99110124 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL,
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS., SANITARY NO, APPLICATION SUBMITTAL DATE
OWNERS NAME: PHONE: CONTRACTOR'S NAME LIC NO.
�� S NIC CONTROLp
CHI I'I.CDENGINE.R:
LNG
ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
'13� 05\(y ❑ Consultant Fees Paid by Applicant(Initial) BLDG EL�EECqCTP B SUCH
❑ LOL k71
LICENSED CONTRACTOR'S DECLARATION QTY ELECPRIC PERMIT FEE
I hereby uffnn mal 1 am licensed ands,pookion,of chapter v(ssmmeneing JOB DESCRIPTI 9N
0w-L wim Section'/OOB)o(Division 3ofthc Business coral Profusion Cod,thainylieconeis RESIDENTIAL:
W0p In PERMIT ISSUANCE
F, Poll force and a ,t 1 1 ❑SFDWL ❑KITCHEN REMODEL
aUU Licenw Le.K Sn�a APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMBING RI:PIPE
tF Q all I Contract., 1
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z p y z I undersand my plans shall he used n puhlic recoNs PANIiLS MODIFICATIONOZ4p UP'102WAMP9 I ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-1100AMPS IMPROVEMENT Ej SWIMMING POOLS
�.�cxl�'� OWNER BUILDER DECLARATION OVER I(SX1AMPS El BATH REM�QF.IIRF.PAIR ❑DEMOLITION
O C 6 1 hereby affirm that 1 am exempt from the Coll....:v Lhwmse Low Elfor the ,CeE—
X
3 U following reason.(Section 7031.5.Business sad Profodim,Code:Any city or county SIGNS ELECTRICAL OTHER
which regmres a permit m construct,alter,improve,demolish,or repair any structure
1^C e+ J-
I'^�� Prior,,hs....encs.alsorcitmor,mcapplahat lnraoch punoino lila mnigned,lochant SPI!CIALCINCUIT/MI$G. ,^ Ask
f'�} mal he is licenmd punuam to the provisions ofthe Contractor's license Law(Chrpmr9 ,+
'CCOQ (commencing with Section71X01 of Divisinnlofine Boniness and Professions CoJclm TEMP.M[iiR OR POLE INST. COMMERCIAL'
A.%o mat he is exempt thereloon and the basis for the alleged exampnon.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
all
Section 7031.5 r
by any applicant for a permit subjects the applicant to a civil penally of POWER DI!VICES ❑TENANT ❑FOOD SERVICE
Ca.,moa then five humbled dollars($5110). IMPROVEMENT
EyC ❑ I,r.uwnerotlhe Iac,ny, amy employees with wages os their sole compensation. SWIMMING POOL ELECTRIC [I OTHER
F. will do the work,and the structure in not intended or offered for will(Sex,.7044,Bulinus ,
a 3 m and Professions Coale:The Contractor's License law docs not apply to an owner of OUTLETS-SWITL'lll$S- T
property who buihis or improves thereon,and who does such work himself or through
his own employees,provided mat tach imprnvcmem,are not intended a uffer,c for NEW RESIDENTIAL ELEC'Of SCVL
sale.If.however,the building or improvement iscold within one your ofcompletion,the SQ.FT.FLOOR AREA $/SQ.Fl�
owner builder will have the burden of proving that he did not build or improve for put-
E]1.m owner of the prepeny,am exclusively contractingm
with licensed nvm
acn to
ptea nrsule.). 'r0'I'A L:
construct the project(Sec.7M4,Business and Professions Cale)The Contractors Li-
seLawdoa tet apply , r it propmy who builds or hnpro ea the rein,and Q'TY, PLUMBING PERMIT FEE
who contracts for such projects with m enmmemr(s)licensed pursuant to the Contractor's
License Law. IIIPERMIT ISSUANCE
[:Ilamaxemplunder Sec ,B&PCforthivmuon
ALTER-DRAIN&V&NT-WATER(ITA) VALUATION
Owner Date
WORKI:R'SCOMPENSAI'(ON DECLARATION RACK FLOW PROTECT.DEVICE LAfN 4--t
I hereby a0irm underpewhy of perjaryoreul W,following dcalwmion- OsIJ , �'
I have and will maintain a Cedifcamof Conwattoxlf-decre for Worker's Conlpcn- DRAINS-FLOOR,ROOF.ARF .GOND. STORIES TYPE CONS'1'RUCOON
.cation,as provided for by Section 37M of the Labor Code,for the performance,of the
work fur which(his peon"is issued. FIXTURES-ITER TRAP
PIM
1 have and will maintain Worker's Compensation Insurance,as required by Section
)of the Labor Cod<,floor the Performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUT' APN
C. Policy I, onyPS I�k.c�l'ah YNteynumbe, V� GAS-EA.SYSTEM-OVER4(iA) k
CERTIFICATE OF I.XEMPTION FROM WORKERS' —M•-, GREASFANOUSTRL WASTE INTERCEPTOR BUILDING O1
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Glisw,lionncedn tbeaonlplead I doepernil is fmmrialmndoeddoll.($IW) GREASE'I'RAI'
or lest) PLANCHF:CK FEE
I certify that in performance nflhe work for whichthix permit is issued,lshall SEWER-SANITARY-STORM EA.NAI FT.
not enpiny ally person in any manner sn as m hecene aubjecl ut the W..kcrx'Cnngen- ENERGY FEE
0 Z cation Laws of Calif..,..[)ate WATER HEATER WNEN'/ELECTR GRADING LLE
z Applicant
NCI CE 10 APPLICANT:If,alter necking this Certificate of Exemption,you should WATER SYSTENUTHEATING
SOILS FEB
become h urn,to the Workers Coons mr con provision of the Later Cale,you mut
�
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
jZ CONSTNUC'fION LENDING AGENCY NEW RESIOI!N'fIAL I'1.M11. Sp.I>E PALO Date Reel a
U 0 I lrreby affect that hem is a .namamn lending agency for the performaral of
e+ the work for which this ernia is issued(Sec.3097.Civ,CJ
0 TOTAL:
U Lender's Name
TOTAL:
Lender's Addle, r
'T' C 1 ccnify that I have revel this application and some the the above moment is RUILDINOfEE /AI n
N mran.1 agree to caanply ,to all city and county ordiomeex and none laws mhnimg to QTY MECHANICAL.PERMIT FEE
U building construction,and hereby autharive representatives of this city at enter upm the SF:ISMiCt Fli6
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save.Indemnify and keep hunmle,the City of Cupertino.,am,, Elf; C PL
liahilitiu.judgmcnb,ewl,mid cv,c,es which mayln any way ammcagaina said City ALTER OR ADD'TO MELD. PLUM 1,4 GPEE
in 0
sequence of me granting of this permit.
API'1.1. N"f UNDERSTANDS AND WILL COMPLY WITH AL1-NONd'OINT AIR IIANDhING UNIT(TO 10,(00 CFM) MECHANICAL FEE
S UN ' REGULATIONS.
P ` fY q \O^\1 ( AIR HANDLING UNIT(OVER IB.W ChM) CONS QCrIDNTAX --
Signature 1 pbcan Iraclor \I IJSTutic \ EXHAUST 1 I00D(WMUCI) HOUSING MITIGATION PEE:
IIA9ARDOUS MATERIALS DISCLOSURE
Willtheapplichad nr mom,building avapah,toomhendle hvallovs material \ HEATING UNIT(TO 100.000 BTU)
as dcfncd by Js Cupenimo Municipal Coda,Chapar J.12.and the IIcalth and Safcry
Cale,Section 25532od! HEATING UNIT(OVER 100.1X5)BTU)
D Yes a PAID
VENTILATION FAN(SINGLE.R&SID) Date Receipt p
Will the air comm or lalta building occupant use cqulpnuQu or devices which BOILER OHP OR 80.000111 Or
mil M1anarJom air conmminanls as defined by the Bay Area Air Quality hDnagcmem TOTAL
District! BOILER-COMP(OVER 100.000 BTU(
C3 Yee
I hncrlho the hauadsm,materiuR tryuirtments undo Chaplerfi95 efthc Cali- AIR CONUITIONIiR ///—ISSUANCE DATE
Irani Babb&Safely Code,Srctiuns 25505,255.13 and 25534.L understand that it the NEW RESIDEN'1'IAl.MUCH. SQ,b..
bulking ro not currently have a taunt.that it is lily ruponsibiloy to notify the occupant
r nenc wN6 must 1e met prior to i....ace of a Cemfi or ea cy.
Owner'Nahmilledagent Date 'I'OIAL: ISSUED BY:
OFFICE