S 3047 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Run.Dlnc-ELECTRICAL Ph ITNO.
BDILDING DIVISION APPLICATIONIPERMIT PLUNKING-MECHANICAL 3047
BUILDING PROJECT IDENTLFIUATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
z— 16-4)4'-4
( OWNER'S N/�sIE�� _ w�P UNE: / x CO TRACI'�'S NAMC" �.r/I�/ LIiNO: _� NIC CON TkULN
ARCHITECT/P.NGINEER: LIC NO: !/(/� A RP.S$,�O /�/'�[ ('T/Y - ��L1 G?� ❑
CON'T'ACT: PHONE _ BU ILDINO PERMIT INFO -
O / ❑ Conandtant Fees Paid by Applicant(Initial) BLDG ELECT PLUM MECH
(� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION - QTY ' ELECTRIC PERMIT FEE
in
I hereby.flifm mI ala licensed anarr.......lens of Chapter 9(entnmrncing JOB DESCRIPTION
A d'Z with Section 90TH.ofDivixlnn3af the Busmessied Professions Gtde,.ndnry license is RESIDENTIAL'
WOO PER ISSUANCE
is fill force andyNc )ct�,' {Z^Z/f-f 1 ❑SPDWL ❑KITCHEN REMODEL
CG4 Lirensc Class y-2 Lie.a T )__S� APPLIANCES-RESIDENTIAL, ❑ADDITION El PLUMBING RE-PIPE
(-' Date Codtdwtor
y ❑MULTI-UNIT El STRUCTURAL
y
ARCH]I'ECTS DECLARATION PANTIES
F m TION
1 Ondersmad my plans shall be used a.public record[ CHIMNEY
REPAIR
OZn'4 UP TO 200 AMPS El INTERIOR ❑CHIMNBY REPAIk
E"IqLicensed Professional 201-IMOAMPS IMPROVEMENT [I SWIMMING,POOLS
OWNER-HUILDER DECLARATION OVER 1000 AMPS El BATH REMODEL/REPAIR DEMOLITION
C W d 1 hereby affirm that 1 am exempt form the Contractor's License Law for the ❑OTHER
O0.t U following mown.(Section 7031 5,Business and No(..too,Code:Any city or umntYI SIGNS ELECTRICAL
W a W h which requires a permit to amstraet,alter,improve,demolish,or repair any structure
prard,it,is,anrr,.Na requires the applicant forsoch permino file veignedsmtemrm SPP.CIALCiRCUIDMISC. -
aas that he is licensed pucswmt in the provisions erthe Contractor's License Law(Clmpter9 COMMERCIA
W�op (commencing with Section9000)of Division 3oflhe Business and Professions Code)- TEMP.METER OR POLE INS'f.
d y C that lie is exempt dco fmtn er l(he basis for the alleged evemption.Any violation of ❑NEW BLDG/ADDI'I]ON ❑DEMOLITION
iuG1 0. Section 9031.5 by any applicant for a permit subjects the applicant Io a civil penalty,)[ POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars($5(10).
��
E]1,as owner of the preprny,or any employees with wages astheir cold compenwtion, SWIMMING POOL ELECTRIC IMPROVEMENT
p. ❑0'1'HHR
will do the work,and the structure iv notimendeJ nrofforrd for sale(See.9044,Business
` and Professions Code:Tim Cannmclora License Law docs oat apply to as owner of DO CLE'I S-SWITCHES-PIXTURKS
property It.builds or inaprovcs thenad,and who docs such work himself or through
his own employees,provided that such impmvemen¢ace nal intended cr cffered for NEW RESIDENTIAL.ELECTR SQ FT.
are.If,however,the buildingorim,owcnent is sold within one year ofourpiednn,the SQ.I-L FLOOR AREA $ISQ.PI'.
wnerhai der will hese tbo arachnid proving that he did our build or improve on,Pur-
' poseof sole).
❑ 1,as owner of the prapeny,ont exclusively contracting with licensed eantmoclars ITOTAL:
construct the protect(Sec 9044,Business and Pmfesslnns Code:)The Convector's LI-
tat Law does not apply to an Owner of pCopeny who booms or raptures Thereon,and QTY. PLUMHINO PERMIT FEE
why contract for such projects with a conlmetol(s)licensed pu¢unnt to the Cnntmclo's
License Law. PGRMI'r ISSUANCE
L] I am exempt under Set. .N&P C for maven
ALTER-DRAIN&VENT-WATER(EA) e 3 VALUATION
/ Owner Date
WORKER'S ted,Of ipaya.DECLARATION RACK FLOW PROTECT.DEVICE
1 hereby affirm under pmmhy of pc jury one of the following decision ons:
E3I have and willforb inerini 37M of the Labor
elfe,fixthe Workersecor h- DRAINS 59'ORIF.S TYPH CONSTRUCTION
.mime,as path thi for by Serino 3900 of the Labor Code,for the pertonnnnce of the
Va
E] Ilierwhicb this maintain
orker EIXTUkE -PER TRAP
1 have end will maintain Workers Compen tunic
w rk for Is inch
h required by Section
3908 of the uhn dq[or the perlLLmmtce n[1M work for whicM1 this permit is issued GAS-EA IEM-I INC.40UTLETS (ICC GROUP APN
MY Wor r' t Ina cool hand Policy r
Policyli GAS-B .V'I'E 4 'A
Cul.iee
CERTIFICATE,OF EXEMPTION FROM WORKERS' CREASE 'TRLW STF.INTF.RCEPI'OR
COMPENSATION INSURANCE a pU1EDIN6 DIVISION FEES. _
f311isseclio0 need not be utmpleted if permit is fornnehandred dolhtrx($Inn) GREASE Q .
nr less) PLANCHF.CK PEE
I certify that in the pechoretee Of the work forwhic110tis permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FI'.
not employ any Person in any manner so as to become subject to the Workers Cooper- ENERGY PER
Z cation L.wsof Califnmia Data WATERHEATF.RWNBNTIETC'HR
z O Applicant GRADING FF.F.
Vzl NOTICE TO APPLICANT,IL after making this Cerlifeste of Exemption,you should WATER SYSTEM(TREAHNG
(~ �? become subject ut the Worker's Compensation provisions 0 the Lubar Calc,you n uIt SOILS FEE
forthwith comply with-Inch provisions or this perinit shut l he deemed revoked. WATER SERVICE.
Q
� ZCONSTRUCT ION LENDING A NEW RESIDENTIAL PLMB. SQ PC PAID
I hereby affirm that there wwagency isvnscninn lending agency for lho performance Of Dale Receipt#
the work fnrwhich this permit is issued ser.3007.Civ.C)
0 V London's NamTO
e TOTAL:
Lender's Address T 1.:
r� a 1 cwlify that 1 have rwJ this application nnJ elate that the,)have infnnnmion is - - BUILDING PEE
tE".I m correct.1 egrea to comply with all city and county ordinances and state laws minting to QTY. . MECHANICAL PERMIT FEE
C..) Z huddingamscrifinn,end hereby awhori.reprwwmtivos of this city to enter upon the SEISMIC HE
above-menli,)nedpmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
IivbillniaLjudgments,costs unJ expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
L15 0
in Oasegnenocuf1h,graining of this penult PLUMBING FEE I
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UND'(TO IL000(TIM)
MECHANICAL PEG
S URCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CPM) CONS"CRUC'CION'TAX
Signature Of AppreardContrector Date EXHAUST HOOD(WIGGED HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the appllcautorfuwm haimingoce.pam stnrc handle haz.Naoe mWcnal HEATING UNI'I(10100,000 BTU)
as deform by the Cupenino Manfcipal Cu R,Chapter 9.12,and the Health and Safety
GMe,Serum.25532(.)7 HEATING UNIT(OVP.R 100,000 BTU)
Yes NO
VENTILATION FAN(SINGLE RPSID) PAID
Dam Neceipl#
Will the e,Diwm of fmmre building ot,,r m use egaipmctt nn devices which
c ivcion-dusair contradictor;as defined by the Bay Are.Air Quality Management BOILER-COMI'(3HPOR IIHI,OW N'fU) TA t
El YO, E]No BOILER-COME(OVER 100,000 RTI!)
I have read the Innocents material.Tequaccents under Chapter5.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomfa Health&Safety Code,Sections 25505,25533 and 25534.I andemmnd that iRhe NEW RESIDENTIAL MECH. SQ,PC
building does notcurfcntly have a notion,Thal iti myres onslbilitytonolifythexcupant
of the requirements which mutt he mw priacm isunna,ol Cerifcad.fOmtpancy. �• (�
Owner acnmhocizedngenn Date TOTAL: ISSUED BY: / x+
OFFICE