S 1622 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY t
CITY OF CUPERTINO BUILDING'ELECTRICAL PEWIT NO,
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING.MECHANICAL J 1622
BUILDING PROJECTIDENTIDeNrION
BUILDING ADDRESS: SAN["1'ARY NO, APPLICATION SUBMIWAL DATE.
OW R\ NAME: PHONE: CONTRACTOR'S NAME: LICNO:
l.�� NIC CGNTROL p
ARC ECf/ENGINEER: LIC NO: ADDRISS: `� ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HI.DG ELECT PLUMB MECH
LICENSED CONT'RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 aurin anirm that I am licensed mal er.....inion,of Chapter (crnnotationg JOB DESCRIPTION
C0Z with Sorms700(forDivismil3itfthe Husinessond Prareso...GtNe.andmylicenmi. RFSIDENTIAL:
FL'W= in full fnrcc and 1. �n�j.1.\e�9 PERMI'I'ISSUANCE ❑STOWE, OKITCHHNREMODHI.
6UU Luaroa Liak - APPLIANCES-RESIDIiN'rLAL ❑ADDITION [-I PLUMBING RE-PIPE
y Z Date 1 undemm� , Conn.ECL RAT` g
ARCHI'I heu,d.E pahlie TION ❑hN1.T1-UNIT ❑MODIFI STRUCTURAL
MODIFICATION H�w PANELS
Z 0,14,,, Anay.tuns shall be umJ as public records MODIFICATION
p Z-'p 11PT02(xtAMl'9 ❑INTf7R10R [I CHIMNEY REPAIR
FSE'; Licenced professional 201-10A)AMPS IMPROVEMENT �SWIMMINGP001S
�rmf_] OWNERTUILDER DECLARATION OVER❑(s)AMPS ❑RATHREMODF.L/RF.PAIR 11 DEMOLITION
C C¢ I bafrby union mal 1 am.seal front The Continuer,lice...Law I the
L O a U fallowing om m.(Section 7031.5.Business and Professions Cafe:Any city or coumr SIGNS ELECTRICAL �,Tf111:R
LO y which requires a .all.construct,alter.improve.dmnolish,or repair any structure
primm its is5uoneq also reyniresthe upplicemfnrsuch.annitlo file usi,madamemmil SPECIAL CIRCUI DMISC.
that he is llcen,eJ.unuann,,the provi,iorsuf the Contractor's Licence Law(Chapter 9
W GO (commencing with Section 9010)of Division J ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
L L e that he is exempt therefrom and,be basis for the allege)esem.nna.Any vodmam of NEW BLDG..DDITION ❑DEMOLITION
Section 7031.5 by any applicant for a lmrmit subjects the applicant In u civil penally al' POWER DEVICES
tkil^m TENANT FOOD SERVICE
m more man five hundred y.or
($SW). IA ROVEMfiNT
SD
El 1,as owner ofthe.rope..,,or my employees with wages as their sole compensation, SWIh1MING WN)I.F.LECIRIC
Fs will Jn the work and fhe.lmrbirc is not inf.nJcd nroffumlfnrsulc(Sop.7044.Business
3 m and Probes ions Gale:9'he Contractor's License Law,docs not apply to an euvner of OUTLETS-SWITCHES-PI XTURM
property who builds or improves thereon,and who does such work himself or,hmogh
his own employers,provided,het mrh improvemems are oat intended or accred fur NEW RESIDENTIAL ELEC'rR SQ 1'1:
sale.11,however,the building or impnmcfnem i,sold within oneyaarof.ample"..,the S Tl'.PLOORAREA $/SQ.Pf.
owner-builder will base the burden of proving that he did and mild or improve(er par
ryw of sale (D\
p I,as owner of the property,am exclusively conflating with IirrnceJ ctru
nncmn In TOTAL:
a ouract the project(Site.0014,Business and ProbrWor,Calef The Contractors Li.
se Law does and apply in an ovenersdpropeny who milds or improves,ncrenn,and QTY PLUMBING PERMIT FEF.
wno,anoacls I..with p lack wifhncampena,l llcea[alpmYmll I to the CalnNe...'a
Lirense Law, PERMIT ISSUANCE
I am exempt under Sec. .H&P C for this reason
Owner Date ALTER-DRAIN&VEST-WATER CA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirmm under
ndeantler penalty of perjury one of the following dedaraeons
❑1base and witlnminein a Ccniticnm of Consent o self-Insure to,Worker's Cmu.ro- ORA INS-FLUOR.ROOP.AREA, 111,1 STORIES TYPE CONSTRUCTION
nation,as provided for by Section 3700 of the Labor Cole,for the permupanm cit of the
work for which this permit is issued. FIXTURES-P TRAP
I have and will nmirtsm Workers Compensation hourunce.as ,,had by Section
3700ofthe LaborCole.f..nhe peffnrmanceoftnc walk for which lhispermit i.issued. GAS-FA.SY' :.1-1 INC.fi OCC.GROUP APN
My Well: ComJ�n.,tion try^ ea car ie{and Policy umber m'
Canine s -Tom_\y;z rill. slip Nn. L__ GAS-1!A.. p -OV'
CIiRTIFICAI'H Op EXI!MP II)N IfROM WORKI!RS'
COMPENSATION INSURANCE GREASE/( rR WASTE INTERCEPT
BUILDING DIVISION PE&S
(This section need not he completed ifthe permit is limn,hundred dollars'1$1011
or lits.) GREASI? AP 1 7 PLANCHI!CK NBG
letnifythm inmeperfommnceofthe wodsfor which this pemtit is issued.l shall SEWE - 1NITARY-STORM EA.2
not employ any person in any manner so as to become subject to the Workers'Criticism- ENERGY IEE
Q Z s:nion Laws of Cafibirma.Dasa WATER VENT/H1.EC1R
Z Applicant GRADING FEE
N
NOTICE 10 APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEAITREA
? hcome subject to the Workers Compensation provisions of the Labor Cade,you must SOILS I TH
buff comply whh such provision,or this permit shall he deemed revoked. WATER SERVICE
0
52 Q CNLENOINGAGENCY NEW RESIDENTIAL PLMB. SQ.Fr 'AID
U rthat there saconctagency forth.performance of
Dam
Fr the work for tthi,permt is issued Sac.3WO,Cle.CJ
ULenders i M
Name TOTAL:
Lenders Address IOTAL:
04 1 ecroy
that 1 have reuA This application and stats that the nMwe information is ^ BUILDING PEE
F h amacct.lagreem comply all all city andmunly anti...ra,undsm¢Iawsrellongm QTY. MECHANICAL PERMIT FEE
U Z building conamction.and hereby authorize representatives of this city to ever upon the SEISMIC FBF.
aNrve-memimand pmpmy Iia inspection purpose.,. PERMIT ISSUANCE(We)agree m save,indemnify and keep narmless the City of Cupertino against ELECTRIC FEE
Iiabilities,judgments,costs anti expenses which only in any way accrue against said City AI,TERORADD'I'OMECH.
in consequence of the gmming of this permit. I'LIIME'NG FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WE TH ALL NON-POINT AIR HANDLING UNIT(TO 10.0010 CFM) MECIIANICALFIiE
(RCF,RP�ULATIONS.
AIR HANDLING UNIT 10,00ECFM) CONSTRUCTION TAX
Si m ofAp son or r Date EXHAUST HOLD(WMUCf1
.HAZARDOUS MATERIALS DISCLOSUREHOUSING MITIGA'T'ION THE
Will the applicant or future building occupant store or handle hamtdous material HEATINGUNI'I'('I'OKa.(Mp BTU)
us defined by me Cupertino Municipal Cade.Chapter 9.12,and the Radio uad Safety
Code,Section 255320)7fOO'o HEATING UNIT(OVER 100,0010 BTIO
E]Yes VENTILA"1'ION PAN(SINGLE RESIDE PAID
. -
Will the aPPlicam or future m ustopped building oratpase mpmcor devices which Date Receipt MHOILER-COMP(3HPOR n),0%)HTU)
cmit Laeml .air contaminants as defined by to Bay Arm Air Quality Manugemem
Darnell ..J.. BOILER-COMP(OVER Iity (BTU)
' ❑Yes t-'fes
1 have real the haaarJnu,materials reuirern
yems under Chapter 69AIR COND['I'ION17R 5 el fine Cali" ISSUANCE DATE
fomia Health&Safety Cade.Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT
(ding does notcmren,Iy hava utenad,that i,knay mapnncihilny to unify mrovea ma
ireotent which moa he met prlonols,uunce of enificmu of Oc Pansy.
Ownerone rer rizeJagcn S Data TOTAL: `ZO ISSUED BY: t • „ v
OFFICE