S 0161 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELECTRICAL PERNUI ND.
CAL
BUILDING DIVISION APPLICATION/PERMIT PING PRNJECTID IDENTIFICATION
S 0161
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA
I ! ,-Ale (�An
'S NAME: PHONE: CO I'ON'S NAMIi: LIC NO:
L 1` Lm In Xyl NIC /^\ GDIvrRD1.a
A ITECI'/�'.gGIMEIL LIC NO: ADDRESS: I,`
AW�CXio �L.0 ry�lr.J 7liD✓✓fxA /7Y ❑
CONTACT: I PHONE: BUILDING PERMIT INFO
pq p q ❑ Consultant Fees Paid by Applicant(Initial) RI.UG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARq'110N QTY ELECTRIC PERMIT FEE
I bench,affirm Nm I nm licensed wader lascivious of chapter 9lgmnmencing JOB DESCRIPTION
MZZ with Section 71%X0 of Division 3 of the Business and Professions Cale,and my license is RESIDENTIAL:
WOO wl PERMIT ISSUANCE
FW in f11orce and IT I. ❑SFDWI, ❑KITCHEN RESIODEI
c4u Lician las, Lich APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMPING RE PIPE
NQ6 lute Contriev,
E.Dy ARCHITECPS DIiCLARA' PANELS ❑MULTI-UNIT ❑STNUCTURAI,
ZO IunJe-t yPlansshall be ueu) public nNs MODIFICATION
OZ�� UPI0260 AMPS MOLT[
[I CHIMNEY REPAIR
fir.N.E"W Licensedmfc n 201-1000AMP5 & IMPROVEMENT C]SWIMMING TOOLS
xQYF.; OWNER-BUILDER DECIARATION OVER IIXq AMPS [I BATH RES10DEflREPA1R C3 DEMOLITION
C C Q I hereby alto.Ilial I am exempt from the Contractor's License Low for the
X1X O6 V following rensmt.(Section]Iq L,S,Business and Podessinns GNe:AnY city or county SIGNS ELECTRIC El OTHER
W 3
la.4, which requires a permit to conswct,alto improve.demolish,or moor any amcture
Q prior to its issuance.also requires the applicant for such Permian rile a signed statement SPECIAL CI IT SC.
that he is licensed personal to the provlMorsof the Contractor's License Law(Chupmr4
p� (commencing with Section 7000)of Division 3 ofthe Business and Profession,C1,12)"9
,1 ME T1[ P ST COMMERCIAL:
t e.e C that he is exempt Nerefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X_m Section 7031.5 by any upphem,for r permit subject the applicant m a civil Penalty of POWER DEVIL []TENANT ❑FOOD SERVICE not more than five hundred dollars 055110). IMPROVEMENT
=Q' ❑La....x, fthe pmpcny,or my employees with wages.,theaudecomPenv1lon. SWIMMING POOL :LECTRIC
cd t: willdo Ne work,undihe structure ism4 intended mattered fnrsile(Sce.70,14,Business ❑OTHER
ro and Professions Cale:The Cattmetols License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
6 3^ property who builds or intPMveS thereon,and who docs such work himself or through
his awn employees,provided in.(such marower ce,me tent intended m offend for NEW RESIDENTIAL ELECTR 16IT.
sale.lLhnwavem IM1e building or improvement is suld within one year ofmmpletion,the SQ.FI'.FLOOR AREA s;/SQ.FT.
eolmilder will have the burden of proving that he did no,build or improve for pur-
ram ofs.le.). PV
P A Y
❑1,as owner of the property,am exclusively contracting with licensed emilme nos r, T
..sure,the project(Sec.7044,Business and Professions Cale)The Cmeractors Li-
eciv,o,Law does not apply it)on owner of property who builds or impmvcs thereon,and QTY. PLUMBING FERMI 'EE ��� ��
who contract,for such prnject,with a cnntmemno)licensed pursuant m rn
the Cometor's EC n
L oat n is Law, PERMIT ISSUANCE I[�{�
O I am exempt under Sec. .B&PCmenu,.,on
ALTEk-DRAIN&V I?N'I'-WATT?R fl?A) ION
Owner Date
WORKER'S COMPENSATION OECLARA'1'ION BACK FLOW PROTECT.DEVICEqbL `�
I hereby affirm undo Penalty of Perjury ane of the following Jcdumtions:
I ham and will maintain aCcnificatc of Comenuo elf-insert for WrrkeJs Compete DRAINS-FLOOR.ROOF ARFA.COND. STORIES .1. PECONSTRUCI'I
,in ux provided for by Section 391X1 of Ne L.bnr,Code.for be performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as requited by Section
3700of IM1e Lahnr Code,Fame perommntcof the work for which,his permit kecam& GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
MyovaWorkers Com'�ensmian lmlrenccc itPolicy ober
crier: �r°run GAS-EA.SYSTUM-OVER 4(EA)
s,v.a r Policy No.:
CERTIFICAI E Of EXEMP'HON PROM WORKE S'
COMPENSATION INSURANCE X''7C> 16�'Er GREASMNDUSTRL WAS TE INTERCEPI"OR
(This sectionocul not be xmidetcdiflhc permit is future hundred dollars IW) BUILDING DIVISIO �SS
or less.) GNEASF.'I'RAI' PLANCHECK OFF
Toy any that to the any mmnersotince Ne becomork e
subjech ct to
permit is issued,Compete- SEWER-SANITARY-STORM EA.2(q FT.
not employ any person in any manner m as to become subject to the Waders'Compete- ENERGY FF:13
OzSaurn Luwsof C.1ho...in Date WATER HEATER WNENT/ELECfR
Z2 Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTIiM/IREATING
a ' became object m the worker's Cmnpensation pmvsioah of be Who CWe,you most SOILS FEE
forthwith comply wiN such provision,orIDis Penni,shall be der ed meeked, WATER SERVICE
Q
Uz CONSem is acONLENOINGAGENCY NEW RESIDENTIALPI.MB. SQ 17. PAID
U hereby which rmthatthereiisued(me 30 leading agency for perfornruncenf Date RceeiPtM
W lox he work for which Nis permit is issued(Sec.309].Civ.CJ
O Lender`s Nome TOTAL:
V F WnddAddress 'I'fYI'AL
I :C eerily that 1 have Gerd,his application and,Late that the aMve information is BUILDING PEE
rA mncut.l ngrcewcnn,pty wiN nn c'ny and amn,y ordinances and,tete laws Gelatins to QTY. MECHANICAL PERMIT FEE
buildingx.,unclinn,and hercbyarNoriee reprusenta,ivcsof lhiaci,y in enter upeade SEISMIC FEF,
ubwemernmeed Propcny far inspection f urpor c, PERMIT ISSUANC17
'(We)agree In save,indemnify and keep harmless the CIry of Cupertino against ELECTRIC FEE
liabilities,' mem:,ensts endexpenses which troy in any way accrue againstmid City ALTER OR ADD TO MECH.
inconm c of tits granting of this permiL PLUMBING I'EE
APPLIC Nc 1NULRSTANDS AND WILL COMPO "WITf ALL NON-P I Alli HANDLING UNIT(T)I(1.(Xq CFM)
SOURC R s 1 ATIONS. MECHANICAL FEE
AIH HANDLING UNITIOVIek I),IXNI CIM) CONSTRUCTION TAX
Signal. ftA nor O EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
RUOUS MATERIALS DISCLOSU ,'
'11th applicant or future building occupant store or handle hrmismus material HEATING UNIT(TO 100,00th RTU)
as Acfined a Cupertino Municipal Cook,Chapter 9.12.and the Health and Safety
Cale,Section 25532(x)? HEATING ON1'1'(OVER 100.0s)BTU)
❑Yes ❑Na
s VENTILATION PAN IS]is RPS)Of PAID
Will thea Iieant or future building t use a ui ment or devices which Due Resa'p,a
pP dby are
y P BOILER—COMP f3HP OR 10(1.000 RTU)
emit District?
us air contaminants a,defined by Ne Bay Area Air Quality Management TOTAL:
Dist x?
r ❑Yes No BOILER—COMP(OVER IIN),IXXI BTUI
Ihove read the he...don,.tetanal,nyuinmentx under Chapter 6.95,frit.Cali- AIR CONDITIONER ISSUANCE DATE
mass Health&Safety Cale.Sections 25505,25533 and 25534.1 understand Nal if the NEW RESIDENTIAL.MECIL SQ.FE
building doe.,not comply have a temmt.Na,it is my responsibility Rs notify the occupant
of the rc blanc..which mus,Sealer prior In mu mer of a Cenificu,e of Occupancy.
Owner or auNurizW agent Date TOTAL: ISSUED BY:
OFFICE