31444 (2) -•APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT ND. 314 4 4
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION '
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
17
OWNS ' N ME: PHONE: C ACI" 'SN 1E: LIC NO:
' G�G Ain/1 NIC CONTROL,.
ARCHIMCI"/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: x PHONE: BUILDlKG PERMIT INFO
/f C7,ff z? 1�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG LECT PLUMB MECH
-/ s ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FT:E
I M1ereby afRtm that I um licensed under provisions of Chapter 9(annmen<in3 JOB DESCRIPTIONpZ whh section]INlO fD tohthe Nosiness an 'rnfesslomC ay�ny licensees RESIDENTIAL,
mad- m2llfmcean if -X7 f�S- / PERMIT ISSUANCE
aU License Class / Lic.N `� OSFDWL El KITCHEN REMODEL
Dore Cammwa APPLIANCES-RESIDENTIAL.
❑ADDITION ❑PLUMBING RF.-PIPE.
II--��ZQZQZQ7 a' ANCI{G'EC'I"S DECLARATION �YIHQ� PANELS ❑MOLT-UNIT ❑STRUCf AL
Z O N Z 1 indent tand my plans shall be used as public records ,//�Il - MO CATION '
OZ-- UPT0200AMPS ❑INTERIOR lk REPAIR
241M Licensed Professional - 201-IIIfN1AMP5 IMPROVEMENT
OWNER-e erupt for.
OVER 1000AMPS D BATH REMODEUREPAIR ODIiMOLITION
'd I herehy affirm thatOW 1 am exempt from the RATI N License Law for the
3 a U following reason.(Section 703 1.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
LL O which requires a permit to construct,alter,improve,demolish,or repair any strucmrc
prior es it,issoance;also rcquirw Nn upplicam for smh perminn Hlea signed statement SPECIAL CIRCUIT/MISC.
�y that he is licensed pursuant 10 the waviness oftheContmerorsLicense Law Chapter 9
X00 feommencing with Section 700()of Division 3 ofthe Busiaessaad Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
L q M ys that he is exempt Nerefmm and the basis for me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a pronit subjects the applicant to a civil Penalty of POWER DEVICES
t ntnrc than five hundred Jollare($SIIIp. ]TENANT ❑FOODSERVICE
Las owner afthe IMPROVEMENT
O ❑ propery,or my employees with wages as their sole cmnpt,mation, SWIMMING POOL F:LECI'RIC
will do the work.andthe stmcmee is not intended mothered fors ile(See.7044,Business D OTHER
and Professions Code no Contractor's License Low doe.,not apply to an owner of OUTLETS-SWITCHES-FIXTURES
a' property who holds or impnrvas Weram,and who dues such work cora lt ,,Ihrougb -
his own employees,provided that such improvements are nm intended or offered for NEW RESIDENTIAL ELFCTR SQjr.
sale.IL however the building or improvement is sold within one yew ofcompletion.the SQ.FI:ROORMBA &/SQ.Fr
owner-builder will have the burden of proving that he did not build or improve for put-
Pose of sale.)
D 1,as owner of Ne property,am exclusively contracting with licensed contractors to TOTAL: 1
construct the project(Sec.7044.Business aad Protessirns Cale,The Contractor's Li. FEB 2 RECrD
tensa Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEV
who amtracts for such pnjects with actual...to,(,)licensed pursuant trite Contractor's
License Law. PERMIT ISSUANCE s t RNU
Q 1 am exempt under Sec. ,B&P C bonds reason _
is
Owner [)areATTER-DRAIN&VENT-WATER MA) VALUATION
WORKER'S COMPENSATION DECLARATION 13ACK FLOW PROTECT.DEVICE
I hereby amrm under penalty of"iny one of Ne following dc6om rues:
❑I have and will maintain a Certificate wComenuo self-inure for Worker's Coni DRAINS-FLOOR.R00P.AREA,GOND. STORIES 'I'YPECONSTRUCTION
sat ion,as pr for by Scetion 3700 of Ne Labor Code,for the pcour nonce of the
hich This pc m i,v,issued. FIXTURES-PUR"TRAP
r hav and will maintain Worker's Compensation insurance,as required by Section
3]0(0 ohthe Lab rCada for,{h performance vfthe workforwhich Nis permil isissue�I. GAS-FA.SY.STEM-I INC.4 OUTLETS OCC.GROUP APN
My Worke/VCaopensalli�h�sulyye„e
ter and yalicy 11 /s/.
Ovrivr (/�'//� (_) Polic Nn.. T 107T GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
(This section need not he completed ifthe permit is for one hundred dollars($100) BUILDING DIVISION ITES
nr Ist - GR17ASETRAP
PLANCHECK PP,E
Ie ify Netin Ne any brmnncenflheworkfnewhichthix permit is issucd,l set- SEWER-SANITARY-STORM EA.200 FI'.
nm employ any person is any manner m us to become mbjca m the Worker'Compen- ENERGY FEC
Z Amino Laws of Culifumia.Date
O O ApPllcom WATER HEATER W/VEM'/FLECTR GRADING PEC
r'-I• (wry NOTICE TO APPLICANT:IL after making this Ceniliece of Exemption,you should WATER SYSTIxfTREA'1']NO
a ; become suhjm m the Worker's Compensation provisions of the Lbor Cale,you must SOILS PEG
W forthwith comply with such previsions or this Permit shall be deemed revoked. WATER SERVICE
�az CONSTRUCTION LENDING AGENCY NIW RESIDENTIAL PLMIL SQ.17. PAID
V I hereby afion that hen is a construction lending agency for the peffnrnanccof Date Receipt is
F the work for which Nis permit is issued(See309],Ci,C.)
U Lender's Name - TOTAL:
Larder's Address - TOTAL: �e
Q., ify i certthat l have reed this application end.state Thal the shove information is BUILDING FEE
h correct.I agree to comply withal]city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEF.
V building construction,and hereby authorive representatives of this city to enter upon the SEISMIC ECC w
42
shove-menlioned property dim inspection purpose,. PI?I<MI'I'ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE. '
liabilities.judgments,costs and expenses which may in any way accrue against said City
AI TER OR ADD TO MECH.
inconsequence of the gmming of this permit. PLUMBING FEF.
APPLI r DERSTANDS AN WILL COMPLY IT14 ALL NON-POINT ABR HANDLING UNITOO 10,000 CFM)
SOU�ERE 1. �� AIR HANDLING UNIT(OVER 10.000PM) MIiCHANICALEEE
CONSTRUCI'IONTAX
Si come fAoililifewitsLownstuar Data EXHAUST HOOD(W/DUCI') HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futureb' goccupaw store or handle hazardous ma¢riel HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino M pal CMe,Chapter 9.12,and the Health and Safety
Code,Section 25532(0)4 HEATING UNIT(OVER IW,000 BTU)
'[]Yes X0 No VENTILATION PAN(SINGLE RESID) PAID
s Date Receipt N
Will Ne applicantor'"on"a building 'he epant use
Air
t or lity Madeswhich BOILER OR 02000 BTU)
mil hazaNnus air contaminan¢as do by Ne Pay Area Air Quality Management TOTAL Dkolet4 BOILER-COMP(OVER 11X),1100 BTU)
El Yes No
I have most fee ozoNous materials requirements under Chnder 695 of the Cali AIR CONDITIONER ISSUANCE DATE
fume Hwd! a ty Cale,Section,21;05,25533 and 25534.1 undcoonn l that If the NEW RESIDENTIAL MECH. SQ,f1'. n rj
huilding ere ate mit ismyresponsibiloym Iifytheoccopunt L i
of the ost 'whooanceofa Cetai Occyltvt
Alcor amnmivedc n [)amTOTAL: ISSUED BY:
OFFICE