law does tat apply to an owner of OUTLETS SWITCHES-FIXTURES
property who builds or i npmves thereon,and who does siren work himself or through" 9gy�
his own employees.provided that such improvements are not tended or offered for NEW RESIDE TIAL ELECTR SQ FT.
-sale ifh erthe building oriniprovementis sold within one year fcmpletion,the - SQ.FT.FhOOR AREA $/SQ.FT.
nerbuilderevill have theburden fp- ng that he did nor buildimprove' for - x - "'
Insecticide.). - , •' 'd
❑1 as owner of the Property, m exclusively contracting will,licensedcontractors to TOTAL: ��
construct the pnaeat(See7040 Business and PI-fiellion,Cad )The Cmaricarce,U ' 1 (�
c ss Law does not apply r f p p rty h h ld np ves thereon dad TY U / U
- who commas mas for such projects with acodtmcl OI'e"sed pursuant to the Contractors ACE 14 LVYfi.
LseIain nac xLaw
❑ eempt under Sec B&PC for this revsI oa PER N/fin
Owner' Date AL • VALUATION
Illpl
_ WORKER S COMPENSATION DECLARATION SBA '11
ND
I hereby affirm under penalty of perpary one of the following declamt on _
❑I have and will maintain a Certificate ofConsent m selfmsure for Workers Compen- DR E
•�gotten,as provided to;by Section 3700 of the Labor Code,for the Performance of the STORIES TYPE CONSTRUCTION
work for which this Permit is issued. SF'' Fl 'P _
1 have and will mainwln Worker's Compensation Insumnee,as required by Section _
37(hi fthe Labor Cade,far performance of the work for whichdin,permit is issued.^ G - OU ,OCC.GROUP ppN
My Wor em's pnsati In ane artier and Polic trber are' ,i.
Camer> '�Palicy No. _ �I GA.
-EA.SYS M-OVER 4(EA -
CERT dCATF.OP EXEMPTION FROM WORKERS' r}�, - -
_ COMPENSATION INSURANCE : G )USTRL WASTE IN TERCEPTOR
- (Th.sect on neednot he complwedifthepermidsforeneh ndred dollew(MOE I%, ti (BUILDING DIVISIONFEES
ar less.) GREASETRAP
I carry thai'n taep rl rte fthew kf rwhich this pe t' issued,lshall CANCH
not employ any Person in any roamer so a,to becomesubject to the Workers'Civilian. S •ew%-STO
z `/.. smion Laws of California.D t WATER HEATER WNENT E R
0 Applies.[ ` "
NOTIOE TO APPLICANT If,after making this Certificate of Exemption, GRAD NO FE you should ^
aS become subject to the Worker's Compensation provisions of the Labor Gude,you most. .r SOIISTEE
Lk1 Qforthwith comply with such For,shares or this permit shall be deemed revoked.
WATER SERVICE
CONSTRUCTIONLENDINGAGENCY s
z NE RBSIDENTIALPLMB. SQ.FT. P D
V O �Ih byaffirm that theren nst ci nl ndiiig agemyfortheperfonwnce of Date R cip1K
Oi-+ the work far which tars Permit is issued(See 3097,Crv,C.) r
ULender N TO C' ^
Liz Lender Address TO
1t I cert fy that I have d this application and state that the above information is ILDI
Cn correct,Iagree to comply wit all oy and'ounty Ordinances and state laws relating to Q MEC VN PERMIT FEE� building e,nsuucbon and hereby authnnze represcritmives of this enter upon the SEISM( F
Iibawa-ftwruiwnad famport,for inspection-pump -
(W)agree to save. d n fy and keep hadmilessth
City
LaFliti 3"dgments,cnsys d xp whit a non CitYof Cupertino PERMI S NCP;
ELF.CfRIC C •
onsequence of the in Y Yway ottrue against suit City ALTER ORA ,CH. - --
me graining of this pc .. PLUMBING FEE
APPLIC RE UNDERSTANDS AN I MPLY W TIT ALL NON,POINT AIR HANDLING UNI 0, )
SOU REGULATIONS_ 9 _ MECHANICAL ,
1-a-
'� AIR HANDLING UNIT,(GIVE Birth CFM)
ig of Applicant/Commemr. Date , CONSTRUC ONT ,
r HAZARDOUS TRIALS DISCLOSURE EXHAUST HOOD(W/DUCT) 'HOUSINGM IGATION
Will the applicant capture Iding oceupem sorra or henJla fiazdNous material HEATING UNIT(TO IOo,IXNI BTU)
s defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sectio"25532(a)? HEATING UNIT(OVER I00,000111U /
E3 Y's Ll No
r - - , VENTILATION FAN(SINGLE RESID) . PA
Will the applicant or frame of lthat,aemipont ase equipmem or•devices which to Receipt is -
enifthazardousaircontaminantsasdefinedbytheBayAreaAirQualityManagement BOILER-COME(3HPOR100,000ITT
G)-
Diatrict?' �• '
❑Yes [I No
- BOILER-COME(OVER 100,000 BTU)
I has iled the hazard' mate'alisra h AIR CONDITIONER - -
ray sent der Chapter flat If - r ISSUANCE DA
fan Health&Safety Cod S t .25505 25513 a d 25534.I u de t d thatf the
M1uilding does not cumillyhres tenon,that it is my responsibility to"only the occupant NEW RESIDENTIAL MEC H. - 'd SQ.FT -
ofinemquiremenswhichmusthemetpriartoissuance of a Certificate of Carrier , r-
Own l or amhanzed agent - Dam ^ - -
. TOTAL: .ISSUED BY.- t
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