S 1236 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PFIj ITND. 1236/�3 6
BUILDING DIVISION APPLICATION/PERMIT DI.GPROJUMB MECHANICAL \V G
BUILDING PROJECT IDIvYTIFICAT1pN
11ILUING//A4E55: S `J•L ^ G I ' 'n, SANI'T'ARY NO. APPLICATION SUBMI'PI'AL DATE.
R'S NA L: PHONIi C T C-�I:S NAME: 6,2
NIC CONTROL#
ARCA 'ECUEN(flit: LIC NO:' All)IBESSi (J J ❑
CONTACT. PHONE: II T BUILDING PERMIT INFO
❑ Contaminant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB EG
LICENSED CONTRAC'TOR'S DECLARATION QTY ELECTRIC PERMIT - PEE
I hereby affair that 1 am licenced under provisions of Chapter 9 mommisnch, J B DESCRIPTION
WonWoZ wim section 7fN)0)arnivtsion3ofmc13uainess;mA Pmfesdane Coae,and mylicenreia RESIDENTIAL,
in full Grrob and c[ PEk MIT LCSUANCF
W - ❑SPDWI. El KITCHEN REMODEL
d,yypyyyU hiecnce Imus i.ic.# APPLIANCES-RESIDENTIAL ❑ADDITION O PLUMBING RF PIPE
Is I
yzW Dale CnnVaelt
QG' ARCHITECT'S DE ION - []MULTI-UNIT ❑SIRUCTURAL
PANELS
Z O m Z. 1 undersmnd my plan.shall be used as public.,,,d,, MQDIPIGATIGN
OZ14- UP 1020 AMPS El INTERIOR El CHIMNEY REPAIR
F4t4] Licenced Profewinml 201-IOOOAMPS IMPROVEMENT (]SWIMMING POOLS
WQ H OWNER-BUILDER DECLARATION OVER IINIIIAMPS [_1 BATH REMODEWREPAIk El DEMOLITION
(�yy' C Q I hereby affirm that 1 am vicarial from the Contramnta License Law for the
C�U following reason.(Seen,).90315,Business ad P,.fwsine,Cdc:Any city m county SIGNS ELECTRICAL OOUT /�
y which q permit I construct,ale p 1 mulish , y structure, C /:
0d priorI 1 .: alsoIh app11 If 'h pe tier I 6 Istaement SPECIAL CINCIIIT/MISC. S.Sb ^ C.
❑❑pp p"l
'hat he k licanAdpurtm n the provisionsoffle Conlrealon'k License La (Clapper)
p (commencing with Section 7003)ofDivision 3 of the Businecoad Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
a pt o 0 'hat he is exempt therefrom and the basic for the alleged exemption.Any violotian of ❑NEW BLDG/ADDITION ❑DEMOLITION
W y
Seat x7031.5 bymy applicant far a permit subjects the applicant to it civil penalty of POWER DEVICES ❑TENANT ❑POOD SERVICE
F'Z Y not morethan five hundred dollars($5011). IMPROVEMEN'P
D I,aroowner,)(the pmpeny,or my unploy,es with wages nn lheirmle cnmpemalimm, SWIMMING POOL ELECT RIC
will do the work.;md the structure is not mended or offered formic(Sec.7044,Bmi.cas ❑OTHER
ta] m and Professions Code.The Contractor's License law does not apply In an own"or OUTLETS-SWITCHES TURFS
R' ,,.,city who builds or improves thereon,and who docs much work himself orthrough
his own employees,provided that such imprm'ements are nal intended of offered far NEWRESIUEN'TIAL EL -
salalf.however,the building or improvement is sold within, yen,of completion,the SQ.III'.FLOOR AREA $/SQ.Up.
ner-builder will have the burden or proving that he did not build or improve for pua-
rose nfxale).
E] Las owner of the pmpeny,am exclusively conuading with licensed watracora,o 1 OTA
construct the pr,co((Sec.7 al Basham vnd Professions Core:)'I'he CnnOacors Li-
waste Law doestrot apply to an owner ofproperty%no builds or improves thrown,and QTY., PLUMBING PER FEE
who contracts for such projects with a contractor(s)I Icro sed pursuant m the W mracmds
Licence Law. PERMIT ISSUANCE
0 1 am exempt un Is Sce. ,B&P C forts rwaon
Owner Data AI:ITR-DRAIN&VENT-WATER FUG VALUATION
WORKde,p COMPENSATION DECLARAHON RACK NIAW PROTECT.DEVICE
1 hereby nflinn under penury nr perjury one of the following dmlm;ni.na
I hvvcand will mainlainaCerlificatenf Cnn.rent In sel Finmfe far Wwksh,Compen- DRAINS-FLOOR ROOF,AREA.COND. STORIES m TYPE CONSTRUCTION
safine,as provided for by Scotion 3900 of the Labor Code,far Ih,perl'mmnnae m the
work for which this pemmil it issued. PIX'1URES-ITR TRAP
1 have and will mainein W,)rkeT's Cn.pensation Insurance,as required by Section
nl'the Labnf Cady fonhe performnnceaf the work fir whibthis peanh k ao.cd. GAS-EA.SYSTEM-I INC.4OUTLE'TS OCG GROUP APN
MyWmk�' Cnn uonlns randPall, -
Carricr:�r Ia �I—tttt ll�\- Policy No tnsu:�, CAS-IfA.SYSTBM-OVBR4(P.A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRIL WASTFL INTF.RCF.PTOR
S1`O141 F9
(Thisee.tionneed not be completed i f the,efmir is for be hundred r1ml...SI00) I1ILDIN, 1VI -
.r less) GREASE TRAP PLANCIIECK AIRI certify that to the perforneaceoflhavork Erwldchthlspeial is isseed,I steel SEWER-SANITARY-STORM EA.2000
not employ any person in any manner so as a subject become subjeco the Workers'Conifer- ENERGY PER
O ,7. Nation Laws of California.Date WATER HEATER W/VENTIELECI'RApplicant9LI RADING FCC
,Z o
i..t NOTICE TO APPLICANT If,after tmrking this Certifi,we or Exemption,yon should WATER SYSTEMITREA'I'ING SOILS FEEt-� baboon subject e the Warkeransinus s Compensation pof the Loloa Code,you mint
Hforthwith comply with s.an pmvislonanr Nle permit shall be deemed revoked. WA'T'ER SERVICE
d Q
UO CONSem is awONLFNDINOAGENCY NEW RESIDLNfIAh PLMB. SQ.FT. �( sin PAID Dale Receip
I heohy affirm that there isnstmcfinn lending agency!the perfonnanbeofvif
rti if
the week far which this penult tx iswed(See 3097,Civ.C)
0 h Lenders Name 'Ala
Ll Lenders Addesn TOTAL:
'fir d 1 crdify that 1 reviewed this application and ,.are that mheallove information is BUILUINC NILE
c.t rn correct.I agree to comply with all city and county a dminces and elate Tawe remdng to QTY. MECHANICAL PERMIT PEE
V building eonnmdion,and herchy authorize representatives of thin city menmru�n ere -
SEISMIC FEE
abavo-menimee properly Fir ihodelicn trefolss. ISSUANCE
agree o save,indemnify and keep Ferri Nn City of Cupertino ngttinst S,SC� ELECTRIC PEE
linbilities.judgmenre;colts vnd expenses which may in any way acerae agauma imCity ALT ER OR ADD TO MECH.
in consequence of the granting of this permit PLUMBING FEE
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UND"I70 IQfH10CFM) MECHANICAL FEE OUR ALATIONS. 1_ Q
(011(, /U AIR HANDLING UNI'I'(OVER IH,f100 CPM) CONSTRIIC'rION'i'AX -
mgn' aHAZARDOUS MATERIALS DIS Da a EXHAUST HOOD(W/DUC9') HOUSING MITIGATION FEE
Will tie applict Iorfare,,building occupant store or handle hawrdoes material HEATING UNIT(TO I00,000 HTU)
as defined by the Coponina Municipal Code,Chapter 9.12, ,to the Health and Safety
Grade Section 255326c? HEATING UNIT(OVER 100,000 RTU)
0Yes [:1 No PAID
VP.NTILATION PAN(SINGLE RESIU) Data Rrceipl#
Will the applicant or future building accupant use equlprical or devicce which O
area be ndom, air canwmh,ame as d,fined by the Bay Arca Air Quality Mamgenteal BOILER-COMP(311P OR IMTM R'i'U) TOTAL:
Did ❑Yes No BOILER-COMP(OV ER 100,000 BTU)
I have rend the hnvmlous matcrialx ruem
ryirents under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATF.
larnia Ilwllh&Safety Code.Seelions 255115,25533 and 25534.I understand that if the NEW RESIDENTIAL.MECH. SQ.FT.
but d' d nomcunwmtly htvealenam.Nat it is my resPnnsibiliymn,)tify lhexapam �]i�- (,�
flh r nenlsw 'In ustheme mriono issuance ofn Certifiune.flRwpuney.
TOTAL:Vq—It O LJ!]R-
amhorized agent Date ISSUED BY;
OFFICE