S 1374 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECrRICAL PE IT No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1374
BUILDING PROJECT IDENTIF'IC'ATION
UILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
oZ/1 G Yy7a,v C.%. 3--1
( NER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
e -,La _ / N/C CONTROLM
ARCI UTEC'VENGINEER: LIC No !•_ ADDRESS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLL ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby M.that 1 am licensed under pmvisions of Chapter 9(commencing JOB DESCRIPTION
WCZ with Section](XXpof Division 3 of the Bu,inessand Pmfic,ions Code,and any license is RESIDENTIAL:
O O PERMIT ISSUANCE
F�
in full ,Classnd elTml. ❑SFUWI. El KITCHEN REMOUI?I.
aUU Licence Claes Lia. APPLIANCES-REHDF.NTIAL ❑AD])ITION [I PLUMBING RE-PIPE
yZ WDt/I Date contractor
Q. ARCHITECTS DECLARATION ❑MULTI-UNIT El STRUCTURAL
ZOyZ I understand my plans shall be used as public records PANELS MODIFICATION
O Z,.Q UPTO 200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
ly LicencJ Prolesoinnal 201-INX)AMPS IMPROVEMENT ❑SWIMMING POOLS
ltil�o w< that I am exempt fr m DECLARATION OVER 000AMPS [I BATH RIiMUGUEI/NRE�PAIR I]UE;�
1IY Q I hereby affirm on I am exempt from the Contractors License Law for the I�
O m U following reams(Section](IJL9.Business and Professions de io li Code:Any city or county SIGNS ELECTRICAL OTHER
al'3 y-y which aspires x permit to conswcl,almq improve,demolish,or repair any stmclurc
01 prior to its ismance.also requires the applicant lot such permitm file a signed statement SPECIAL CIRCUIT/MISC.
ythat he is licensed Pursuant n the provisions of the Contractor's License Law(Chapter 9
WIYpO (commencing with Section]00(pof Division 3 of the Business and Professions Cade)or TEMP.MITER OR POLE INST. COMMERCIAL:
li m o y that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION [I DEMOLIT[ON
XmIi Semion]0315 by any applicant For o permit subjects the applicant to a civil pewlty of POWER DEVICES
[-]TENANT ❑POO])SERVICE
t more than live hundred dollar,(1500).
^Z Y IMPROVEMENT
=6 pl,arre work,the pestruc,onnyemplendes wilhwagesmtheir(sale 70dpcasinen, SWIMMING POOL ELIiCI'RIC
SFG will du the work,and me snunum is not intended arra'eredfor sale(SmA(FW.Ousines ❑OTHER
W3 m and Profession,Code:The Conmalm,License Law class net apply to an owner of OUTLETS-SWITCHES-VENTURES
property who builds or improve,thereon,end who does such work himself or mmugh
his own employees,provided that such improvnnenls are not intended or ofrcred for NEW RESIDENTIAL BLEC'I'R ,
,ale.It,howeverthe building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA USQ.Fr.
costact-ludikier will have me burden of proving that he did not build or impmve for put- [] p ' D
"scofsale.). P K
1,as owner of the property,am exclusively contracting with licensed comndons m TOTAL:
construct the project(Sec 7044,Business and Professions Carl The Contractor's Li-
cruse Law does not apply to an owner of property who builds or improves smic..m,and QTY a,srAR PLUMBING PERMIT FEE 'UPII/ d All)
who contracts for such projects with a commnnr(s)licensed pursuantto the Contractors
Ua,.,e law. PERMIT ISSUANCE
❑Iemexempt ua&,See ,B&P C for do,sa en ITY Ur LUrrm
Owner Do,, ALTER-DRAIN&VENT'-WATER(1?A) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROI'EC'L DEVICE
1 hereby affirm under penalty of perjury one of the following declaration,:
Fj I have and will maintain a Cenificam of Consent o self-insure Na—Worker's Camper- DRAINS-FLOOR,ROOF,AREA,GOND.
onion,as provided for by Section 37M of the Labor Cade,for the perfr mmuce of the STORIES I'YP.CONDO'RUCTION
work for which this p_nuir is....ad. FIXTUR17S-PER TRAP
1 have and will maintain Worker's Compensation Insurance,us required by Section
37(X1 of the Lahr Code,for the Performance of the work for which this permit is issued. GAS-GA.SYSTEM-1 INC40UTLE1'S OCC.GROUP APN
My Workers Compmrmtion Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-13A.SYSTEM-OVER 4(EA)
CERTIFICATE OR EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WAS 117 INTERCEPTOR
(This section need not be completed if the permit is forane boa and Jollam(SIM) BUILDING DIVISION FEES
artnc.) CREASE MAP 1'LANCHECK FEE
I certify that in maperfommncc ofth kfor whichthispermitisi...saLl Andl SEWER-SANITARY-STORM EA.21X1 FT.
nolemployanY Mrx'nn in:vlV7�tan�ar ,yr be mne�y}FJatJuth�}Varkun'Cumpen- ENERGY FB13
zZ. .eniun taws ol'CnI' WATER HEATER W/VENT ELECfR
Ci Applicata GRADING FEE
NOTICE TO APPLICANT:If.ellermilibroIl Carifcam of Exemption,you should WATER SYS'fEM/I'REATING
Wamne abject ret the Workers Compensation provisions of the labor Cade,you most SOILS FEE
Fak7 6mhwim comply wild such pmvisions or this lmnnil shot[he Deemed revoked. sFL
WATER SERVICE
Q
CONS,
hemisa cumarin LENDING AGENCY NEW RESIDENTIph PLMN. SQ,PT. PAID
U O work
which
tar thin there isocomsmetien lending agency for
the pcnfomnnce of Receipt It
Ws F the work for wbicM1 this permit is issued(Sec.300],Civ.CJ
O U Ixnders Nanta TOTAL:
U Lendeh AJdreo "TOTAL:
I cattily Thal I have read to,a,humiom and state mat the above information is qw�NSTRUCTIONTA
ILDING PER
h correct.l agree to comply with all city and county ordinance,and stale laws miming to QTY. MECHANICAL PERMIT
wip—
Z building construction,and hereby aumorim representatives of this city to Win,
the ISMIC FEE
space mentioned property far inspection purlxrms' PERMIT ISSUANCE
(We)agree hs save,indemnify.nd keep harmloss the City of Cupeninn against ECTRIC FF.
Ipdolides,pil,oans,costo and,xExrsa,.1ichnay in any way accrue r,unosaid City ALTER OR ADD TO MECH.
an nmgoencc aft runling of .mit. PLUMBING rEE
APPLICANT E STA ' .'AND WILT.COMPLY WI'I'It ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCER In. O' CIIANI:ALFEE
-r 5 AIR HANDLING UNIT(OVER 1RgX)CIT1)
Sig sure of Applpim Contract... Dam EXHAUS I'r IOOD(WIDUCI) HOUSING MI"fIGAT10NI'li
H RI US MATERIALS DISCLOSURE
Willtheopplinnt or Poore Wilding ecen,anl nme.,handle hmvdumnaterial HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)4 HEATING UNIT(OVER 100.000 BTU)
L]Yes 0N PAID
VENTILATION FAN(SINGLE RESIO) Data Rcs m,t M
Will the applicant or(mum Wilding occupant use equipment or devices which
emit haaardeas air cnnmminenu as defined by the Bay Area Air Quality Management BOILER-COMP OUT ON I00,IX0 BTU)
District? TOTAL:
E]Ya, ❑No BOILER-CUMP(OVBN 100.000 BTU)
1 base mail the hazardous materials mquimmems doter Chapter 6.95 of the Cali- AIR CONDITIONER AT
Fonio Health&Safety Cale,Sections 25505,25533 and 25534.1 understand mat if the NEW RESIDENTIAL.MUCH. SQ.Fr.
building does not ecmandy have a tenant,that it is my responsibility to notify the occepmn
or the requirmacnu which moa he met prior In i.ssnance of a Cenifieate of Occupancy.
Owner or aulammed agent Date TOTAL ISSUED BY:
OFFICE