S 2702 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
�^ CITY OF CUPERTINO BUILDING-'ELEC'T'RICAL PERMIT NO.
R?TIDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n O
-BUILDING PROJECT IDEN'DFICATION' G
,
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
OSoO L4
OW E S PHONE: CO RACI'O NA L NO'. - ^/�
U' !r N/C CONTROL#
s 11 /ENGINEER: LIC O: ADDRESS: Y ❑
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D TACT: PHONE. ' BUILDING PERMIT INFO,
G _ F � �, ❑ Consultant Fees Paid by Applicant(Initial) - BLD ELECT PLUMB MECH
�( E:1
IICPNSPDCON'f CIORSDT .ARATION QTY. - ' ELECTRIC PERMIT PEE
l nereby effort r . doe p bs of chapter 9(commencing r . JOB DESCRIPTION
Woo wimsealm17gxgrfDt ardTonne a eP fe,a on.coat ane myliaa errs RESIDP.NTIAJ:
F O w. in full force and effect. s PERMI'P ISSUANCE .3 r
04-J Fie ense Class ❑ El SFDWL KITCHEN REMODEL
vFi4G Dam Commcmr APPLIANCES-RESIDENTIAL ❑ADDITIONEl PLUMBING RE-PIPE
HRE'PS DECLARATION ❑MULTI-UNIT' ❑STRUCTURAL
ypy2 d s rrc
all used a,mdahezeck, PANELS MODIFICATION
OZr�a UP'f0203 AMPS El INTERIOR L1 CHIMNEY REPAIR
F-..F., mics n _ 201-If100AMP5 - IMPROVEMENT _ SWIMMING POOLS
OW -tlU1LDER DECLARATION OVH210g1AMP5 L1 BAT] REMODEURP,PAIR El DEMOLITION
f C g c s 1 hereby nfHnn Lha am rxempf from the Contractors License Law fnr the
F4es V fallowing reason.(Statim 7031.5,Business and Profession,Code:Any city or county SIGNS ELECTRICA ❑OTHER
pyd which adiful..permit1 o confined. h p t I',h p' yswclam
m.4
tums,to itsI y Ine apor' ti ,pencratIn To.,ilmoul,mmorent SPECIAL CI RCUIT/M ISC.
m�
that her,'1 dp to flaw pamen,ionsoffe Contractors LFew(Charm-9 -
a
(commencing with Section 7000)of Divi,inn3 ofthe Business and Professions Code)or TEMP.METER OR 1101. COMMERCIAL, '
oWthat he is exempt therefrom and the basis for the alleged exemption.Any violation of ElNEW BLDG/ADDITION ❑DEMOLITION
o, Section 703 L5 by anyapplicaut for apronm il pen
it suhj-is the la a cost of POWER DEVICES NANT ❑POOD SERVICE
YX1 oat more than l ave hundred dollars($500).
❑ I,as owner of the property,or any employees with wages as their sole compensation, SW 1NG [ELECTRIC IMPROVEMENT
py will do the work,and n
I heslruure jabot intended or rl(n'ee rmsalo(Sed.91144,Business O ❑OTHER _
Lamand Prom,aions Cade:The Contractor's License Law does not apply to an owner of TLETS-SW1TC S-PIXTURBS O
pmpeny who builds m onpmves thumb,and whoAoes rich work himself or through
his own employees,provided Wal such improvements arc not intended or offered for NP. P.SIDF. TIAL ELE rR SQ FI'.
sale.IL however,the building or improvement is sold within site year of earn,dirgllm SQ.FT.FLOOR AREA $/SQ.FT.
er-builder will have the burden of proving the,he did oat herald or inipmve fnr pur-
p se of cele.). -
❑ 1 as owner of the property am exclusively contracting with licensed I actors of
construct th projeed(S 9044 Business tend Professions Code:)ThContractor 4[,1 @_
s l d I'pplyt fp p (y who thaildsorimlerovesdided,and QTY. 'PL B ERMIT FEE �Q(J
who contracts for such projects with a contractors)licensed pursuant to the Confm am''s
Lrdoo,Law. PERMIT'ISSUANCE
❑I am exempt ander see. ,B&P C fnr thin rennin
DataM
ALTER-DRAIN&VC '- ATER(EA) VALUATION
v
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
I hereby affirm under penalty ofpcTury one ofthe following declannirbs lD QQQ
❑ I have and will maintain a Certo Mam of Gmsenl to eelf-insure far Worker's Compton- DRAINS-FLOOR,ROOF,AREA,GOND. S'IORIBS TYPE CONSTRUCTION
,stun,as provided fez by Second 3903 of the Lahr.Code,Ruds,performance of the
work fid whieliWas poemo k icmed, FIXTITRES-PER TRAP !L
❑ I have and will maintain Worker's Compensation Insurance,an required by Section
3900 offhc Labo,Code,memo pert madmof the work far which this permit is issued. GAS-EA.SYSTEM-I INCA OU'I OCC.GROUP p APN
My Worker's Compensation Insurance carrier and Policy number are ! ZZ
Carrier: - PolicyNo,: GAS-EA.SYSIFM-OVHR4 )
CERTIFICATE OF EXEMP'[ION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL W .TE INTERCEPIUR 'sol
(Thi ,adfunncel net becomplomd if Wepertnhls for mindhundred dollars($lot)) - BUILDING DIVISION FFES
or los.) GREASE'I'RAP ' PLANCHP,CK FEE
Idady the nthe performance of lhnwozk liar which thtspumil is issued,ishnll SEWER-S I'I'ARY-ST(IRM FASO , r O
bol ennpiny any person in any manner er ns to becomo sublecl to the Workers'Compete ENERGY PP.F.
o 11-11
�i cation Lawsof CalVnnum Date
z Q Applicant - WALL IEATER W/V /ELECPR ,RADINGPEE
h NOTICE TO APPLICANT`If,after making this Corundum of Exemption,you should 1AR SYSTHMDGREA'ING
W
become
W complywith
the Worker's Compensation pmvti amsrs f the Labor Code Fd grail W, � _ OILS FEE
F _
pywhh such provisions or this permi �ATP.R 9HRVICP. �
Q -
� z CONSRUCT10N LENDING AGENCY NEW RESIUGNTIALPLMB. SQ.Ff. PAID
U Iherehy affirm fhanhueis xcrnxwuion lending agency far Weperformnmm�f um Rcdan0
the work for which this permit is issued(See 3097,Civ.C.)
O U
Leader's Name TOTAL'.
GU Lender',Address TOTAL:
� 1 certify that I have read this upplicmiml and slide that the above infrrtnvdon is r :ELECIRI
D G FE.
.F, 01 wtiwl.1 agree to comply wiW m1 coy and a,amy ordinances and sem laws relating to QTY. MECHANICAL PERMIT.' FEE
V z building conslmclion,and Lambs aullnrim representatives oftnis city in convicted the M FF.
above redefined property far inspection purposes.
(We)agree to cave,indemnify end keep harmless IheCity of Cupetlice against PERMIT ISSUANCE t ' PEElialudifice,judgments,costs and expenses which may In any way amore aguinst said City ALTER OR ADD TO MECH. Z QWeresequenm4SIT , permit. MBIN 'EEAPPLIC -DEL) D WILL COMPLY WITH i .I. ON-POINT AIR HANDhINO UNIT(T'O IO,OIHI CFM)SOUR -( HANICA PEE
tf AIR HANDLING UNIT(OVHR 10.010CFM)
/ CONSTRUCTION FAX
Si nature vtc EXHAUS"p HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZA2 US MATERIALS DISCLOS RP,
illthe applicant mium middle,amupanl stare In handle ammalsnmmrial I[PAT'ING UN I'f(TO 103,003 BTU)
as ceramic by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cada Section 25532(a)1 HEA'T'ING UNIT(OVER 100,000 BTU)
E]Yes
Fa< V EMULATION FAN(SINGLE REST D) PAID
Dore Receipt#
Will the applicant orlams hoodefireg oche Bay
eea AirQuozdevicesement BOILER-COMP LIPP OR 100,030 BTU)
noir hvardous air contaminants as defined by Ino tiny Arca Air Quality Management T 1.
Dislncl^. -
E]Yes BOILER-COMP(OVER 100,000 BTU)
I have mad the hazardous materials requirements under Chapter fi 95 of theCab- AIR CONDITIONER ISSUANCE DATE
fruit.HealI &Safer Cit inns 255051
25533 end 25534.I undestand that it the NEW RESIDENTIAL MECH. SQ.FE r
building n m leiand lhm ile're, spnnsibiliryn notify occupant �i—
,Ift I prior to issuance of a Coof., enf c ey.
l y
Owner orized agent )n 7 T TAL: ISSUED BY:
OFFICE