S1418 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO NIIILDING ELECTRICAL PF. IT NO
RUII.DING 6IVISI.ON APPLICATION/PERMIT PINGPROJECTIGN'11FI I. � 1418
BUILDING PR(1JRC'T IDEN'1'IN'ICATIUN
BUILDING ADDRESS: SANITARY NO. APPLICATI NSUBMITTAL DATE
%f 4z/
OWNER'S NAME: PHOWi: CONTRACTOR'S NAME: LIC NO:
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N/C CONTROL#
�ANCIIITECTIENGINEER: - LIC NO:' ADDRESS'. V C4 qS
M^r'�7 ❑
q 70 F_ty,611n
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUUM,B MEED
❑ ❑ ya ❑
LICENSED CONTRACTORS DLCLARAI ION QTY ELECTRIC PERMIT FEE
I hereby,IRrm f co1 licensed d na
n m co-pl 9( not cin, JOB DESCRIPTION
�0� w llh Seri mt]IHNI)ofD ".ritn3 fid Baa II f,sio:L d,' 1 ylicnsei, PIiRMIT ISSUANCIi RESIDENTIAL:
F u:. to full fnceand effect ❑SIUWL ❑KI'I'CHEN REMODEL
QU E Li,var,e C1 GSCo Lic.k APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RHdIIPE
-d,d Dam p a�" ' ��Commmor
Fly 6,11.ON ARCHITLCPS DLCL AHUN PANIiLS ❑MULTI-UNIT ❑STRUCTURAL
biz Iunde,mand my plane.hall bamocimspoblic ruordx MODIFICATION
OZK)—a UP 10210 AMPS El INTERIOR Ll CHIMNEY REPAIR
F-y,FW Licensed Protc—oval 201.1000AMPS IMPROVEMENT ElSWIMMING POOLS
WNF.R-NUILDIiRDECLARATION OV17RI000AME'S ❑BA'1'HREMODFUREPAIR ❑ EMOLITION
Cw C C Q I hereby oil!.than 1 am exempt from the Cit thio ac's License Law lin the J.
[I OTHER
ge 3 L) following reason.(Section 01131.5.Business and Pndi,sions Code:Any city or county SIGNS ELECTRICAL.
� which requires a permit to contract,alter,improve,demolish.or repair any structure GSI Y�/1st.
LLQ
^`w
Cj j pri f fI. minutesth ppl' II vhpc n IIc,,,-cd.r¢meet SPECIAL CIRCUITIMISC.
7+ Iha,lte is 1 dp - nl life the C mactim,Ueemi,Le (Chapter 9
Rotimanang with Section WEBB of Division 3 o the liusmeas and Professions Cade)or TEMP.METER OR POLL INST COMMERCIAL'
u:_pO
d 6 e x that he is exa-En therefrom and the basis for the alleged cxcmptim.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^vi Section 90315 by any applicant for a pvrmil zcomes the op,l,.nuo a civil penalty of POWER DEVICES ❑TCANT ❑FOOD SERVICE
main than h,1 humlred dollars 155018.
Fz>• IMI'ROVF.MIiNT
Q Lo the
rk the proppny,or myemployeeswith wagesas rlale(Sec.en1.Busi less SWIMMING POOL ELECTRIC
ES_ willJmhe wort,and the stmnure is not intended or offered sole(Sir.]t1W.Business ❑OTHER
WF
a$ and eny wl fi Code:The Contractor's License Law does nut apply to an owner of OUI'LLTS-SWITCHES-Il%TURES
a'3-. pralxny wbo buil,,or impmvcs Ihcrcn improvement,and who docs such work bimsv.n or through
his own onployms,pmlding that such entisuldw are not intendedyoff or offered for NEW RESIDEN'I'IAh ELEC'llt SQ[T.
wle.If.however.the Funding or Improvement ismlJ wiNin one yearufrnmplpion.the SQ.FT.I9,OOR AItIiA SISQ.PP.
er-builder will v r M1ave the burden of proving that he did not build or impro'e for put
-
I vnI ala.).
I,as owner of the property,am exclusively contracting with licuttmd commcmrx m 'TOTAL.
construct the project(Sec.7094,Business and Professions Code:)The Commaors Li-
se law does not apply to an owner Of property who bunds or improves lhemer,and QTY, PLUMBING PERMIT FF.E
who reenacts for such Eajects with a cannaetono)licensed purxunnl m the Contractor's -
LiccnseLaw. PERMIT ISSUANCE
C] IM.e car,under See .B A,P C for Ibis reason
AGER-DRAIN&VENT-WATER B:AJ VALI]A ON
Owner Dale
WOR KER'S COM PENSA'I'ION DIiCLARA'I'ION RACK FLOW PRO I'F.CT DEVICE
1 hereby aRnn under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Comm to self-insure for Worker's Compen- DRAINS-FLOOR.ROOF,AREA.POND. STORIES TYVECOVSIRULTION
sution,as provided for by Section 3700 of the Lino r Cade,Irz the performance Of the
work for which Chia panel is issued FIXTURES-PER TRAP
rtryrt 1 have and will maintain Worker's Cornpen.v M Insurance,as required by Section
3]Wafthe labor Colo.(of the performance of Ne work for which this permit is issued. GAS-EA.SYSI HIM I INC.4 OUTLIi'I S OCG GROUP APN
My Work c{,-Compenamin Inxu ` rand Policy°P
Carrier \I'r e ��-(,Mrf carrier Policy NO •` I1"a1^599 GAS-CA.SYSIF.M-0VEk 4(EA)
CERTIPICA'I It OF EXEMPTION FROM WORKERS' GRIiASFJINUUS'I'RI,WAS 17 INTHI10EPI OR
COMPENSATION INSURANCE 13UILDINCI DIVISION FEES
(This.section need not becompleled ifthe perdollars(5
ind is foronc hundred 1(X1) GREASE IRA['nr Ifus-) PLANCHECK FEC
I cantly that in as,prrfonfarce ofh t work fur which(bin p.Main iv ixnua1,I,L1I 51!W L*R-SANITARY-S'I ORM EA,200 FT.
not employ any Edson in any manner sit as to bemnm sbjreno the Wmkcrx'Compen- HNEIIGY FEL!
O Z ,mien laws of Califnmia.Date NATER HEATER WNENT/ELECTR GRADING FEE
Z O Applicant
NOTICE 1 O APPLICANT`.If,after onflong his Comm cam of Exemption,you sM1ould WAI ER SYSTEM/TREATING
Iwme eoval oct et fire Wnrka's Compenaodon lllw saoa5ofthe Letter Code,you turd SOILS PEE
Wprotoc tl comply with such provielninar this permit shall he Jecnsedrevoksrd. WATER SERVICE
Q
CONSION LENDINGAGENCY NEW BESIDE SQT. PAID
U 0Iherebyaffnnthwthem
isaotxwetion ludingnguncf the @rinnnnneunf T
Uum HeceipfK
LT.. — the work for which TMs pefmn a issued Sce.3(07.Co,C.)
C) U Isndeh Name, TOTAL:
r W Lenders Address T(TAL: L
I candy in.,I havu read 16ix application and fate firm rhe abova inoomo tion is
BUILDING FEE
F` y comeet.l agree,to comply with all city and countyordrancew fact sure luwsreiadng to QTY MECHANICAL PERMIT FEE
U Z building construction,and hereby athome mpresenfmives of this city it)enter Open The SEISMIC 19Ji
d,mc mentioned properly for inspection putpty s PERMIT ISSUANCE
(We)agree III cmc,indcmady:mJ keep harmless the City of Cupertino agoinm ELECTRIC 1171.7
Iiabilincs,jim,ntem,cool,andexpenm.,whichmay in any way aceroc against sail City ALI ER OR ADD 10 MITCH, �
in mequenae of the granting of this Permit
I'Ll1MBfNG Igili
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON'POINTAIR HANDLING UNIT(TO 10.000 CFM1I)
MECIIANICN,PCE
SOURCE REGULATIONS. � y
hrv: ��� Y61� -� -�� AIR HANDLING UNI'I'(OVER In'd XI CPM) CONS I'RUCIION TAX
'
Signature of Applicam/Confranor Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WIII he Opplicumm boom handingnccapant,mre or handle hxnmm,mmttial HEAT INC,UNI'F(TO 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safety
Code.Section 2553200! HINTING ONE 1'(OVER 100.000 BTU)
❑Ycn PA
VIiNTILATIGN FAN SINGLE REDate RreciplX
a Will the applicant or future building Occupant nae eyulpmenl ar devices which Is
BOILIiR-QIMP(METIER 100,(XI1111TU)
mit haurdouz an contaminants as defined by the Bay Area Air Quality Management 2 1District' BORLER-COMP10VE R 100.(X10BT U)
❑Yes Ki NoI have read the haeardous materials Is under Chapter 495 of the Cali- A I R CONDI1I ONER ISSUANCE DATE
fomiag oesn Safelytly haSections .thati 255JJand3534.1 to ersty th chatifthe NIiW RF_SIDI?NTIAI.AICCII. SQ.1'1', tAY
building Jcex not currently have a tenant,that if is my responsibility fur nosily the occupam
Of the ngnirements which must bit tact prior m issuance of a Coni From of Occan amY Uwneroruuthorized a,ent Uae TOTAL: ISSUE I3 YQ'��
(�
OFFICE