S 1686 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFC
F CUPERTINO BUILDING-ELECTRICAL ' "NO 1686
xUILDIN.UNISION APPLICATION/PERMIT rLuhlmrvc.MRcunmcnl.
BUILDING PROJECT IDENTIFICATION
SA
BUILDINGADDRESS: NI'I'AIIY NII. TM, CAI'ION SI11iMITlAh UAI'liifs VAI C-- ��� 48
OW NI? 'SNAME7 PI10NE: CO TRACI)R"y NAMIi: LIC NO:
I f,- / - ��Q NIC CUN'I'It(lL#
�i ARCHITECUE INEER: LIC NO: ADURL S: V,/(Q/ /� ] ❑
CONTACT: PHONE: EUILIJING PERMIT INFO
ElConsultant Fees Paid by Applicant(Initial) BI.DG Ia.ECI' PLUMB MECH
OG
�( L r0t ❑ ❑ ,�' ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT' I°8G
I hereby Fri.that I am licensed under pm,l,lona of Chaper,9(coa nomang JOB DESCRIPTION
Oaz, with5edion]OW)of Divlalon3ofthenusinwsand Pro!,ions Code,and my license is RESIDENTIAL'
m O O PERMIT ISSUANCE
F,z m full l ince and effect, ❑SFDWL ❑KGCHIiN REMODEL
�U License Class Liv.# APPLIANCES-RESIDENTIAL ❑ADDITION *PLUMBING BE PIPH
F Z [)ate Contractor
NdARCHITECT'S DECLARATION ❑MUI:TI-UNIT ❑STRUCTURAL.
Foz I undermand my plans shall be owdas puhllereand, PANELS MOUIFlCATION
.z°.zr4—a OTTO 200AMPS [I INTERIOR El CHIMNEY REPAIR
[.r3 tFw Licensed Profeesionol 201-100AMPS IMPROVEMENT ElSWIMMING POOLS
OWNER-BUILDER DECLARATION OVIiR I"AMPS ❑BATA REMODEIJREPAIR E UEMOIJTION
2' d r the
following reason.(Section 7031.5,Business and Professions Code:Any city or tin
SIGNS ELECTRICAL ❑OTHER
I herehy afltrm no 1 am exempt became Contractors License Law in
3 W F which requires.po,a it to consumer,alter,improve,demalidt,or repair any mmemre
1,+0 prior to its issuance,also requires the applicant for such permit to file a signed statement SPE CI AL CIRCU IDMISC.
that he is licensed pursuant to the provisions of the Cmnractors License Law(Chapter 9 _
C� (commencing with Section 701 of Division 3 of the Business and Professions Codd or TEMP.MFTHROR POLE INST.
L 6 oy• that he is exempt therefrom and the fiaais for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLI HON
km4. Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty Of POWER DEVICES ❑TENANT ❑PDO[)SERVICE
.. oto more than five hundred doll...($500).
E�G
El Las owner of the property,or my employees w 01 HER HIMPROVEMENT
with wages as their sole compensation, SWIMMING POOL ELECTRIC H
� � will do the wkan
ordrhesuucme is not inrenderm.ffcred fnr sele(Sec.9D14,Business ❑ ER
W _ and Professions Crile:The Contractor',License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
la 3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended Or offered for NEW RES IDEN'I'I AL F,LEMR SQ PC
sale.If.however,the building or improvement is sold within one year ofcompleuon,the SQ.14 f.FLOOR AREA $ISQ,Ff.
er-builder will have the burden of moving that he did not build or improve fou pur-
,so of salt).
❑1,se nwner of the property,um exclusively contending with licensed contrrs acto1. TOTAL'
answer the project(Sot.7044,Business and pmfiessiom CodeU The Contractors Li.
emse Low does not apply to an ow net of property who builds or improves thercom and QTY. PLUMBING PERMIT FEF.
who comercts far such projects with aemoomm s)licensed puts uanito the Contractors
License Law. PERMIT ISSUANCE •s—o
❑ 1 am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT T-WATER(CA) VALUATION
Owner Dole
Q
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE
I hereby am ffirunder penalty of perjury one of the following deremtinn, Z/000
❑I have and will maintain a Certificate of Consenttoself-insure for Worker's Comped- DRAINS-FLOOR,RODE AREA.COND. STORIES '11Y PECONSTRUCIION
,aria.,as provided for by Section 3700 of the Labor Cade,for the performance of the T
work for which this permit is issued, FIXTURES-PER TRAP
JM,[have and will maintain Workers Compensation Insurance,as squired by Section Is
3700 oRhe Labor Cole,for the performance of the week for which this permit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUT' APN
My Work Co pq�atiu once r b and Policy n
Carrico rl 'esu, r Policy No.: 6�/ GAS-EA.SYSTFhLOVER 4(FiA) �r^w
CERTIFI TF.OF F.XF PfION FROM WORK.RS, GREASF/INDUSTRI.WAST F.INTERCEPTOR �V
COMPENSATION INSURANCE BUILDING DIVISION FENS
(This section need not be completed ifthe permit is for no hundred dollars O R10) GRPASETRAP
or less) p1.ANCH[CK Ig31i
I,mofy that in the perfowanceofthe work far which his permit i•issued,[,hall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become lapel 10 he Worker'CompacENERGY t-
O z ,.tion Laws of C.Insorm.Dare WATER HEATER R'NENTIELECfR GRADING TEE
z Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SY$TI?M/1 BEATING
F" N become subject 1.the Worker's Compensation Provisions of the"We Code,you must SOILS FEE
fnnhwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE, p
CONSTRUCTION LENDING AGENCY NEW BfSIDENTIAI.PLMB. SQ.FT. PAID
V 0 Ihereby affinm that there isaconstruction lending agency for pcHnrmance of Receiptp
r. the work for which this permit is issued(Sec.3097,Civ.CJ ♦,
Lender.Name / e 'TOTAL:
0 WLenders Address Tarn r .
y 1 certify that I have read this application and state that the above infomution is BUIL MN�pEEu"�
FN mtrccr.Iagreemcurni with ullcityandcoumy Ordinances and state laws rdatingm QTY. MECHANICAL PERMIT FYl]1
U z building construction,and hereby authorim representatives ofthis city to enter upon the SEISMICFEE
above-memiened property for inspection purples. PERMIT ISSUANCE ELECTRIC FEE
at
(We)agree to se,indemnify and keep harmless the City of Cupertino against 1
babiliries,judgments,costs and expenses which may in any way acme against said City ALTER OR ADD TO MICH.
in consequence of the granting of this permit, PLUMBING FEE Q xy
APPLICANT UNDERSTASIS AND WILL C MPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to."CFM)
SOURCE REGUL - 'S MECHANICAL FEE
5 ;H:P-9(6 AIR HANDLING UNIT(OVER 10,010 CFM) CONSTRUCTION TAX
Signam Com wtm Date EXHAUST HOOD(WIDUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupam store or handle hasardous mammal HEATING UNIT(1010BWRI BTU)
as defined by the Cupertino Municipal Calc.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? HEATING UNIT(OVER 100,010 BTU)
El Yea ONO VENTILATION PAN(SINGLE RESID) PAID —2J-v� y).26
Dam Receipt#
Will the applicant m future building occupant use equipment or devices which BOH ER-COMP QHP OR[00il 00 BTU)
emir hvallons sir em mm arta,is defined by the Bay Area Air Quality Management TYPAL: ()/. 910
Dtstnot? BOILER-COMP(OVER 101,000 PTU)
❑Yes FIN.
I have read he ha cerduus materials npuiremems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
her.Health&Safety Code,Sections 25505,2553]and 25534.1 undemmrd Nut if me NEW RESIDENTIAL MECH. SQ.FT.
building does nil eanemly have a tanner,that it is my respnnsibiliry m norily the occupant
of Ne mquircmems which must be met prior to issuance of a Certificate of Occupncy.
Owner orroulum ad agent Dam TOTAL' ISSUED BY:cXD'9— An->a A—fie.
OFFICE