S 1065 (2) APPLICANTTO FILL IN INFORMATION WITHIN REDLINES BALL POINT PEN ONLY
CITY OF CUPFRTINO BUD U:NG-ELECT RACAL PERMIT'NO.
BUILDING DIVISION APPIdCA'PION/PF.RMIT PLU]IHNG-MECHANICAL S -. -06
BUILDING PROJECT IDF.N'I-IF'ICATION J
UILDINGADDRF'_SS: SANITARY NO. APPLICATION SUBMITTAL LAI
k4EWSAM
T'iMVNE CON RACTUk'S NAME: LIC NO:
NIC CONI"ROLA
EST LIC NO: ADDRESS: ❑
CONTACT: PHONE: 6 :ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LDG ITLpEpCf PLUMB MECU
A ❑ ❑
LICENSED CONTRACTOR'S D[CLARA'IION QTY. ELECTRIC PERMIT FEE
1 hmeby all nn mat 1 on licensed under,..soon,of Chapter 9(commencing JOB DESCRIPTION
WOO
WOO with Stegp)o
n.9f Division 3 ode.
flle Business and Pmfessinns Caand my licePERMIT ISSUANCE
licensees PERMIT
F,, in fill force and effect. ❑SFDWi, ❑KITCIiIiN REMODEL
QUU License Class Lic.# APPLIANCES-RESIDEN ❑PLUMBING RE-PIPE
FTT ZW Dam Contractor
ARCHITfT CSDEPANELS
CLARAGON ❑MULTI UNIT ❑S'I"RUCURAI.
Z O EL)Z I andemandmy plans shall bo used our,public..ad, MODIFICATION
0 UP TO 200 AMPS ❑INTERIOR ❑CHIMNHY R17PAIR
t: Liccosed Professional 201-10WAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION
OVER 1000AMPS ❑BATHRF.MO EI&E. lib)I] lib)�1X
uCu1< 1 hereby affirm that 1 am exempt Gnat the Cotton,Coo License Law for rite
a�6U following rcunon.(Scniun 0031.5.Hminus;mA Prufus,inns Gde:Any city or chanty SIGNS ELP,CTRICAL ❑(IrHEk
aI'3 C,y which.quite,a permit to rVrsuran,eller,improve,demolish,or repair any stmc.rc
Flan Pitot to its lswance.also requires the applicant for such petmitto file a.signed smtmnem SPECT At.CIRCUIT/MISC.
u
sssss'�y that he is llamon
J puunnua the provisions of the Contractors license Law(Chapter 9 -1 /Vo da"M T��qn
W TYOO (commencing with Section70011 of Division 3ofthe Rusires,and Professions Code)or TEMP.METER OR POLE INST.
a a c that he is owarre therefrom and the basis for the alleged exmnption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 9031.5 by any applicant for a Permit subjects the applicant.a civil penalty of POWER DEVICES
W^rn []TENANT ❑FOOD SERVICE
not mom man five ffhunJrte dollars(SSW). 01 TMIPROVTMENI
"~'ZQ Q Los owner of the p.peny,or my entployoex with wages as their rule mmpcn,wtion. SWIMMING POOL ELECTRIC=�2 will do lhework.and dicameture is not intended orotrcred forsalelSu.Jlwl.Business ❑0'PHER
F
ate]—m and property
who
Code:The Cmntaanr'x License w Law docs nm apply s if owner of ONTErS-SWITCIIIS-FI%TURF_S
his o ny who hails,or impedes there., pr who nts a such wnrk himded or of through
his own employees,lomvidcJ that such improvements are not imendeJ or offered for NEW RESIDENTIAL[LECTR SQ Pn
owner hawecnll have lthe had en(theatre.iThat he id non iyear ofrontpletI... the SQ.FT.RWRART:A SISQ.I4.
awntrbuildcr will bout rite hnnicn of,.sing That he did sol hdi1J nr improve Gx pur- PA
p�
ql s owner of the prnpeny,am exclusively aontracttn6'+''thlliccnscJ contractors to TOTAL:
crinoline,the project(Sm.7044,Buono..and Prufrs,in To Cud,,('The Camruvtds Li- /���
c sc l.aw llors not apply nr an uwnerof pr ny who builds orimprove,dwasn.and QTY, PLUMBING PERMIT FEE RELY! �� M
I'll
umtansja svchp ''Mrs wtth''a``can��t T)Iicensed pursuant to the Contractor% //L'�ye�gyn
License Luw.ge(yr
m eaemp Arita Sec. .6&P C lar this rte, PERM I ISSUANCE
WOwnmor
Dote ALTIiIt-DRAIN&VIiNT-WATER(EA) 'ION
41#0WORKER'S COM PCNSATION DECLARATION HACK PLOW YkOf[Cf.DEVICE
1 hereby uRrtm under Penalty of Perjury one of the folltmmng dctlarauons:
I have and will maintain aC•ertiticme of Con%ent toxoaf>lnsure for Wnder%Coa,zr- DRAINS-FLOOR.ROOF,AREA,CONDSTORIES TYPECONSTRUCrI(
,noon,as pnovidW for by Section 31110 of me tabor,Code,for the ptrfcmmnce of the
work for which this permit is issued I FIXTUR12S-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
3900ofthc labor Cook,for the performance afthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP MIN
My Worker',Compensation Insurance canter and Policy number arc:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMI-ENSArION INSURANCE. GREASrANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PEES
(This section need not be Completed if the penal is bronc hundred dollars(5I W)
GREAS
or less) ETRAP
PLANCHECK FEE
I certify mat in The Perfnrmancc ofine w for which this permit is is,vN,Isbell SIiWEk-SANI'PARY-STORM EA.2q1 FT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
O Z sources laws of Califcmia.Date WATER HEATER W/VEN-MLECTR
Z Applicant IGRADING FILE
r h NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should WATER SYSTEMoTREATING
a ; become subject to the Worked Compensation provisions of the Labor Code,you must SOILS FIiE
forthwith comply with such pmvtvons nr this punnet,hull he Jtamed invoked. WATER SERVICE
� Z CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PLMB. SQ�I?. PAID
U O Ibereb,dT..a tktmere i%aconsooeion lending agency fame le,brin ounce of Dam Receipt#
LI. r the work for which this permit is issued(Sec 3097.Civ.C.)
O U Lenders Name TOTAL:
>, w Lender's Address TOTAL:
I certify mre
at 1 have ad this application and state that the above inrm
foation is BUILDING FIA:
j_ IL comet.l agree to comply with all city and county ordinances and state laws renting to QTY. MECHANICAL I'F,RMII' FEE
UZ building constructor,and hereby authorize representatives of this city in enter upon me SEISMICFEE
abo e-racntioned property for im,ection Purposes. PERAtFF ISSUANCE
(We)agree to save,indemnify and keep hendess the City of Cupertino against ELECT'RIC IT 17
Iiabildies.judgments.costs and Colonists which may in any way accrue against said City ALTER OR ADDTO MECH. s OF
in consequence of me granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL CO PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IIkW)CFM)
SOURCE REGULATIO S I MECHANICAL FEE 10
0 AIR HANDLING UNIT(OVER IO.gX)CFM) CONSTRUCTION TAX
Signature of AP icanU4mlruc.r Dae EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS P -RIAI S DISCLO URF.
Willther, IrcanTorfuaue dm,crenpontsaae or handle M1vardomnnacrial I MATING ON IT(TO 100.000 B'TU)
es defined by the Cu,cnino Mu eipal Calc,Chapter 9.12,and the Health and Safety
Code,Satins255J2foIT HEATING UNIT(OVER oncoo Bill)
VENTILATION FAN(SINGLE kiSID) PATO
Will the air cont or future a budding by the B y A equipment Qu or devices which nam Rertipt#
mit husuNnus sur contaminants m AcPomd by rite Nay Arca Air Quality Monugumtml HOLLER-CONI'(311P OR I(HI,(NX)B'I'U)
TOTAL:
DtzWn^ HOILEk-GOb1P IOVIiR I W,gXI RTU)
❑Yes ❑No
I have read the hazardous mmeriaN tequimements under Chapter 6,95 of The Cali- AIR CONDITIONER ISSUANCE DATE
famin Health&Safety Ctdr Sections 25505,25533 and 25534.1 undoodand that if the NEW RESIDENrIA[.MITCH. SQ.IT.
handing rices not
of ie requirements which must hn temnatnpt.rT000rt m it iisx smuynrcee t)fa C eni fictote o ff(ykthceupocnccuyp.ant
Owner or authorized agent Dam TOTAL: ISSUED BY
_ =, OFFICE _