S 0165 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPERTINO BUILDING-F.LHCTRICAL PERM rvD.
APPLICATION/PERMIT I•LUh1BING-hll!CHANIGAI, S 0 1 6 5\
BUILDINCy DIVISION BUILDING 1'ROJ F:CI'IDENTIFICATION
BBI[ )INCy�D 5: i(ARY NO. APPLICATION SUBMI'TIAL PATE
T e'1�
NA H CONTR OR N ME , / LIC N/V CONTR(lh out
AR(fFflrECT ' GINITR: LI NO: ADI CONTACT: MCI_. CQ BUILDING PI?RMIT INTO
Consultant Fees Paid by Applicant(initial) G HL17CT PLUMB MECII
❑ ❑ ❑
LICENSED CONTRACTOR'S DECIARATION QTY IiI,ECTRIC PERMIT FIiE JOB DESCRIPTION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
OZZ with 9cdinn llXNq of Divixinn3 nl thelW%inexs In I'nslc%xin eC den my license is RE•1 NTIAI'
1_ 'n full formanleff , I'ERMI'1'ISSGANCIi ❑SFDWL ❑KITCHIiN REMODEL.
UU Limn%c CF Lica APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUA1111NG RE-PIPIT
mG1 ata Cammnor ❑MULTI-UNIT ❑STRUCIVRAI.
? R ITECPS DECL A PANELS MOD119CATION
zc.z I understand my plans shall be coed as public records UPTO2011AMPS
Q INTERIOR ❑S IMMIN POOL
L,yF� Licensed Profe%sinwl 2t1I.I1NDAMPS IMI'ROVIiMIiN'f SWIMMING POOLS
�6Yf j OWNER-BUILDER DECLARATIONOVER((NIB AMPS ❑HATH MMODHIIRFPAIR [:1 DEMOLITION
I hereby oIT,.that 1 am exempt from,he Comenclu's Licensc Law for the Q OTHHR
m U following reason.(Section 1031 5,Blom—and Prolesxions Code:Any city or county SIGNS ELIiCfRICAL
1+)as W 1- which rcyuirm a pemit m eonnmal.1111!,improve,denolish,or repair any lancram
F�Oa pUnr a+its issuance.aka requireslhe upplicantfm such permil to file axigncd xtatemem Sp1?CIALCIRCUITIMISC.
E s�} the MTs lienee)Punuanuo the provisions of the Contractor's License Law(Chapter 9 COMMERCIALW�Q0 (cmndamemg with Seen,.100muf Dilwon 3ofthe Husinessand ltofesslons Cdrim TG1P.hfETEH OR VOLE(NST [I NEW BLDGIADDITION ❑DEMOLITION
m c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 70315 by 1ny applicant far a perm,mem s Ihu,pplicant Ina civil Penally of POWER DEVICES ❑'TENANT ❑TOO])SFI VICF.
not more than five hundred dollars 050q. IMPROVEMENT
SD ❑
1,a%owner of the property,or my employees with wages as their role compematlnn, SWIMMING,POOL ELECTRIC []OTHER
t. will do the work.and theonaum is not ienemimmoBe,ed for sale(Sm.74J.Business
W m and Professions Code:The Coca.mear's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thercmn,and who docs.such work himselfo,Through NIiW RESIDIiN'1'IAL EhEC'I'R SQ IT.
his own employees,provided that such improvements are not intended or oBemd I'll SQ 1,PI.JyRtRn $ISQ.F'.
IL however.the builtdingn,impeavement is%old within one ycaroR.a.Es tion.the II�r //YY VV
owner builder will have the burden of proving that he did not build or improve for Pur-
ponenfeowne (JUN 19
I,.,owner of the propmy am exclusively tt+mmning with licensed a%mraclm to (1[CII
construct the project(Sec.704,1,Business and Prat%inns Com:)'Ihe Comeaensr'x U. R[ (1
cens,low does not apply to anowmcro(property who builds or improves thereon.and QTY. PLUMBING PERMIT FEF.
whocolnracu fur.such Prcjwts with acconexctor(s)licensee pursuant to the Conlramor's CITY Or GUFEHTINO
License law. PERMIT ISSUANCE
I am exempt under See. .H N P C for this rcanm
AI:113R-BRAIN ffi VP.NT-WATER(EA7 VALl1A'I'ION
wilm Dam
.I WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby ration under penalty of perjury one of the following dcdarutions:
I havcand will comaninaCenificam of Cons,',%%elf-insure for Worker%Compen- DRAINS-FLODR.ROOF.AREA.GOND. STORD;S TYPE:CONS'MUM(ON
smlaa,as provided for by Section.17N)of the I.abnr Coda,for the performance of the
work lir which this permit Ia issue). I>IX'IURES-1117
walk
El 1 have and will mammon Worker's Compena.Him Insurance.as ammred by Section
3NNlnffle LannfGNe,for Performance of the work for which this Permit is ismcd. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
y�°^'er and Policy number an:
Carrier ' jLa and
tic GAS-EA.SYSTEM-OVERJ(IA)
CHRHFI 'ATFGI'IiXFM PDON FROM WORKIiRS' GRFASUINOIIS'I'RI.WAS'117 INTERC17I DER
COMPIiNSATION INSURANCE BUILDING DIVISION I I S
(This section nod retbe completediRhe p,mit is Torun hundrtddellim($IIX) GREASETRAP PLANCHFCK FF.H
or less.)
toy any that in.in arymmcer... ,obeomefor whichthis termiticer,C,lshelf lliWF.H-SANITARY-S'IORM tA.21x1 Flt IiNIiHGY Bili
not a enToyany pervoo In nor mune na us m hcunm nunjum e+the Wnrkery CmnPen-
Oz �sntinn Lnws of Culili+mia.Dae WATER IIHATIiR WIVENIIIiLEC IR (TRADING Bili
Z Applicaal
NOTICE TO APPLICANT:If,after making this Certifies',of EnemPtion,you should wAIT'R SYS1'EM/BG'TING SGIIS FF[
became subject u)the Workers Conacmation provisions of the lahor Code,you must
lim oils comply withtech p..sision%onhis cmin,shall be decnmdrevoked, WATER SERVICE
1.14
0 Q PAID
CONSTRUCT ION LENDING AGENCY NEW RESIUIiNI'IAL PLMB. SQ.IT. Date v 'pt
U 0 (hereby affirm that is a construction lending agency for the performance of
[2s the work for which this permit is i...ed(See.3191,Civ.C.) TOTAL:
Q 1'" Lender's Name 'TOTAL:
OU.d Lender's Address BUILDING II?li
ly 1 certify that 1 have read this application and state that the above information le FEE
1. V) cancer.I agree u+comply with all city and county ordinances and seam laws mlvtingm QTY. MF.CBANICAI.PERMIT SIBSMIC Ft11
V Z buildingcamm.nian,andhemhyaothoriu apremartmesofdo,city memeripr,the
above-mentioned Property for inspection purples. PHRMIT ISSUANCE pI.LCrRIC PIiI
(We)agree n,save,indro nify uad keep lot rndcss the City of Cupertino a,,in't
Iiabilieies,judgmicans,encs and expenses which may in any way acme againsty ALTER OR ADD TO MECH. PLUMBING i9ili
in cmnmquence of the granting of this permit.
API'LICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON-POINT AIH HANDLING UNIT(TO 10,"CFM) MI!CHANICAL ITE
SOURCE REGULATIONS. �^ /�
(..{I AIR HANDLING UNIT(()VER 10,(NIII CFM)) f.ONSTRUC'I'[ON TAX
a APpli onuacmr Date I EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAY.ARDOUS MATERIALS DISCLOSURE
µ51l the apPlicam or!marc builAing occmpam.sort nr handle ha%aMou.v nm¢dal HL'ATING UNIT(TO Il10,IX1f1 BTIO
a%de0ned by Nc Cape in Municipal Code.Chapter 9.12,midds,Icahh and Safely IILA'1'ING UNIT(OVER INLINNI BTU)
'ndc.Swoon 25532(11)'? PAID
❑Yes ❑No VHNTILATION PAN(SINGLE RESID) Data Rccci,T X
J 1 Will ere npplicam or fuwea handing"mar all me equipment m devices which 13011.F.R-COMP(3HP OR 1110,(x1)BTU)
mil hairwou%air mnmminam%ax defined by the Hay Arca Air Quality Management TOTAL:
DUmimY BOILER-CGMI'(OVER (XION)it'I'U)
❑Yes ❑Na
AIR CONDITIONER ISSUANCE.DATE
1 have mad fet haas ,Se matedWs 5.2553 a under Chapter understand
of the Cali-
B+mia Health c Safety common,
e,aans .that i 255)3 ad n534.1 n notifyth ethe tw if the NF.N'RCSIDPNI'IAI.MLCII, SQ.FT,
• nu the reuicnous which have awn+ani,iorlu%my moomof aC'itymnmifyompanup:ml
1 of thertyuircmnns which must ne"let Pdnrm!%mance olaCenilinitn nl Occupancy.
a Owner or authon cal agent Date TOTAL: ISSUED BY:
OFFICE
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