S 0709 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMII'NO.
BUILDING DIVISION APPLICATION/PERMIT PI.UAtnwG-MF.eHANICAI. S - 0709
BUILDING PROJELT IDENTIFICATION V 9
SANITARY NO. APPLICATION SUBMITTAL HATE
BUILDING ADDRESS:
"AA GPHONE: CONTRACTOR'S NAME: - LIC NO'.
Iwo T) �J O J WI DCII NIC CONTROL#
RCHITELT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: a ,BUILDING PERMIT INFO
77 eyt' Iia ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB NIECE/
LICENSED CONTRA R'S DECLARATIONQTY •` ELECTRIC PERMIT FEE
I hereby affirm mal I nm licensed wader,mvisiom of Chapter 9(comrtereing . _ JOB DESCRIPTION
QWZ 2<"eedon?000)uUmssion3bfthe Business Emil Professions Code,and my license is RESIDENTIAL,
F W in full force unr ofgcn. O-.� PERMIT ISSUANCE 'DWI ❑KITCHEN REMODEL
ZF `i ZaO Lic.# APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
y� ate)y4'4- 1 7 - Conmacmar
'�¢0' ARCHITECT'S DECLARATION ❑MULTI-UNIT' ❑STRUCTURAL.
F 7y I understarJ my phn,,hall he used as public recoMs PANELS MODIFICATION
Z O— UP TO 20X1 AMPS
oz— UP
El INTERIOR ❑CHIMNIiY REPAIR
I•4.F+W Licensed Professional 201-IOMAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION
..I OVER 1000 AMPS Ll BATH REMODEIJREPAIR ❑DSMGLIf1GN
GG I hereby affirm that am exempt front the Commeror's License Law fur the
iyyxy O y V following reason.(Section]031.5,Business and Prof ions Code:Any city or county SIGNS ELECTRICAL ❑OTHE2
t++a WFJ which requires a permit to convincer.alter,improve,demolish,or repair any structure /)
Ov prior it)its Issuancealso requires the applicant for such pennhmfileasigned statement SPECIAL CIRCUIT/MISC.
119 mal he is licensed pursuant provisionsofthe Contractors License Law(Chapter!)
CCC Q (communing withSection 90W)of Division 3 ofthe Businessand Professions Coda)or TEMP.METER OR MET INST. COMMERCIAL'
dp�Oo O that he is exempt Therefrom and Tho basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iCm
Scaleup 7031.5 by an,.,,heart rnr a permitwhjects the appllcnnl loo civil penally of POWER DEVICES WANT C1 FOOD SERVICIi
H�y,
auto nore than rive hundred dollars($500). IMPROVEMENT
sac C] as owner or the proper,or my employees with wages as theirsnle compensation, SWIMMING POOL ELECTRIC
will ratio wark,andtha nmcmreis not imendedomlTered for,ale(Sao.9040(Business OT ER
3 and Professions Code:The Continuer License Law does nal apply In an owner of OUTLETS-SWITCHES-FIXTURES
,,.pony who builds or Improves thereon,and who does s.,It work himself on,.pair
_ his own employees,provided that such improvements me not intended or offered for NEW RESIDENTIAL BLECIR SQ PP. -
sale.IL however,Ihehuilding m impmvanent is sold within one ye rr of completion,Int $ISQ.FT.
nermuilder will have the harden of proving that he did not build or improve for par,
pn e of s own TOTAL:
❑ Lax owner of the property,am exclusively rnmru"ing with licensed nmtrncwa.In
DEC 0 4 1997
construct the project(Sec.71144,Business and Professions Coda:)The Contruator'x[,I-
came Law does not apply to an ow,net of property who builds or improves thereon,and QTY" PLUMBINGPERMIT FP.E..
who contracts for such projeets with or cortm"oq,)I Iwnscd g...an,Io the Contractors
License Law. PERMIT ISSUANCE v
❑I am exempt under See. ,B&P C Torok reason BY
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
I levo and will maintain a Condition,of Comenuo self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONS'I'RUCTION
nation,as provided for by Section 3700 of the Labor Code,for the performance of the -
wark for which this Fermin is issued. FIXTURES-PER TRAP
'vc and will maintain Worker's Compensation Franca.,as aaryired by Section
OOofthe Labor Code,for the performance of The work for which Ibis permit is issued. GAS-EA.SYSTEM-1 INC.4 OUi'LETS OCC GROUP APN
My Wor Con pion Inspiring currier and Policy ,Q,Eher aro:
Carrier: • fancy No.:e r���p GAS-EA SYSTEM-OVER 4(BA) -
CERTIFICATE OP EXEMION PROM WORKERS' GREASE/INDUSTRL WASTE INTF.RCEFFOR
COMPENSATION INSURANCE BUILDING DIVISION PEES _
(Thiseecilon real nol be......hand ifthe permit is forcre lmndred dol Is,($1AE OREASE TRAP or loss.) PLANCHECK FEE
I send,Thal indo,arfomatme.finewmk forwmcl nhispermil is issued.Lbap SEWER-SANITARY-STORM EA.200 P1'.
not mII,1,any Forma in any manner-so.,,a become subject no the Worker,'Compen- ENERGY FIN
O Z sodium Law,of California.Date III'ER HEATER WNEN'I/MF.CTR GRADING FEF,
2 Applicant
Tn NOTICE TO APPLICANT:If,after making this Certifrme of Exemption,you should WATER SYSTEM/1'REATING SOILS PEE
F^ •" become subject n the Worker's Compensation provisions of the Labor Cole,you rn.st
forthwith comply with such provisions nTYilm panni,shall be deemed revoked. WATER SERVICE -
Q
CONSTRUCTION LENDING AGENCY NEW BESIDES TIAL PLMB. SQ.Up. PAID
� '7" I hereby affirm that hem is a construction lending agency for the performance of Dane Reeei
LU 2 the work for which this permit is issued(See 3097,Civ.C.) DAL.
O U Lender,Name _77--
W ].enders Address TOTAL:
F. I comfy ma,l have reed this application and state Ihat me above information ie - BUILDING FEF.
correct.I agree to comply with all city and comply ordinances and state Taws relating In QTY. MECHANICAL PERMIT FEE -
U 7 building construction.and hereby authorize representatives of this city no enter apon,he - SEISMIC ME
aba6amentioned property for inspection purprnnx. pERMTf ISSUANCE
(We)agree to save,indemnify and keep hamate.,the City
of Cupertino against ELECTRIC FEE
Iiabilinies,judgmems,cosb Ind expenses which may in anyway accrue against said CityALTER OR ADDTO MECH.
in consequence
fine 6mnnin,of thi,Penni! PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING I]NIT(TO 1h0(10 CPM)
MSCI IANICAL FF.F.
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 141X10 CFM) C(]N$TRUCTION'1'AX
Signature of ApplicammCommcnor Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE.
HAZARDOUS MATERIALS DISCLOSURE
Will,he applicant or future building occupant sm r m handle hacoNous mnterial I(EATING UNIT(TO 10),000 B'IV) ell
as defined by the Cupertino Municipal CMe,Chapter 9.12,and the H.Im and Safety
Code,Section 25532(.)7 HEATING UNIT(OVER 100,110()BT U)
El Yes ❑No VF,NTI LATION FAN(SINGLE REBID) PAID
Dam Receipt#
Will the it croma ar future buildjagby the B use equjpment or devices which BOILER-COMP(3HP OR 100,(100 BTU] -
ia hazardous air contaminunip as defined by the Boy Arco Nr Qneiry Management TOTAL/
poison"? BOILER-COMP(OVER 1 W,BfH1 BTU)
C]Yes ❑No
]have reed the hazmdnus mnladals regoireanenns under Chnpcer 6.95 of the GEli- AIRCONDITIONER ISSUANCE DATE
fornix Health&Safety Code,Sections 25505,25533 and 25534.1 undcowand Thal it the NEW RESIDENTIAL MECH. SQ.Fri.
buildingdosnocunen0yhaveamnwt,that in is myrwlamsiMlily mnatifytheoavpum I// Li I
of the Feyuiremems which must he met Friona issuanccnf u CertiErzne of Ocaapaoy.
Owner araulturined again Data T ISSUED BY:
OFFICE