S 0621 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. /�
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL 1
BUILD]NG PROJECT IDFNTIF'ICATION V S 062/1
BUILDINGADDRESS: SANITARY NO. AP'LICA'I']ON SUBMI'I'1'AI.OAH;
OWNER'S NAME: {r , PHOE: CONf ACH)R'I NAME: LICNO:
�s � ♦ NIC CONTROLp
sRCHITECf/1?NGINEER: LI NO'. RISS: C ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby ammo that 1 am licensed under previsions of Chapter 4(commencing JOB DESCRIPTION
Z with Section70hB.f Division 3ofthe Businessland Professions Code.and my license is RESIDENTIAL:
F1_ in full ferceand effect. PERMIT ISSUANCC
❑1 F, r ❑5FDW1. ❑KITCIRiN RE-PIPE O Llcens Clrs LiLK
F U s APPLIANCES-RESIDENTIAL ❑ADDITION MBING RF.-PIPE.
NQ6Z V, Dam Contractor
Tai
ARCHITECTS DEC)ECLARA)'ION ❑MULTh UNIT' STRUCTURAL.
g" I ndny Plum 1l he usul as Pon is recnrdv PANELS MODIFICATION
OZ�-p /�/� �/J� UP'rO 200 AMPS [I INTERIOR 11 CHIMNEY RHPAIR
License es.� nal 201-1000AMPS IMPROVEMENT- 0SWIMMING POOIS
OWNER-BUILTDECLARATION OVER 1001 AMPS ❑BATH RI3MODEUREPAIR ODE OLITION
I hereby affirm that um exempt firm the Contractor's License Law for the
x6xdU following....(Section 7131.5,Businessland Promssioas Cede:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to con tral,aIle,improve,demolish,m repair any sve,ame
Prior to its m...ce,aIs.means,mornplicanl for such pc.I.to lile..i,pedsmmmein SPECIAL CIRCUIT/MISC.
!7y that he is liecnwd pursomk m the provisions rfthe Contractors License Law Whitacre) COMMERCIAL:
(commencingwith Section 7000)of Division 3 oftbe Businessand PmmsaionsCede)m TEMP.METER OR POLE INST.
6 d c that he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7131.5 by any applicant for a permit amens the applicant m a civil penalty of POWER DEVICES TENANT ❑FOODSERVICE
1k...Z} not mmc than five handled dollars($500). 1P IMPR VEMENT
C�Q ❑ Lns owner of the pmpeny,onny empinyece with wages as their mlc enmpensation, SWIMMING POOL ELECTRIC R
willdomework,andthestmcwreisnot imendedorofferW formle(Sce.]841,Business
Wand Professions cmc:,he Convemnrs License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
4i propeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements am not intended mothered for NEW RESIDFNTIALELECIR SQ pill -
ame.IL however.the biddingor improvement issold withinoneyc.of.......Idiom the SQ.FT.MCI&X11EA S/SQ.F.
owner-builder will have the burden of proving that he did not build or improve for pur-
[3 1.i .cmirse SEP 2 2
❑1,m-rwncr of the property,em cxduxively convecting wird IicenmJ contractors to TOTAL: g TILL gyrfatD
cornball the III(Sec.]Mr.Basin.,and Professions CWc:)The Contractor's Li-
close Law does nm apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a carnations)licensed pursuant o the Contractors CITY Ur UUrthl INU
License Law. PERMIT ISSUANCE: --
C3m I aexempt under Sol. .B&P C for This reason
ALTER-DRAIN Ar VENT-WATER HDIO VALUATION
mer
Date
WOR KEREN
S COMP DECLARATION BACK FLOW PR(YrECT.DEVICE
1 hereby affirm under h f
\V Penalty at perjury one of theelf following do rker's ns:
❑ Ihlave and will Caim.ina Cman 3710 of Crneemo som.forthe Workers Comp en- DRAINS-FLOOR,ROOF,AREA.CUNT). gTOEllig l'YPE C(INSTRUC'I'ION
smirk, r provided far by Section 3]W of the Lubar Csxle,for the perinrmance of rhe
work for which This permit is issued. FIXTURES-PF.R TRAP
❑ 1 have and will maintain Worker's Compensation lmnmoec as required by Section
317 of the labor Code,for the performance of the work for which this permit is issued.
GAS-EA.SYSTGM-1 INC.4OUTLETS OCC.GNOUP APN
My Wor rs
er. Coa �n�'ecaricrad PolicypbR � f
GAS-EA.SYSTFM-OVER6(PA1pa
ANLFLu ' H
1 CATIOFPXr1M WORKERS'
COMPENSATION INSURANCE GREASIANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not becompleted lithe pemtit is foronehuadml dollan(EI00) GREASETRAP
or IcesNCHECK FEE
I certify that in the ptrlrmmana ofthe work forwhich this permit is issued,Ishall SEWER-SANITARY-STORM EA.207,IT.
not employ any person in any manner so as to become euhjecnmen
o the Workers'Cop - ENERGY FEE
ZZ it,,.Iawsorciddianis.Dam WATER HEATER W/VENP/ELECIR
O Applicant ` GRADING FER
NOTICE TO APPLICANT:If,after making this Cenifcam of lixemptirn,you should WATER SYSTEM/IREATING
become subject o the Worker's Compensation provisions of the Labor Cock,you must MADS FEE
Qforthwith comply with such provisions or this panni,shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAI)
r7 Z Date Receipt#
V Q lI.,hereby which
thi Nanam,I isacrnswmionlendagency for the performance of
F 112 Leader's
for which this permit 1.issued(Sees,3097,Co.iv.CJ
0 L,rdee,Name - TOTAL
W Lenders Address
y I certify(list I have read this aP,hvmEmr and state that he above information is BUILDING FEE
F rA coned.I agaem comply with.11 cityaod coumymdiwnmsundamm laws alining tu QTY. MECHANICAL PERMIT FEE
V building construction,and hereby mnhnrim represmnmivcy oC(M1ivdry mercer upon the SEISMIC FEE
above-memirned property for inspection purposes. P12RMU ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino zgairtl ELECTRIC ITE
Iiahilides,po,nenrs.tmtsmudcxpekmswhich relay Iran,way.ccmeaminst said Chy ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the graining of this permit.
APPLICANT U DERSTANDS AND WILL COMPLY WE ttl1terr,NON-POINT AIR HANDLE NO UNIT('1'O I WINE CPM)
SOURC .y11,1& MECHANICAL N T
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sig canUC r Date IiXHAUST HOOD IWMUCq
HA RDOUSMA BIALSDISCLOSURE HOUSING MITIGATION PEE
Will the applicant orfuture buildingmcupan,stow or handle haeardous material BEATING UNIT DO 1W,0309T11)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Salify
Code.Section 2553200? HEATING UNIT(OVER](In"BTU)
❑Yes E]No VENT ILATION FAN(SINGLE RP_SID) PAID
Will thea leant or from building cu ret use equipment or devices which Dam Reccip,p
PP alby eBOILER-COMP(3fIP OR 10(l BTU)
I emit hawdnus air conmminams as Jefinal by the Bey Area Air Quality Management TOTAL:
11� Dionet? BOILER-COMP(OVER I f(ta)(I BE U) �
I
C]Y. [D No
I1 have mon'ramaterials(M1e hNous terials rcyuiremcnte muter Chapter CONDITIONERr 6.95 of the Call.. ISSUANCE DATE
fomia Health&Safety Crile.Scalars 5503,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECII. SQ,IT.
building doer not cmmntly have n lenunl,that it Is oy respanihllly to notify rho rccup.nt
of the requiremenm which must he met prions Rapture of a Cenifcme of Occupancy.
Ownerortaffacad agent Date TOTAL ISSUED BY: TOP
OFFICE -