S 1189 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
NUILDING DSVISION APPLICATION/1'ERMIT IY.USIBINC.-An?CHANICAI.
BUILDING 1'R(IJECT IDENTIFICATION
]SANEITARYO. APPLICATION SUBMITTAL DATE
BUILDING ADDRESS:oS 6 w '2�CJW 'It:S NAME I'lit)NI' CONIRACTORSNAME; LIC NO, CONiIt(11,N
A CHITE /E OINLF.R: LIC O: ADDRESS:
GONTACD PHONE: BUILDING PERMIT INFO
❑ Consultant Fm Paid by Applicant(Initial) BLDG ELECT - PLUMB MECH
❑ ❑ ❑
LICIINSEDCONTRACTOR'S DF,CI.ARAI'ION Q'TY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I am licensed under provisions nI'Chapter 9(commencing
04z with Section]OIX17 or Division 3nOhe Business and Pmfn,aaaa,Code,and my Brenta is RESIDENTIAL:
err 5 tom[FF`�' in lull force and effect.
PERMIT ISSUANCE' ❑SFDWI ITCI IF.N REMODEL
Q— Oarenw Class Li'.#ctor APPLIANCES-RESIDENTIAL ❑ADDITION UMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MUCI'I-UNIT �rrYYY77/�11�YYYMODIFICATION
��M
z z 7 z I undersand my plans shall be used as public records CHIMNEYRE
UPT0200 AMPS [I INTERIOR El CHIMNEY REPAIR
oz-o
I'ROVIiMENT SWIMMING POOLS
���� Littnsed Professional - 201-10WAMPS ❑
DWN]IR-BUILDER DECLARATION OVER I"AMPS ATH RHh10J�/ I)IjMII�MI'AN
I hereby afEnn than nm exmnpt from(he Contra License Law far the aa'' -'�/�/"
ad U Ildlowing reams(Section 9U S,Ifuvineu and Professions Cale:Any city or county SIGNS ELECI'RICAI. ❑0 HIiR _'���` ` ` S�
4 which requires a permit u,Oresund,alter,improve,demolish,or repair any structure
prior its issuance,alwregnues thcapplicaut foreuch Permian file v signed statement SPECIAL CIRCUI']')MISC.
fC� that he is licenseeliosuatnnttcimusisieasofhe Commemr's License Law(Chopter9 COMMERCIAL;
W CC (corraw.6ngwim Seen..]000).f Divinnn 3mme Btumessiod Pmfessinm Cod)oTEMP METER OR POLE INST.
vr
that he is exempt forefront and the basis for the alleged exemption.Any violation of ❑NEW BLDMADDITION ❑DEMOLITION
�y
Section 701 LS by any applicant fora permit adjudsthe applwmam a civil Penalty or POWER DEVI F_S ❑TENANT [3 1:001)SERVICE
not marc than five hundred della.(SSW). IMPROVEMENT
F�Qhas owner of the n or employees with wv es as their sole compensation, SWIMMINGPOO :C)RIC
❑,I ❑ pope y,a Yg pens. El OTHER
will Pr lesions and h no Contractors
ore a torot s License
or a wdo for Mle(See apply t an haBusinessa1
3 andpro ProfessionsiIdso me Cam theoCos Lind w Lawdiesnotapply t r owner nl' OUTLETS-SW IPS-FIXT'URIiS
his o ny who build,tar aided th thcrcon,and who nts ar n work himself or through
his own employees,provided that such improvements are ern intended or offered for NEW RFSIUEN'I'IAL tors "N St]Irl'.
sale.If however,the building or improvement is sold within one year ofcompletion,the SQ.FI'.FLOOR AREA SISQ.FT.
owner-builder will have the burden or proving that he did not build or improve for par.
pose of sale.). AL:
❑1,as owner of the Purperty,am exclusively contracting with licensed comMemrs to
ennswet the PmjWt(Sec.](114,Business and Professions Code:)The Contractor s 1-i- ^
ctnve Law does not upply to an owner of popery who builds or improves thereon,and QTY. PLUMBING P. FEE r B , D
whocrnvucis for,such projects with a commands)licensed pursuant to the Contractor's ,I ^I
License Law, PERMIT ISSUANCE µ
❑ lame pt under Sea. ,II&PCfa thlsretxm 4
ALTER-DRAIN&VEN'I'-WATER(EA) gs DA'IT a
Owner Dom tory O
• IherebyaffinnunderrPenaalORKERSCOyof-perjuryoneofhefollwinngdeclarations: BACK FLOWPR(1TIiCT.OIiVICE OFr
❑I buveand will maintain.CcrtiftcaeofConsenno self-insure forWrover's Campen- DRAINS-FLOOR,R(A)F,AREA,COND. SIORIr_S //DECONSTRUCTION
Munn,as Provided for by Section 37W or the Isom CMO,far the pedonnamce of the
work far which this permit is issued. FIXTURES-PER TRA]'
❑ 1 have and will maintain Worker's Compensation Insurance,as required by learn m GAS-EA.SYSTEM-)INC.J OUTLETS (ICC GROUP
3WN)of he Labor Code,for the performance ofhe work for which this permit is issued. ANN
My Worker's Cmmpar inn]nmrunce eamie.nd Policy marts,ore
Curtis,: Policy Nu: f)QqG_EA.SYSTIIM VER4(P.A)
CERTIFICATE OIt EXEMPTION FROM WORKERS' GREASEIINDIIS'I'RE,WASTE INTERCEPTOR
COMP17NSATION INSURANCE BUILDING DIVISION FEES
(ThissectionneeJ notbeemtpRtcd ifthe Permit is for one hundrecidollan(SHE)) GREASETRAP
PfANC11ECK FEF,
or lossy
Icenify that onthe performanceando(t,mwork for
Wvm,michhi.tomtitisir.C..lshull SEWER-SAND'ARY-STOHAt EA.2IX114.
ern employ any peon in any manner sit n m become subject,o the Workers ComPen- ENERGY PEE
zZ Applicants of California.Date WATER HEATER W/VENT/ELECII GRADING FEE
o-5 p) NOTICE TO APPLICANT.If,after making his Cenihe..of lixemp,inn,you shndid WATER SYSTEM/1'REAT'ING
(~ 5 femme subject to ht Workers Compensation pmvivinns mf he Lahnr Code,you most _ SOILS FEE
kms forthwith comply with such previsions or this panni,shall he deemed revoked. WATER SERVICE.
PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PCMB. SQ.I'I'. Date eve t
U O thereby of ran fathom is.cnneouction lomdingagency fare performance of
,he work far which his permit is issued(Sec.309].Civ.C.)
TOTAL:
U.
V Lender's Name
Lender's Address O 1
[y. 1 I certify that I have readthis application and are
made above informe,inn ix BUILDING IT.
Ly Vcured. m.l agree comply with all city and county ordinances and state lows relating to QTY, MECHANICAL PERMIT FEE SEISMIC PER
7j
U a huilding rim9metimi herehyaulhnrio,representatives of his city,.cher.pan he
nMws-ours bred property for inspector purrytves. PERMIT ISSUANCE ELfiCTNIC PEC
(We)agree m vast,indemnify and keep harmless the City or Cupertino n"sora,
liabilities,judgment,cost and expenses which may in any way accrue against said City ALTER OR ADD TO M ITCH. PLUMBINOFEE
in consequence of the".ming of this permit.
APPLICANT UNDERSTANDS A plwrkL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ITOW CFM) MECHANICAL rE
SOU -REGULATIONS.
AIR HANDLING UNIT OVER 10.11(10 CIM) CONSTRUCT TAX
IC
ignore of Applicant/Cnalwoor D e EXHAUST HOOD(WIDUCD HOUSING MITIGATI FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or farm huilding occupant store or handle hazardousmaterial HEATING ON]'](TO UMIL0 BTU)
as dented by the Cnpenino Munlci,al Code,Chapter 9.12,and the Health and Safety HEATING UNIT(LIVER I(N),fENI BTU)
ly
Cada,Section 25532(x)?
E]Yea ❑No VENTILATION PAN(SING LE RES ID) PAID
Date ReceiptN
. Will the applicant Of future building mecupant use equipment or devices which _BOB ER-COMP(3HP DR IOO '1 BTU
mastodons emit rdons air contaminants as formal by the Bay Area Air Quality Management TOTAL:
Dtsmat4 BOILER-COMP(OVER 100,1300 BTU)
E]Yes ❑No
I have road the buoudou.e materials requlremtm.s under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE,DATE
litmiu I Ieahb&Safay CMe,Svcdons 25505,25533 and 25.134.1 understood that if the NEW RESIUHN'TIAI.MECH. SQ,I'L
huilding dons not currently have a reaant,that i,o my reslsarmidly to notify the occupant
of the requirements which must he area prior m inamuce of a Cenifica,e of Occupancy,
Owner or momisd agent Date TOTAL ISSUED BY:
OFFICE