B 0589 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF
CUPERTINO BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATIONIPERMIT PING R PROJECT
IDENTIFICATION
,50001 20289
BUILDING PNOJECT IUENTIPICATIUN
HUILDINGADURFSg: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNS :S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
c p C wlG� / NIC CONTROLX
JAR 'HI®C NGINF,ER: Z ' LIC NO: ADDR SS: ❑
S S, /tgg HL
CONTACT: PHONE: I BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDGELECT PLUMB MECH
11 P, ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
X00 with Section]g107 ofDivision3 ufth<Business anJ Professions Code,end my license is RESID NTIAL:
41 O PERMIT ISSUANCE
F Occ in RJl force and,Hess ❑SFDWL ❑KITCHEN REh10DEl.
aU[' Licenu Clar` G LicX r APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE,
Fm Dum Conwcmr
mats ❑MULTI-UNIT El STRUCTURAL
F,Dm ARCHITECTS DEC PANELS MODIFICATION
Z p K I understand my plans shall the used as public records
OZ-0 UPT01200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Licensed professiooel 201-10WAMPS IMPROVEMENT )]SWIMMINGPOOLS
OWNER-BUILDER DECLARATION OVER loss)AMPS ❑BATH REMODELREPAIR C1 DEMOLITION
IX 6 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
NyU fallowing reason.(Section 703 1.3,Business and professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
0t. which requires o Permit a conswcl,almq improve,demolish,or minor any..Ore.
Prim m as isammus,.lso naturesthe.,icuntfar such permit o Cie.signed statement SPECIAL CIRCUIT/MISC.
} that he is licensed pursuant In the provisions ofthe Conluctoes License Law(Chapter 9 GQtr�—�--
ad C mammendng with Section]IXNgof Division 3 clone Husinesaand Professions Cod11 cr TEMP.MFI'ER OR POLE INST. (-OMMFR IA
4F��g 0 of that he is exempt therefrom and the basis for the alleged exemption.Any violation of C)NEW BI.DG/ADDITION ❑DEMOLITION
W^
Section 7031.5 by any applicant for a permit subjects the applicant to a civil pcnahyof POWER DEVICES ❑TENANT [I FOOD SERVICE
Z} not more Nan Eve hundred dollars(SSW). IMPROVEMENT
=� 0Les owner of the propeny,or mycmployces with.,genas,heirsnlecompnxulimh SWIMMING POOL ELECTRIC El OTHER
will do the work,and the structure is not intended ro0ered fnrsale(Sat.7044,Business
and Professions Cade:The Connector's License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
pre eny who builds or improves thcmm,and who does such work himself or through
his own employees,provided that such improvements are not intended or uttered for NEW RESIDENTIAL ELECTR S FT.
.It.IL however,the building or improvement is sold within one year ofcompletinn,the SQ.17vurcn
$/SQ.FT.
C11,awner-huilder will have the burden of proving that he did not build or improve for pur-
,am of Awn JD
1,us owner of the property,am exclusively cannoning with licensed contractors m TOTAL.
conswcl the project(Sec.inert,Business and Professions Code:)The Cnneacoofs Li-
censeWwdoes nm applyroan ownerof property who builds or improves thereon,and QTY, PLUMBING PERMIT F
who cnnnialfor such projects with a consweards)licensed pursurdto Nc Commences _ - (JITI
License Lew. PERMIT ISSUANCE.
IamesmplunderSm. ,B&PCfnrohisreasan
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Own Dam
WORKERS COMPENSATION DECLARATION BACK FLOW I'Rt]T[iCT.DEVICE
have
and will
under Penaltyiris of peOury one of the followingore'declarations:Coo
]on.as amlwie for by Section
37M of GmmnuoCode.sure for Workersce of the DRAINS-FLUOR,ROOP,AREA,COND. STORIES TYPE CONSTRUCTION
rodeo,as provides for by Section J]W of the Labor Code.for the performance of the
work for which this permit is issues]. FIXTURES-PER TRAP
❑I have and will fair.Worker's Compensation Insurance,ns required by Section
37W of the Labor Code,fonhepednwance.f the work for whiehthis permit is owed. GAS-EA.SYSTEM-IINC,4OUDA:S OCC.GROUP APN
My Wnrkcfs Compenvtion lnsumn.v errand PolicynynNxim,
Cartier: n iG0/ G am Palicy Nn.:S(/V 6,D 4VA �2 B GAS-EA.SYSTEM-OVER 4I
GW
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/INDUSTRL WAS TE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not he completed Ban,permit is furan,hundred dollars(811X)) GREASE TRAY
nr
Less
PLANCHECK FEE
I certify that in,M1e perfarmance afmhe work forwhichthispermitisicied,10mll SEWER-SANITARY-STORM EA.200 17.
not employ any person in any manner so as m hcypme suj uo the Workers'ComPen- ENERGY PEE
Z wiion Laws of Carton in `Te WA'T'ER HEATER W/VEN'L)ELECTR
OQ Applicant�/r�/� yr - �— GRADING FEE
q y NOTICE TO APPLIO N ,Jr making this Certificate of Exemption,you should WATER SYSTEMRREATING
a 7 become subject to the Woramrs Compensation prvisimis of the labor Code,you must S01LS FEE
{JJforthwith comply with such provisions or this pewit shall be deemed revoked WATER SERVICE
gi� Q PAID
O
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.F. Data ReceiptX
V I hemebyulBrm that there iso connrninn lending agency forthe Performance of
Us Ir the work for which this pew9],it is issued(See 90CM C) TOTAL:
OU Lender's Name
W Lender's Address TOTAL:
1r' 1 venify that I have mad this application and sure that the above information is HUILgING FEE
correct.l agree to comply with all city and county ordinances and slam lawn riming m QTY. MECHANICAL PERMIT FEE SEISMIC FEE
Ll z building construction,and hereby authorize representatives ofthis city to enter upon the
above-memloned propeny for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to ewe,indemnify and keep females, he City of Cupeninc against
liabilifies,judgments,c.,mmid expenses which may in any way cecra.,am,,said City ATTER OR ADD TO MECH. PLUMBING FEE
in consequence of the gron,ing of this pewit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10.000CFM) MECHANTCAI,PEE
SOURCE REGULATIONS
AIR HANDLING UNIT(OVER I0,100 CFM) CONSTRUCTION TAX
Signature of Applitanm/Contmcmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store nr handle Inzamaus material IMATING UNIT(TO 1110.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health end Safety HEATING UNIT(OV[0.100.01(s)BTU)
Cade.Section 25532(.)1
C]yes �Nn - EVE�IIATIONGLI;FAN(SIN
AIDDae RecciptX
Wll the applicant orfuture building eeceprm use equipment or devices which P CHIP Ofe enmio hazardous air contaminants as defined by the Bay Area Air Quality Management T IAL:
District^2Yes $4P(OVER I hove read the commuos materials requirements under Chapter 695 of the Cali- NERISSUANCE DATE
time.Hmlth&Safny Cade,Sections 25505.25533 and 25534.1 understand Nut ifthe TIAL MEbuilding does not currently have a tenant,that it ismy responsibility to notify the occupant
of the rat wty�h post met oruiaax.nfaCenificamofOce y.
Ow r zed m Date SSUED BY:
OFFICE