S 0090 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. _ _ _ _ _
BUILDING DIVISION APPLICATIONIPERMIT PINGPROJECT ID11ANIFIC switO 2f1-- 299990-
BUILDING
f1 F] n
i BUILDING PROJECT IDF_�l'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O NIiR:S NAME: PIfONIi: CONTRACfON'S SAME, LIC NO
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C
c NIC CONTRf M
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A CI TF. NGINIiI?H: LIC NO'. - AUUNESS: ❑
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FCO�A�: PHONE: BUILDING PERh11T INFO
❑ Consultant Feet Paid by Applicant(initial) BLDG ELI P MECH
LICENSED CONTRACTOR'S DKLARATION QTY ELECTRICPERMIT FEE
firn�mat I am B«mood wdcr misions of Chem,9(cn nnenwol; JOB DESCRIPTION
DMZMETviaim 3ofine B.,i«s ae Ponfaier.,cwe,aril my Beeman is RESIDENTIAL
IHiNMIT ISSUANCE 6:2 lnz):2 ❑SFUWL ❑KITCHEN RF1.10111iL
IJc.MAPPLIANCES-RISIDEN'IIAI, ❑ADDITION ❑PLUMBING RE-PINE
C'nmmcm
on Q a ❑MULTI-UFR [_1N
STRUCRAL
4LT5 DECLARATION
A
F D m PANELS MODIFICATION
Z O-IZ IUMemmM mY plan,tholl M1ell M1e uurlupublic ntt.rds
OZ—� UP TO 2110 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F-NFW Licemed Pmfsaoral 201-10MAMPS IMPROVEMENT 0SWIMMING POOLS
gQ a; OWNFA-HUILDER DECLARATION OVER 1000 AMPS ❑RATA REAfODEURI:PAIR ❑DEMOL111ON
C Q 1 hereby aRrm Nat 1 em exemq from the Cmtrstafs I,iceme Law f«de, ^ ra
iw tV fullOwin6 mown.]Section 1031A Business aril Pmfe siom Cole:Any city«rounly SIGNS ELECTRICAL
QfHFR {A-F,•/L SYr�
which"mo,o permit to crmsmcl,alter,impose,demolish,m eepau any—1—
O¢J pnmm its iasusnce.also mquin,the apphicam «ouch permit to flcasi6nNgvc—i SPECIALCIRCUITIVIISC.
that he is licen W pim uenuo the provisiema of the Comracnx's license law(Chapier 9
d
a1�00 (contnwming with Smmm.0M0or Divirirn luftha Butiaxtonil l'nrfuviun,Calc)« It?MP.MITER OR PoI9INS'T COMMERCIAL
-IA
d ry,m y Hatt he ix si,W1 tivem(rvm wJ the bar,N Gx the diegal uuo,ion.Any violwim of
❑NEW BLDG/ADDITION ❑DI'.MOLITION
4X1 a Sc lion 7031.5 by any applicant f«a prnnit wbjmts the applicant a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
fin not m«e thus five bunrhe bllers(S500).
E.Z y IMPROVEMENT
Q ❑ Luwaerofde the, y.nrm no,meyccr air.ff to,Heirsok compcnation. SWIMMING POOL ELECTJ�k
t=� will du de xork.end the avunum is inti.._ ._.«oRacd fm sok(Sc.1UL1,Hmirres ❑OTHER
L
3 w mad Ponfim ions Code:The Convenes Licit taw non,Wily does nly to im weer Fl
of OUTLETS-SWITCHES- KIURGS
ton,who Cuildc«imptave thernv,and who d¢,OVIO work himself«Wwgh Nr:W RISIU[MWL ELECfR PT '
his own cmpla c ,powuMil Nin soeh im rmry oma arc not intended to-,Rue f« SQ.ET FLOOR AR LSQ.IT.
sok.If,hwe,se,no,building Or impo:enent is sod winin One year Mcomplctinn,nu
owarbuilderwill have the Imrden of Nxi,m,that he did eW build or inymnve for sw
,oworsole). %ft' 5 M-nag
❑ h us owner.rde pnojv ty.am exclusively comm zing with liccnwrl contractor-,to TOrAI.;
amaruct the pro,«t(See 7(w.11-i— it Pm&ssima Com:)'lly:Cmuonrr'n IJ- /.�r
wnwLaw dues no apply,.an nwnmof m,,,Oy wno build,nrbn,,uves,hnnw,and QTY. PLUMBING PERMIT FEE Y OF GUrEyf
ho con.f«sucn pmjccu with•eomwOrO)license pumwm m the C.ntmcmfs I'1 1N0
LMnan law. PERMIT ISSUANCE
1 inn exi m,t under Sec. .B&P C for this mmn
AI TGR-DRAIN&VENT-WATER IEA) VALUATION
Owner Dv
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
I hueby aRinn under penalty of perjury not,tithe billowing declauims:
I Mvc end wJl nuimain eCcm6cae of Cnn.¢nuoadf-inwrc fm Wurkcr'a Cnmpcn- DRAINS-FLOOR.RODE,AREA.GOND. STORIES TYPI3CONSTRUCTION
anon,as pnvidnd for by,11 o317X1oI rhe Labor Code,for the peifsmanec,of me
wok r r wh.h,Lie pomt,i,ineved, FIXTURES-PFA TRAP
I have and will maintain WorRer's C,mgsnatOn Insurance,as nequlad by&.a6m
3700of ne LdberCode,f«the pamommO,of the,work fa whi,h thio pemdt b i,we1 GAS-ISA.SYSTEM-I INC 4 OUTLETS OCC.GROUP APN
My W'M sC«npensuion h%amnec comer and Policy number arc:
Carrier. Po icy No.: GAS-FA.SYSIEAI-0VER J]EAI
CERTIFICATE OF EXFAPI'IO,N FROM WORKERS
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION ETES
(This inion nee not 4 cmtpkte ifdu petmit M.one hundreddlvs(SIM) GREASETRAP
PLANCHECK PEE
I anify rant in the prfanu«'c Mtbe w«4f«wnichthio pcmtio&cOs,e,I shell g1iW13R-SANITARY-WORM 1?n.11M11T.
m.crnpiny any perwn in any g yye wnjttt to the Wntkcri CmOpco I ENERGY FEE
Zvulnn lawipfCelif.mla llalc \�Y WAI'1IR HEATER W/VFM/[LHLTR
z Applicm'�l�! GRADING
FEE.
NOTICE PCfEANEElicr n -ing this Cmifiente of f!xempum,You eM1uulJ WATER SYSTEMIPREATING
bcnmc mbjvtit to doe W«kcr s Compensation positions of ne,IaMr Crile,You moa SOH-S FTE
foohwith comply oah such rovioom;Or On punct sell be Jetted n-keh WATER SERVICE
a0
CONSTRUCTION LENDING AGENCY NEN'RESIDENTIAL PLMB. SQ.FT. PAID
�Z IhrmM afrmtthu,leea.e.nanr,u,n lending agency r«ue petr«mm�ee.r Dote Reaip.
�- ,he wok for whicn,his Penni,n inaed(Scc.3091.Civ.C.) TOTAL:
1c ,N.
V LCnJmS AiIho,i TOTAL:
L11 I renify then I have mad this applic Linn end sate shat the above information is HUILDIN
harrttt.I agme to comply with all city and aunty md'mmn ltv told state laws relining to QTY. MECHANICAL PERMIT FEE
u undiin,,.ruaim.and herehy oullom,mpesenwivesofthhdry men,evupm the SEISMIC
r ab,os-nenfioond pro,eny Or inNwiwm pupures. PERMIT ISSUANCE
(We)agree m sena indemnify arW ote h ..r mmithe City of Cupertino ugeinst I].EC R
liohilitics.judgrtems.rano and capcnrca which nayuwy way accrue a8airut said City ALTER OR ADD TOMECH.
in con"m..fdegrwing.fthn Pami,. PLUM GF'EE )
APPLICANT UNDERSTAND'AND WILL COMPLY WIT RLI.NON-POINT AIR HANDLING UNIT(TO I0.010 CR)
SOURC . A TIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.00 CMI CONSTRUCDON TAX
,5SKre anl/Cmtmeta Date EXHAUST HOOD(WNUCT1 HOUSING MITIGATION II]?
HAZARDOUS MATERIALS DISCLOSURE
Will the npplicam a foram mudding«cnptm u«c.r ha ill.Itvadius mucdal I]EATING UNIT(TO 100.00)BTU)
as he( e,1 by the Cu,Omo Municipal Gvl4 Cnaper 9.13,and the HeOth and Safety
Cnk,Section 255311n)t HEATING UNIT(OVER 1011.0011 BTU)
Ye N.
VENTILATION FAN(SINGLE RESID) PAID Oye RettlpM
Will the applicant m futue huildin,ces,a ant use cquipmem ur cic, u wbicb
emit M1a:udou av condominiums m defined!by We they Ar An Quality Mamguaeu BOILER-COMP(3HP OR IM."BTU)
ITs ? TOTAL:
0y,,, ON. BOILER-COME(OVER 100.000 BTU)
E have mad the ha,u .,malMidst immenu under C101Au 6.95 of me Cali- AIR CONDITIONER ISSUANCE DATE
fi-,a Health&Salety QNc,Scnim,25515,25533 and 355H.1 uule aaml th,if the NEW RESIDENTIAL MECH. SQ.EL
buildingrkvx not currently have.mn:uu,rhe,It is my mpoosibilhy mmaify Ihe(sc n.,
or Lue"am,mm which ma.h;ntet psiocto b...fa Ccnitirmc.r OcO,,m,.
Ow mrd 1Win DatcTOTAL: ISSUED BY:
OFFICE