29322 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES.USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PFRMTF N0. •<JLL
2 9^ 2 2
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL' L .�JI
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
0 196ffmk�9 OL-Vuq 6
OWNE 'SNAME: , `PHONE
CONTRACT'OR'S NAME: LIC NO:
S• O1.1..A�C.K. NIC CONTROLN
'ARCH ECPENGINEER: LIC NO: ADDRESS: ❑
CONTACT: ^ PHONE: BU ILDING PER INFO
Q Q/-" A P4+77,30
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH '
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE > 1:1 ElO W Z 1 hereby arson mat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WNSection 7000)of Division 3ofthe Bminessand Profcssiom Cod, it my license is
FOO n full force and effcei. YPERMITISSUANCE RESIDENTIAL:
xZ License Class Lic.# ❑SFDWL ❑KITCHEN REMODEL
hRub
QW Date Commcmr APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RF.-PIPIT
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
Z p y Z 1 understand my plans shall b used as public records MODIFICATION
O Z.. UP'102N)AMPS
Q f2 L" d Professional ❑INTERIOR ❑CHIMNEY REPAIR
I-- W License
�iis. OWNERBUILDERDECLARATION 20IdCW AMPS IMPROVEMENT
" Q 1 hereby affirm that I am exempt from the Commeturs License Law for the OVER 1000AMPS ❑BATH REMODEIJREPAIR El DEMOLITION
k 36 F following reams.(Section 7131.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
YI V.y which requites.permit to comwet,alter improve,demolish,or repair any sumctua
f—�0 prion.its ismuncc,ulso requiresthe applicant for such .it file a signed statement SPECIAL CIRCUIUNUSC.
omheislicenscdpursmmmthep,wI,TomofthcContmema„License Lsw(Chapter9 '
1y�C00 (commencing with Section 7”)OfEtsision 3 ofthe Business and Professions Curb)or TE P.METER OR POLE INST COMMERCIAL
6 cq that he is exempt therefrom and the basis for the alleged exemption.Any violation of
N Section 703 L5 h applicant for a permit subjects are licant to a civil ❑ EW BLDG/ADDITION ❑DEMOLITION
y any ) pP pcnalry of PO E EVICES. �NANT' ❑FOOD SERVICE
y I more than live hundred dollars($Slq).
E=a0 ❑1,mownerof Ne progeny,or my employes with wages as their wle<ompcnsmion. S M ' POOLELECTRIC IMPROVEMENT
p. will do Ne work,end theswcm¢is nm imcmded oro[forcd for Rale lScc.911/4,Business ❑OTHER
L3 m and Professions Cede:The Contractor's License Law does not apply tom owner of OUTLETS—S —FIXTURES aaaaas \
propeny,who builds or improve,thereon,and who does such work himself m through
his own employees,provided that such improvemems me not intended Or offered for NEW RESIDE AL EL-KR SQ FI'. '
sale.If,however.the building or improvement is sold within one year ofrompletion,the SQ.Ff.FLOOR AREA $/SQ,FT.
ter-builder will have the burden of proving that he did not hoild or improve far par-
you of sale.).
❑I,as owner of the progeny,.B exclusively contracting with licensed undhders I.
onsrmct the project(Sec.7W4.Business and ProPossions Cede:)The Contmdor'x Li-
cerise taw does not apply to an owner Of propeny who builds or improves thereon,and QTY. PLUMBING PER IT FEE lf��
who contracts fir such projects with a eemmctors)Beamed puauantto the Conuamods
License Law. PERMIT ISSUANCE
C]I am exempt under Sce. .11&P C for this feu.on Coy 1996
Owner • Date + ALTER—DRAIN&VENT'—WATER(EA) —' V VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 2'r!'n'�s�•
f� Ihereby afBrn under penalty ofperju,One ofthe following Jeclamtions:
❑ I have and will maintain a Certificate ofComenuo sell-insure for Worker's Cornea- DRAIN —FLOOR,ROOF,AREA.GOND.
sation,a,provided for by Section 37M of the Lobo Code,for the performance of the STORIES TYPE CONSTRUCTIOf
work for which this permit is issued. FIXTUR RTRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700of the Latin Code.for be perfnrmnncc of1he work for whichmi,permit is issued. GAS— ' .S EM-1 INC.4 OUTLETS Air
txC.GROUP APN
My Worker's Compensation Insure,,carrier and Policy number arc:
Carrier: Policy Ne.: GAS—EA.SY iM- ER tAJ
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEAND STR ,INTERCEPTOR
(This section need not be completed it de,Permit is far est hundred doll.,1$1 Oft UIL IN DIVISION FEES
or les".) GREASE TRAP PLANCtI r�
toy any that in in eftorany member
of the bornork esubjer which this couthe Workers'
r iesued,rs'Co ,en-,hafi Out SANITARY—STORM EA. WET.
.whom Laws of Culifnmia.Date ENI F;
OWATER HEATER W/VENT/ELECTR
Z 0 Applicant GRA 'F E
y NOTICE TO APPLICANT:If,after ranking this Certificate of lixemption,you should WpTlik SYSTEMlBEATING
CZ become subject w the Workers Compensation Permit
steal of the Lahr Code,you man SOILS FF.E
�
forthwith,amply with such pmvizions or permit shallbeJeemW revoked. WATER SERVICE
G (�
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.FT PAID
V 0 l hereby affirm that there is a constromion lending agency for the performance of Date Receipt#
L4 I—' the work for which this permit is issued(See.3097.Civ.C.)
Lenders Name
V Lender's Address TOTAL: TOTAL:
0. 1 ttnify ohm 1 M1arc read this.pplicmion and stmt ohm the abwc infonnminn is BUIL ING FEE
Z? corset.l agree h comply with all city and county ordinances and state laws hitting toEAIRIIANDLING
CHANICAL PERMIT FEE
(.l Z building construction.and hereby authorize representatives ofthis city as enter upontbe SETS
ahsvc•meminncJ pnrPeny for inspection pupnsn' ANCE
(Wel agree m save,or inspection
and keep harmless the City of Cupcnino against ELECTRIC FEF.
Iiabilities,judgmens,coos and expenses which may in any way neem,agah.isaid City, D TO MECH.
in consequence of the gramm,of Nis permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINTNG UNIT(T0 IU.(1W CFM)
SOURCE REGULATIONS. MECHANICAL FEE
G UNIT fOVEk lfl(HNI CF,M7 CONSTRUCTION TAXSignature ofApplicanUConuactor Dau OD(W/DUCI')
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will dru,plierritafture buildingoccapmt smmmM1andlehccomirusmandal HEATING UNIT TO 100/0I0 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Hculth and Safety
Codc.Section 25532(a)'I HEATING UNIT(OVER 100,000)BTU)
❑Yes ❑No
VENTILATION PAN(SINGLE RFSID) PAID
Will the applicant or forum building Occupantsex equipment or devices which are
rnnBayReceipt#
Droit M1alnus air ennwminnma un dclindeby the BBay Area.Air Qua ality Mun.gement OOILBk—COMP(3HP OR IOO.WO BTU)
Disuin? TOTAL:
[IYes E]No BOILER—COMP(OVER IIIn,IXI()BTU)
1 have reed the hmanious materiAs AIR CONDITIONER
rc,u 533 nos.2553 1 Lod ultra of the Cali- ISSU
lnmia Health O Safety Cod,have
hereoon,n.
.IBM i 25531 and 25534.1 u notify th Nat if the NEW RESIDENTIAL MECH. SQ.FT.
building does not t,1ha i have a hret p Nato is sea ce ofasCenitim nobly,,anon,,m
of the myuirement.which man be met prior m issuance of a Cmifcate of Occupancy.
Owner or authorized.genl Date TOTAL;
:ISSUEDY:
OFFICE