S 0218 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUD. -ELECTRICAL. 1 E nr"° .O^q
BUILDING DIVISION APPLICATION/PERMIT rI,uMBINc MscxnNLrnL L 1
-BUDDING PRUipur IDENTIFICATION
BUILDING AIS' S:_ /� SANITARY NO. API'LICA'1'ION SUBMITTAL DAL
O 0 CONTRA R' I N('
NIC CONIROLX
ml
�\RCHITI IENGINEER: LIC NO: �,✓ 0. .
CONTACT: ,A ONE f BUILDING Pf:RMIT INFO
(% l /I/!/// ❑ Consultant Fees Paid by Applicant(Initial) BIAG gLF. PLUh1 n]yCll
LICENSED CONTRACTORS DECLARATION QTy - ELECTRIC PERMIT -' FEE' ❑
CwZ JOB DESC PTION/❑
1 Junta,alrrm that I um licenced under provisions of Chapter 9(commencing -
with Section vKMgofEwisian 3ofthe Business and Yn,- sons Gal an my 1,ccn,cis RESIDENTIAL
{+1 O O PER ISSUANCE
in toll force anti dl I. ❑SFOWL ❑KITCI{NN REMODEL
,UU LtccnxCas Lic.p gPPL1ANCGti-RFSIDENTIAI. ❑ADDITION ❑PLUMBING RE-PIPE
Z W Date Canonical, n
;n< ❑MULTI-UNIT ❑STRUCTURAL.
ARCHITECI"S DF.CLAR 10
p,7w _ PANIIIS MODIFICATION
ZO iZ„ lundermand mY plum.dhoti br uxd us Puhllr mcnrtlx
OZO UP T02(XIAMPS ❑INTERIOR El CHIMNEY REPAIR
F-4F-; Licensed Pfofcuional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER Haiti AMPS El REMODPL/REPAIR ❑DEMOLITION
.a..II I hereby affirm that 1 um exempt limn the Contractor's license Law for the
�W( W J following reumn.(Section" ,Business end improve,
de ions Code:Any citys county SIGNS ELECTRICAL OTI{{r
413 W y which requires n permit toviresmconstruct,aaltc�pplicant
nt for such
demolish,or leash any tenure
I"'LL UO�11� prior to issuance,also requires Ne epplicamfor such perminn Rleesigned statement SP[CIAI.CIRCUIT/MISC. ,
2Npw mat he is lierm'ed pursmamt In the pmvslnre of the Carl—'-aox Llec-le Law(Clmpter9
Wd� (wntnaerem,with Section 70(X6 of Dl vLdon 3 of the Bmmesa and PrnfeWoov,Cde)a, TEM I'.METER OIL POLE INtiI', COMMERCIAL
IIIthat he is exempt therefrom unit Ne basis for the alleged exemption.Any vitiation of [I NEW BLDG/ADDITION ❑DEMOLITION
M Section 701.5 by any applicant for a permit subjmu the applicant to a civil penalty of POWER DEVICES
>' not mare than five hu^drcd dollars(550tH. ❑'IMPROV [I FOOD SERVICE
~ QI,as ownend'the m norm In cern with wa es ns lhcirrnlw unn tion, SWIMMING WRl1.Ii1.F.CTRIC 01 HER IMPROVEMENT
❑ ❑ t po Y Yemp Y 6 purrs^
F willdo the work.trod lheswcutreisnonimended proffered Imo,apply.7M4,Bmv,of O'I'HCR
W m a 4 IN
nd Professions Call:The Commcmh License Law does not apply to If ,rater of OUThFTS-SN'ITCHFS-ITXTURfS
M 3^ pro,my who builds or improves(human,and who does such work himself nr tnmugh
his own employees,provided that such insprovcmentx arc ns intended or offered for NEW RESIDES PIAL ELEC,R SQ FT.
sale.If.however,the building or i mprovement is sold within one year of completion,the
SQ.F1'.ILOORAREA SISQ.PI'.
owner Wilder will have the harden of proving that he did not build or improve for pur-
posc of sale.).
I,as owner of the property,am exclusively central with licensed contractors 10 TOTAL:
mvtmct the ponect(Sec 7044,Business and Professions Ccde:)'I'he Cmttmcmr's Li-
cense Law does not lady to an owner
i-censeLawdoesnotladytoanowner ofpmpeny who builds or improves thercon,and QTY s'. "'PLUMBING PERMIT ,FEE
who contracts for such pmjmts with acontmnor(s)licensed Pursuant o are Contmnoes t
License law. PERMIT ISSUANCE
(] I am exempt under Sec .I{A P C far this,cavo^ 1,
,ALTER-ORAINk VENT-WATIiR IEA) (P54-4-
I
�A ❑p'''Ipry
Owner Date [,iJX `�J'A
WORKER'S COMPENSATION OECLARA'1'ION BACK PIAW PROTECT.UIiVICF,
I herebyaffirmunder Penalty to perjurymal
t) the followingdeclarations:
❑ Ihave and will for
eCenificatn ofCeLabor Code,
mforthe Wommuhe of the
URNNS-FLOOR,BOOP,AREA,COND. STORIES TYPE CONSTRUCTION
tininn,as provided for by Section 3]110 of the IaMm Code,for the perfnnnance of the
Zo hth
for whiris permit is issued. FIXTIIRF_S-PER TRAP
w I have and will maintain Workers Compensation Insurance,as required by Section
3700oflhe Lamm Cade.for the pvrmhomtct,of the work for which lI,s per it ix issued. OAS-I'A.SYSTIiM-I INCA OUTLETS OCC.GROUP APN
My Workc atiss Bran artier and Policy n O> GAS-EA.SYSTEM OVER 4(IA)
Cartier. lg„�( Policy No.:
l�'�CERTIFICATE 0 EXEMPTION{ICOM WORKIIRS'
COMPENSATION INSURANCE. GREASIIINDUS'1'RI.WAST[?IN'IERCIiPfOR -
(This section need not W comparedifthe person is farrow hundred dollars($100) #,' . BUILDING DIVISION PEES
or leu.) GREASE TRAP PLANCHECK FEE
I eciifythat in us,pminrmancenflhe workfar which this permit is issued,Lucia SEWER-SANITARY-STORM EA.200 F..
not employ any person in any manners,as to become subject to the Workers'Compen- ENERGY FEE
O Z .ration Laws of California Dmc WATER HEATER W/VENTrELECIR GRADING FEF.
Z 2 Applicant
to NOTICE TO APPLICANT:If,after making this Cenifienm of Exemption,you should WAl'17R SYSTEMILREATING
f~ ^ become subject,the Worker's Compensatin^provisions of the LaMar Code,you must SOIhs ITE
G forthwith comply with xuch provisions or this permh shall W di revoked. WATER SERVICE
Q
CONSTRUCTION is ac0NLENDINGAG agency NEW RFSIUENTIAI.PLMR. SQ.Ff. PAID
.7 sZ, Umc Receipt%
1 hereby affirn Ihanherc is s ed(Sec.30 lending agency for the performance of
L) � the Leede,work for which this permit is issued(Sec:309],Civ.C.)
Lender's Name 'I'pTAL:
U leader's Address TOTAL:
1 rectify that 1 have lead this applinn and state that me aline inhmnatiom is BUILDING FEE
r/a1 icscorrect.l agree to comply with all city anti county ordinances and,nate lowsrchning to QTY. MECHANICAL.PERMIT FEE
fJ Z building constmninn,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
abnvesentinned property for inspection purposes. PERMIT ISSUANCE
(We)as.to save,indemnify aad keep harmless the City of Cupenimt against ELECTRIC FEF.
I iabilities,judgments,costs and expenses which may i it any way seem,against and City AETIiR OR ADD*10 M ECI 1.
in consequence of tie granting of this period. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY Will Ii ALL NON-POINT AIR HANDLING UNIT(TO to,(XXI CFM)
AL I
SOURCE REGULATIONS. CONS IRICTTONT
AIR HANDLING UNIT(OVER 10,000 CFM) CONS'1'RIICfION'IAX'
SIB^^sreof Applicmn/Commcmr Data EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MAIE.RIALS DISCLOSURE
Willthe application,future building aceupa^t maters handle hue.N^us^tanerial HEATING UNIT(11)10X1,000 BT U)
as defined by the Cuperli^^Municipal Code,Chapter 9.12,and no Health uad Safety
Gale,Section 25532(n)7 - HEATING UNIT(OVER 100,000 BTU)
Dyes VENTILATION -AN(SINGLE]HIS PAID
n Use Rwmtptp
Will the applicant, fntum building occupard me equipment or devices which g01LElt-COMP f31{P OR IIX1,fNN1 BTU)
emit hvzardrus vin camtaminums aro lined by the Bary Area Air Quality Management TOTAL:
District? BOILER-COMP(O VER 100.(X10 HTU)
E)Yee,
I have most the hazardous materials comimarl ander CMlpmr 6.95ofthe Cull- AIR CONDITIONER / WISSUANCE,DAT[:Irma'Health Safety Cade,Sections 25505,25533 vnJ 25534.1 understand that if the NF.W RfSIDENTIAL MF.CfI. SQ.IT.
builJingd utcu oily haute mnant,ohm it is my msrymsibilinymnsify theoccupantithe hich must met prate ofm
or th g TOTAL ISSUED BY:
OFFICE