S 0581 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING.-ELECTRICAL PERRMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB TNG-MECHANICAL S 0581
BUILDING PROJECT IDENTIFICATION,
BUILDING ADDRESS: SANI'T'ARY NO. APPLICATION SUBMI'CI'AL DATE
OWN G 'SNAME: ONE: CONT CT R'SN LIC NO'
1 NIC CON'TROT,p
ARCHITECT/ENGINEER' I.1 N0: ADD .: - - •/ E:1
4 %1Y .a
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EL� PLUMB MECH
LICENSED CONTRACT ORS DECLARATIONQTy ELECTRIC PERMIT FEL^ ❑
I hereby affirm that I am licensed d p r soapier 9(comm 'ns JOB DESCRIPTION
DMZ with Secion]000)af Division or me Bus it fe,smn.Gale and my license is RESIDENTIAL
f+1 O O PERMIT ISSUANCh;
tYWF in full force and � LD ❑SFDWL :1 KITCHEN REMODEL
dV License Class Lia# APPLIANCP.S-RESIDENT'IAL ❑ADDITION El PLUMBING RE-PIPE
y 4 Dme I arm nr
A CHITECT'S UECLA ATIONElMULTI-UNIT ❑STRUCTURAL
ZOE2,zj PANE MODIFICATION
understand my plana shall be used as public rettoNa
Oz,-Q UPTO 20d AMPS El INTERIOR L1 CE HMNF.Y REPAIR
.y..F.
� YI Licensed Professional 201-InN)AMPS IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDER DECLARATION
C 1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑BATH REMA./RF IR DEMOLI I
0.O W V following reason.(Section 9031.5,Business and Professions Gale:Any eery m county SIGNS ELECTRICAL. ❑OTHEIL.
3 W F which requires u permh to construct,alter,improve,demolish,or repair any structure
F�aO prior to its issuance,also requires the applicant for such permit lofile asigned statement SPEC[Al.CIRCUIT/MISC.
that he is licensed pursuant In the provisions of the Connector,Limroa Law(Chapter 9
¢al (commencing with Section 900mof Division 3 at he Buaiues,uad Prdfia,,om Code)or TEMP.METER OR POLE INST. COMMERCIA
0. that he Is'exempt don firam and the basis For the alleged exentpdon.Any violation of ❑NEW BLDG/ADDITION (_1 DEMOLITION
W N Section 7031,5 by any applicant Earn permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE:
not more than five hundred dollars S.50m. IMPROVEMENT
Sd �I,as owner of the property.or myempinyces with wages as lheirxolealmpenaallnq SWIMMING POOL ELECTRIC
'WFO will do the work,and the structure it not intended or offered for sale(Sce.]044,Business ❑OTHER
W m and Professions Coda The Comme n's License Law dues not up,gy to an owner of OUTLETS-5W ITCH ITS-PIXTUR S
0. property who builds or Improves Thereon,and who docs such work himself nr through
his own employees,provided that such improvements are not Intended or offered for NEW RESIDENTIAL ELECT, FT
sale If,however,the building or improvement is sold within one year ofcmoidetion.am SQ.IF FLOOR AREA VSQ.EP,
owner-builder will have the harden or moving that he did not build or improve rnr par-
' pose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed comrsemrs to OT
construct theproject(Sec.](144,Business and Profession's Code:)The Con..."a a
arise Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT E., P A ' p
who commas for such projects with a e marasmus)licensed pursuant a1 the Contiamors
License Law. PERMIT ISSUANCE
E] ;am exempt under Sec. ,B&P C far this reason
- ALTER-DRAIN&VENT-WATER(EA) AUG A 3p
Owner Date -
WORKERS COMPENSATION DECef.HoWON BACK PLOW PROTECT.DEVICE. CITY Ur UUr'tHIINU
'• Thereby cel mai under penallyne cf C.aoueofthe falllnving dealnmlimH: -
IMlve Provide maintain of the Laor Code,fomfer Workman Compel- DRAINS-NLOOk,ROOF,AREA,CONK STORIES 'TYPE CONSTRUCTION
anon,m provided for by Section 3]IN)nRhc Labor Cada,for the performance of the
work for winch this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Gtmcof the n Insurance,h his yr a i Section
3]fNloRhe Labor Cade,for the performance of the work for which this perntit is issued. GAS-EA.SYSTEM-I INCA OUTLETS OCC GROUP APN
My Workey'v Co�pc�Iian Imyrynce a�ier andpi oicy
Carrier, DO I� bpi /�nlicy N:i' ra L GAS-BA.SYSTGM-OWR4(EA)
CHRTI KATE OP PPION FRO WORKERS'
COMPENSATION INSURANCE GREASILINDUSI RL WASTE INTERCF.PI'OR
fiI111,DING DIVISION FETES_
(This section need not be completed i r the permit is for one hundred dollars(S1O(p GREASETRAP
or les�d PLANCHGCK FE
I certify that in the performance ofthe work for which thispermit is issued,l shall SEWER-SANITARY-STORM EA.200 PF.
not employ any person in any manner sn as In become subject m the Workers Compel- 13NF,RGY FEF.
smion Law,ar Culirmnla.Dare WATI?R HEATBR W/VENT/FLECTR
Q Applicant I -
GRADING PEE
f~ � NOTICE TO APPLICANT.If,after making this Cem1cate of Exemption,you should WATER SYSTEMIT BEATING
become sobjectto the Workie,Compensmern provisions of the Labor Craft,mu muss SOILS FEE
Uj ✓'7r forthwith comply with such provisions or this permitshall he decried revoked. WATER SERVICE
a Q
U O CONSTRUCTION LENDING AGENCY NEW RF,SIDF.NTIAI.PUSH. SQ.PI'. PAID pale Receipt#
1 hereby off tin Ill.,amitthemi is s co(Sce3Fiction lending agency for the perfomwnce of
N Ibewmrk for which this permit is issued(Sec.JIN)],Civ.CJ
Lender's Name TOTAL'
0 Lender's Adshms, TOTAL: pUILDIN( F,F.
I certify that I have read this application and state that the above Information is
C4i h eared.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U z ,huildingconstruction,and hereby authorize representatives afthis city memerupanthe SFISMICfP.F.
above-mentioned property for inspection purposes. -
(We)agree to save,indemnify and keep harmless the City of Cupertino.,.fast PERMIT ISSUANCE ELECI'RI
iahililles,Judgments,costs and expenses which may in anyway accrue against said City - ALTER OR ADD TO MECf{.
in consequence of the granting of this permit. PLUMB F..
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(ID 10,000 CPM) MECH ICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER gg1E CFM) CONSTRU A
Signature of ApplicanUContraemr Date EXHAUST HOOD(WMUCT) HOUSING MITIGATE) PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Pomre buildiagneco,out,bru or handle bawrdous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cameroun Municipal Code,Chapter 9.12,and the Health and Safety
Coda Section 25532(1)? _ HEATING ON['P(OVER 10r,"BTU)
E)Yes 0 N PAID
VENTILATION FAN(SINGER NBSID) Dvtc Be IpI#
Will the applicant or Blum building occupant use equipment or devices which
emit hazardom air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 B'I'FIT
VAL.
District?
❑Yes E]No BOILER-COME(OVER 1133,000 BTU)
I have read the moment,materials requirements under Chapter 6.95 of the Call- AIR CONDITIONER ISSUANCE DATE
folia Health&Safety Code,Sections 25505,25533 and25534.I understand that if the NEW RESIDENTIAL MECH. SQ.PL
building does nn,carro,caly have a Ienanl,that it i,myn rymsibilil,to notify due W.,111
ofN yuirc els which mostM met prior,iawonee ofaCnificutenf Oeupuncy.
Own a bort at TOTAL: ISSUED DY:
OFFICE