S 1526 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HULLOING.ELECTRICAL PEgy1IT NO. 1526
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. I
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
?)e74 4 Z.tiD �G u .,lft9
OWNyR'S NAME: PHONE CONTR,4CT R'S NAME: LIC NO'.
LIPri W I&I/C.") 4.15's- 3 lips, C/Al SIC •� CONTTRROL#
G
ARCH ..CUE NEER: LIC NO: AjIjIe �r — /1 ElC%�.7
fJ W�IV1
CONTACT: PHONE: BUILDING PERMIT INFO
S"df ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MECH
LICENSED n dunder CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE �Y
Ti
1 nemny morin that Into licensed under provitiont of Chapter 9<ammmaneins ]OR DESCRIPTION
�aZ with SeeticarAMll)ofDrvfainn3ofhe BmseesiiniProfessions Cnde,andmylreenscis
WF
O O ecftMff ISsugrvcE RESIDENTIAL:
F in full a Cla s effect.
Cep„ ❑SFDWL �ITCHENREMODEL
aUU Dana Class Lick APPLIANCES-RESIDF,NI'IAL �itDUIT10N PLUMBING RE-PIPE
til Datc Cnntrngor
A.shall be meet
UsPublic re—oN PANELS MULTI-UNIT ❑STRUCTURAL.
Z O y�y I undarawnd my plain shall be usW ac pnMrc unrJs - MODIFICATION
Oz-'C UP T(120U AMPS OINTERIOR OCHIMNEY REPAIR
�,� 4i Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
•. OWNER-BUILDER DECLARATION OVER 1000 AMPS El BATH REMODBVR 1 EMOLITION
d ulU 1 hereby formout 1 ant exempt(rant the Comoodn',License Law for the
X d fallowing raven,(Section 9031.5,Business and Professions Cods Any city recertify SIGNS ELECTRICAL ❑UTHER I
W 3 fat y which requires a permit to construct,alter,improve,demolish,or repair any structure
�'��Q'pdor to its issuance,slm rcyuires ha applicam for suaM1 Penni!to file,signed slalemenl SPECIAL CIRCUIT/MISC.
mat he is licensed pursuant to the provisions ofthe Cnmmeto(s license Law(Chapter 9
I+I 00 (commencing with Sectem?000)of Division 3 ofthe Business and Professions Cade)or TEMP METER OR POLE INST COMMERCIAL:
d c eG (hat he is exempt therefrom and the basis for the alleged exemption.Any violation of ElNEW BLDG/ADDITION ❑DEMOLITION
'^
Section 7031.5 by any applicant for a permilsubjmla the applicant Ina civil penally of POWER DEVICES
y ❑TENANT [I FOOD SERVICE
E, nm more than five hundred dollars($500) IMPROVEMENT
C�Q ❑Losoe w.,k,lhcpestruc, misrot intended wfmwaeesrsalei(Sec.munpemmion, SWIMMING POOL ELECTRIC
6 22 will domework,andthe he Corcisnot� License Law red does cut apply to an,Businawn,,of ❑OTHER
n
and arty whob Cmfe:The CUnweren License Law msec nm apply ma if owner Uf OU'1'LETS-SWI TCHES-FIXTURES
property who builds or improves thereon,and who roes such work himself or through
his own employeesprovided that such improvements are not intended c offered for NEW RESIDENTIAL ELECI SQ FT
' sule.lf,hnwevea thee bullring or improvement .,of rcmenl is sold within one year omm Fletion.lhe SQ.Pf.FLO RAREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of nv1eJ.
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.9044,Business and Professions Code:)The Contractors Li- -
Cause Law does not apply In an owner of properly who bar Ids or i mproves thereon,and QTY. PLUMBING PERMIT FEE
wh ,ornects fareuch projects 'hn contract.,, licensed pursuant who Cmmnmror'a 1
License Law. - a s:' •D
❑ PERMIT ISSUANCE
1 am oxcmpl c ,B&P C for his rcusom
ALTER-DRAIN&VENT-WATER(EA) VALUATION
owns Date IJI-C
1yV
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE D ��/O
q� r—
IherebyafrmunderpenaltyofperjuryoneofthefollowingJeclumtimvu •
E]I have and will maintain v Ceaificate of Consent to self-insure far Worker's Compel- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
,inion,as provided for by Section 391X1 of he Labor Code,for he performance of the
work for which this permit is issued FIXTURES-PER TRAP
❑ I have and will auint in Workers Compensation Insurance,as required by Section -
3900oftheLabor Code,for the performance ofthe work for which this permit is issued. GAS-E,.SYSTEM-I INC.4 OU'ICFfS OCC.GROUP APE
My Workers Compensation Insurance carrier and Policy number arc
Carrier: Policy No.: GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR
010 Brunn need not be completed if he permit is forone hundred dollars($100) 1 'DIVISION S
GR BASF.TRAP
or less) PLANCHEC
(certify that in the any Performanceof
as tohe
which his Permit i kar,'C,Isha- SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner w as to became nubjed In the WnrkerK Gnnpen- ENERGY FEENJ
,7. soden Laws of Callfnmio.Data WATER HEATER W/VEM'IELECIR
z
NOTIAppliCE
- GRAD(
ry V] NOTICEun APPLICANT:Il after making his Certificate PC of Exemption,you should WN]ER SYSTEM/IREATING SOILS FEE'
becomeh coin l y the Worker's Goons or this erhat steal of Inc Lamdecided
evoke,you man
W
forthwith comply with such provisionxmthls permit shall be deemed revoked. WATER SERVICE
0. Q
UO CONSTRUCTION[.ENDING AGENCY NEW RESIDENTIAL TUMID. SQ.FT. PAID are Receipt#
I hereby affirm perm,i is v ed(So,,30 lending agency for the performance of
he work for which this Pamir is issued(Sec J099,Civ.CJ
lenders Name TOTAL:
{U IwJer's AJdmss 'TOTAL'
I certify that 1 hove read this application and state than the above information is BUILD( I FEE
Zi correct.I agree to comply with all city and county oMimanrz and nate lows reliningm QTY, MECHANICAL PERMIT FEE
U Z building contraction,and hereby authorize representatives of this city to enter upon the SEISM( FEE Oil
vMwe-memioned pm any for inspectran purposes. PERMIT ISSUANCE
(we) m save,' damnify.a keep harp ass the City of Cupertino against ELECT IC PEE
diabilitres.' dgmems,costs an expenxes whichinay inany wayaccmeageinstsaid City ALTERORADDTOMECIL
an conse ce of If of his par mit. PLUM NO FBF,
APPLIC. NT Bks'T IS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,(100 CPM)
$OIIRCF :GGLAT MECHA IGLFEE
AIR HANDLING UNIT(OVER Proof CPM) CONSTRUCTION
.00 Signa reofApplicanuumntmetor OO are EXHAUST HOOD(W/DUCE HOUSING MITIGA'T'ION
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant r future building occupant store erbundla hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and he Health and Safety
Cade,Saotron 25532(x)7 HEATING UNIT(OVER 100,00M BTU)
❑Yes L]No PAID
VENTILATION PAN(SINGLE RES Of Date Receipt# ,
Will he applicant or future building occupant use equipment or devices which ROLLER-COMP(IHP OR IW,UIXI BTU)
emit hauardous air contaminants as defined by the Bury Area Air Quality Management TOTAL
District^ BOILER-COMP(OVER 110,000 BTU)
❑Yes El No
I have readhe hazardous materials reyuiromems under Chapmr 6.95 ofine Call- AIR CONDITIONER ISSUANCE DATE
hmin Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MCH. SQ.ET.
l building does not currently have a talent,that it is my responsibility to notify the occupant
1 of the requirements whichmun he at pdnnn madmoofa Ceaifcvtenf Occupancy.
Owner or authorized agent Date TOTAL I ISSUED BY:
OFFICE