S 2859APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPIACATION/PF.RMITPLOSIIII.NG-MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMITNO,
RU1LDINGAINARE5S:
O'L
SANITARY NO,
APPLICATION SUBMI'fl'AL DATE
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OW
ER'S NAM[ i: I'1{ONE:
1�• 1 7— 4
CO CIOR'S NAME' p LIC NO:
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N/C
❑
CONTROL
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II1TIf TIEN01NEER: LIC NO:
ADDRES.
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COMACr PHONE:
FraF a 53-c�1s
❑Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
❑ ❑ eer Cl
LICENSED CONTRACTOR'S DECLARATION
hereby arfimt mat I an, lice ad order pr Wkiom or Clegarr, 9 (,onanencing
with Secvit l(XXpaf Division 3ofm. Bmiress and Pmlcesicnxeale.;md my license is
in full internal l e
Lich
Cnmractnr
QTY. ELECTRICPERMIT FEE
JOB DP,SCRIPTION
RESIUF.NTIAL
❑SFUWh ❑KITCkIP.N REMODELt
❑ADDITION L4*l.+MBING RE PIPE
❑MULTI -UNIT Ll STRUCTURAL
MODIFICATION
El INTERIOR ❑CHIMNHYREPAIR
IMPROVEMENT (]SWIMMINGPOOLS
❑ BATH REMODEUREPAIR ❑DEMOLITION
❑QTIILR f
PERMIT ISSUANC'li
APPLIANCES—RESIDENTIAL
ARCHITECTS DECLARATION
Iundersmndmyplans mall fe.,edas pidit, accord,
PANELS
UI"T0200AM1'ti
Liamed Prol'msional2111.1(X10AMPS
OWNER -BUILDER DECLARATION
1 hercby union Thal I am exempt from the Contractor's License Law ror the
following rcaam. (Section 7031.5. Business and Profesium, Code: Any 61y," .Ducey
which replaces a permit m comtrua, aper, improve, demolish, nr repair any slmemre
prior to its ssuanee. aIsit requires the a ppIloan Ifor such pc+minu rile a signed .stmemeut
hatheisliccrsnlpumuanlltiheprovlsinnatDhe Cuntmcltr'e Licetsehew(Chuplere)
fcood"namg with Sect 7000) of Divixion 3 of Ne business and l'r inns Code)or
Nut he is exempt Iherefmm and in, hosts for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not more than rive hundred dollars (5501).
1I. as moor of the pmprrt, or my employers with wages a�Neir Cole rompcnsation,
will dome work,andthe structure isnot intended moffemJ husale(Soc. 104, Business
and Professions Code: The Contmcmr's Licensc Law dam nm apply to an owner of
property what builds or improves (hereon, and who does such work himself it through
his own employees, provided that such improvement are not intended or offered for
sale. If, however. the building or improvement P,mId within one yearofahntpletiur.'he
er-builder will have Ire burden of proving that he did not bul4 m improve for Pur -
Face of cele.).
❑ I, as owner of the property, am exclusively contracting wilt licensed comment. to
attract the pnhject (Sec. 9144, Buainess and Profe,,ian, Cude:)'Dw Commmtrx Li-
enwLaw cities not apply mall owner of prupeny who builds or improve, IIcrCon. and
Who Contract Ila Such projects with a Csmaa mot licensed pursuant to the Contractor's
Lice... Law.
C]I am eaempl under Sao ,B&P C for this reason
I, B1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUI I'/MISC.
'1'I7MR METER OR POLE IsEt
COMMERCIAL:
4W HLDG/ADDHlON ElDEMOLITION
❑TENANT ❑FOOD S17RVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING MX)1, 131.GLTRIC
OUTLETS— SWII'CIIHS— FIXTURES
NI7W RESIDEMI'I Al. E?LEC R SQ FT.
SQ. ET. FLOOR AREA
$/SQ. FT.
'TOTAL:
QTY. PLUMBING PERMIT FIT.
g
PERMIT ISSUANCE. ) 7
ALTER — DRAIN & VENT— WATER (FA)
Owner Date
VALUATION
WORKERS COMPIiNSATION DECLARATION
I berehy'abnoa ondm w liyul'perjuryoreof env following dalonninns:
[3 [have and will niannomn a Certificate ofConsent to self -insure our Warker'x Compon-
workf xe phrrvidW for mi Section 311X1 of Na Labor Crile. (or the performance of the
work for Which this aintiiis issued.
❑ 1 have and will maintain Worker's ante o In, w lk far hi h required t i Section
31(X1 trmel.af.,r Code. for me pvrftnnw.e Done work far wmm� miapermnix issued.
Car my edo Codh psut�In Qun4r offerPol yNhxyn n %o
CHILD -'ATE OP EXIT IPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissenion readmit beemn,leted iflhe p.rmil is (Drone hundmJ dollars (Sl(k97
inhe's)
I cenifytdin the performance ofthe Work far which this permit is issued. I shall
not employ any person in any ammmr su as It become subject m Nc Workers' C..,,a-
onion Laws of California. Dat.
Applicant
BACK FLAW PRGIECT. DEVICE
DRAINS- FLOOR, ROOF, AREA, CONE).
S'fOHIfS
'I'YPI3 CONS'1'RULTION
FIXTURES - PER 'I'RAP I ��
GAS -EAC cT'bLl
r>ec. ekouP
O
SI 17M
GAS -E�:. YS'1'i?M ) h. (BA)
GREAS WASTE INTERCEPTOR '13PTOR
GREAS AP R O
BUILDING DIVISION
PLANCHECK FEE
,S'EW'ER
'ANITAkY- STORM EA. 2(X1 FT.
ENERGY FEE
WArER I ll TEIt W/VFNT/F.I.P.CTR
GRADING PIiE
NOTICE TO APPLICANT. IL after naking this Certificate of Exemption, you should
become abject m the Workrs Compensation provisions mine Labor Calve, you most
forthwith Comply wish such pmvi.sions or pnmitim.11 R deemed revoked.
CONSTRUCTION LENDINGenAGENCY
ihcrchy ul Orn that Nma isu Cnnxtnaclivn lendingr,aagency for the perfnnnuncc of
the work for which this permit is lxwcd(Sov. 3091, Civ. C.)
Lenders Name
WATER
SOUS 1:17E
/ WATER SERVICE
PAID
ate Receipt If
NNEWRESID[N'1'IAI. PLMU. SQ FT.
TOTAL:
TOTAL: /'OI
Lenders Address
NUILDI FFF
1 sandy that 1 base read this application and slate Ina the above information is
correct. l agree to comply with all city and county ordinances and suite lows relating to
building construction, and hereby anlhori ze reprvsentativev of this city to enter clam the
da,c-n endnncA pmpCBy f r;;;spmdnn pnrpooas,
(We) agave m save, inden unify tmd keep tom less the City of Culwrtion against
liuhilities,judgmems, toss and eapcmes which may immy way.aaaati,mma said City
in asequence oflhegrunting tflhis permit
APPLICANT UNDER.STAN A ILL COMPLY WITH ALL NON -POINT
.OIIRCE REC ,A7'10.
4.g�g4
QTY. MHCI IAINCAL PERMIT FIEF:
SEP \ IC :HF
PERMIT ISSUANCE:
ALTER OR ADD'I'O MECH,
ELECIIt C' PCH
PLUMB 'G FEE
AIR HANDLING UNIT ITO 10.01CF10)
MECHANIC .TGE
AIR 14ANDLINGUNIT (OVER 10,(XXICFM)
CONS 'IRUCTION TAX
Si npP anVC< Due
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building becupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
Code, Senior 25532m)? -
El yes _1 M1 "
ch
Will the applicant m future daft ng.ccue B use ea Air entQu Br dManaS Management
emir hazallom air ammminnnb rte defined by the Bay Arca Air Quality Munagemrnl
DISV CI?
❑Yes ♦.]TRS
1 b;we readthe hxvrdaus tremriuls reyuircmcnts under Chapter fi:15 nl tM Cali-
foil Health & Surety Cady St-nanx 25505, 25537 mud 25534. L understand flat Ir the
Id in Ia Ely Menu ,al it¢myou"i lhility tonianydans,:ii'm
aft arc nn ms ed t Prior to nificmc ifGfOc r.
MkCR�u` ��
EXHAUST HOOO(WIOUC'1)
HOUSING MITIGATION PEO
HEATING UNIT (101009000 BTU)
HHAI'ING UNIT (OVER 14,0011 BTU)
PARI
Date Reecipttl
VENTILATION PAN (SINGLE RE.SID)
IlOI1.ER-COMP (3HI' OR 100,00ORTU)
BOILER — COME (OVER 100,000 ITT[))
AIR CONDITIONER
ISSUANCE: DA'PF:
(J
A - 9P
U
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. FI'.
TOTAL
Owner nr amhnri��zed,�, I Data
OFFICE