S 0956 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELE(]TRICAL ',E "'T"" 0956
BUILDING DIVISION APPLICNFION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDEN'I IFTCATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DAD
1
OWNER' ME ff-
� �kF_ CON'C Q'OR' ME: G� LIC Nt]:�
s / /✓•l• NIC CON'fR(Il.x
�ARCI If FUTAINGINEER: LIC NO: ADDRESS: ❑
CONTACT.
PHONE: BUILDING PERMIT INFO
//2�� 1� 1�/[� `� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
if' C V6�!_ J' ❑ ❑ ❑
LICHNSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I berehy amm,duct I am licensed under pro . n
visionOf Chapter 91 occulmg ]OB DESCRIPTION
negZ who Seed i7a)0)on)....b,a30Ws,Business and Pn+ms.ionsCode,and toy fsan.e is RESIDENTIAL
I ^a �r PI:RMI I'ISSUANCE
C�� in toll lam and elf• Jf-NJ (,Z ❑SFDWL ❑IBE I'LumIEN I21iMOUIJ.
QUzU I,ice,ee Clan l.ic.a x APPLIANCES-RESIDENI'I AI, ❑ADDI'T'ION ❑I'Ll1MHING RI 1'll'li
.10. Oath Comore or ❑MULTI-UNIT ❑Sl RCC[
ARCHI'I'E.CPIS DECLARATION PANELS
~m oo
Z I maderxmad my pl:mx shall be used us public nae ds MODII'ICAI'ION
OZ`^0 UP TO 2W AMPS [_1 INTERIOR ED CHIMNEY REPAIR
I:�F41 Licensed Pndessional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑HATH REMODELREPAIR ❑DEiMOI.ITION
C Q 1 hcrchy aftimt that 1 am excmpr tentative Contractor's License Law tar the ❑OTHER
XO a V following=son.(Section 7031.5,Business and Professions Code Any city or couoY SIGNS ELECTRICAL
1+1311 y which requires a permit or construct,alter,improve,demolish,or repair any structure
F'u•OQ prior to its issuance.also requires the applicant for such perminn file a signed statement SPECIAL CIRCULn
f. y'4 the Be is limnscJ pursuanunlhe pmvisinns of the Contractors License low fChnpmr9COMMERCIAL'
1+100 (commencing with Seainn]O((LII of Division 3oflhe Business and Nofasinns Code)or TIiME METER OR
0.1 e K that he is exempt Ihcmfn.m and the basis for he alleged exemption.Any violation of [I NEW BLDG/AUDITION ❑DEMOLITION
XnLL Sedion]IIJ LS by any ePPlicumfor apennit subjecu the apPEicannoacivil penAry of 1'OWIiR DEVICES ❑TENANT ❑FOOD SERVICE
ty not morcman five hundred dollars S50O. IMPROVEMENT
ESQ ❑Las owner ofthe provxdy or my employees with wages as their sole compensation, SWIMMING POOL
'LE
❑OTHER
1.. will do the work,and lhesbuctum isnm intcndedor offered I...lc(Sec.AH4,........ l�
cz
L 3 m and I'mlexein is Gyle:The Comrednh License Law drew not apply to m owner of OUTLEI:S-SWIT _. y
progeny who builds or improve.Thereon,and who does tach sod h:manlf or through
his own mnployee.•provided hat ouch improvements ate nal bmended or nfl'crcA for NEW RESIDENTI
vale.11,hawever,Thchmidinganmprovemenl nssold within one Year of completion.the SQ.FT FLOOR AREA $/SQ.I'I'.
rhadder, will have the hurden of proving that he did not build or improve for par
pa.enf.:ac,). TarnL:
� 1 alproperty. IYcoarsening lith 1 Ind -m PA
ciam,niac,n p J t(S 7IW4 Binice,andY f::- 11--:1 1 rC Irasculr 11i.
1.aw does not apply to an Owner ol property n builds p .hereon. d QTY. PLUMBING PERMIT FEE
woo comme"loremh pr tjuu,with,,umtramonO[accused pec' ou the Contractor's Cl xx�
Llceme Law. PERMIT ISSUANCE u
I am caempt under See .B&P C for this mdsnn OF L.
ALTER-DRAIN&VENT-WATER Bl. �{•sJ,AI'ION
Owner Date ����C�JJ
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of Perjury One of the following declarations:
❑I have and will maintain a Certificate of Comenuo self-insure for Worker's Cmnpen- DRAINS-FLOOR.ROOF AREA.CONO STORIES TYPE CONS I'RUC'HOI
cation,as provided for by Section 3]00 of the Labor Cade.for the performance Of the
work for which this permit is issued FIXTURES-PER TRAP
0 1 have and will maintain Workers Compensation Insurance,as required by Section
3])Doflbe Lahr Code.finds,Performance of the work for which
hhis permit is issued. GAS-EA.SYSTEM-I INC.a OUTLETS OCC GROUP N'N
no
Came"r4rxl-r--p-_yT—Jy—l-mroFC.'d,arrier�N'Policy NoPolicay(-d- =� GAS-EA.SYSTEM-OVER1(IiAI
CGRRTIIFICCAATE OI'EXEMrLr PTION FROM WORICIi S' GREASF/INOUSTRL WAST[INfERCEI?OR
COMPENSATION INSURANCE —BUILDING DIVISION PEES
(This action need nm he completed ifthepermit is for one hundred dollen 1511X) GREASETRAP
PLANCHECK PEE
or less)
Icenify thin in the Performance ofthe work for which this plant is issued.I shall SEWER-SANITARY-STORM EA,Sx1 PT ENERGY FEE
not employ any peons,in nay"cone,so as to become xuhjed la the W..keri Co open
Z emium Lowe of l'alilimnia.Uwe WNIiR HEATER W/VENTiELLCTR
ApGRADING PR
Q CH
NOUCH TO APPLICANT:If,after nesain this visions of of Exemption,you ashould
ust WATER SVS'PEMlfREATING SOILS FEE
H >
became xahjccl m,the Worker's Componr this provisions steal n[the labor Code,you next
LLi ti forthwith comply with such provi.inns mnhls permit shullMJeemN revoke]. WATER SERVICE.
WQ
a. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.1.7. PAID
,U Z 1 m Receiptp
U O (hereby affirm tbm,item isaconmmcunn lending agency far the perlormunee of
the work for which this permit is issued(Sec.309],Cir.C.) 'fD"fAl.:
Q Lender's Name TOTAL:
C) LUl1 Lenders Address E.
-DING F
1 cer ifY thm 1 have read this application and ware that the above information is
Fit dmect.I agree Bscomply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEL' SEISMIC FEE
U Z building comraction,and hereby onthome mprecentativeS of this city to enter upon the
afrove-mentioned progeny for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
We)agree to save.indemnify and keep Includes,the Cityof Cupertino against
Iiabilitics.juJgmm�n,coos unJ expenses which may in any wayaceate.1mil".aid City ALTER OR ADDTO MECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10.000CFM) MECHANICALFE
SOUIB-i RT¢ULATION{S.
/ AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION 'A%
S stn .ef pplicnM/Condor Darn a/ EXHAUST HOOU(W/DUCT( HOGSINGMIDGA'[ON filo
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicantor folarc M1nilAingaccupnnl.mrc Or handle haeminu.n acriul HEAD ING UNIT OPO HNMAX)If'I U)
it,defined by the Cnpenino Municipal Cole,Chapter 9.12,and he Health and Safety IIHATING UNIT(OVER((MON)BTU)
Gide.Section 2553260?
E3 Yee El No VENTILATION FA N N ENGLE RFSI D) PAID
Dille Receipt in
Will the applicant Or future building Occupant use equipment or devices which BOILER-COMP(311P OR 18
0 ,0(X)BTU)
emit harach us air contaminants as defined by the Bay Area Air Quality Management 'TOgM:
Memo? BOILER-COMP(OVER I0TOCO 13'N)
❑Yes ❑No
AIR CONDITIONER ISSUANCE DATE
1 have read the taaathmm
re materials egmmmenunder Chapter 6.95 of the ctil-
fomia Health&Safety Cole.Sections 25505.25533 and 255]4.I understand that B the NEW RESIDENTIAL MI CH. SQ.PT
huildogdOcs on correctly have a tenant,that it is my ml ve sibiloy m notify the Occupant
of the"womems which must be met prior m issuance of a Cenifcae of Occupancy.
Owner or mala nzal agent
Date TOTAL: ISSUED BY:
OFFICE
..................................
7fFT T i�i7l F I
5 0
V3 4
-215
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