S 0078 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. n
BUILDING DIVISION APPLICATION/PF.RMITPLUMBING-MECHANICAL
BUILDING ADDRESS: - BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL.DATE
1.00143 ens ()0 vls�� Dig eO �;,No
O�yER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
1 IS�R�'I� FAQkkS LnM i L oa SG4H2 NIC CONTROI.p
IRCHITECT/ENGINEER: LIC NO: DRESS:
C a�l�ew 'D¢ �, ❑
CONTACT PHONE: - - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BI rr ELECT PLUMD MECH
K
LICENSED CONTRACTOR'S DECLARATION Y' X
i hereby afftrm mat I am QTY ELECTRIC PERMIT FEE Imlicensed under provisions of chapter 9(commencing JOB DESCRIPTION
QOC wire Seaion]ggB of Divixinn3of the Business and Prnlbxaions Crile,and mylicense is
in full force and effect. PERMIT ISSUANCE RESIDENTIAL
�ei License Class ' Lie.X ❑SFDWL �41TCHENREMODEL
``�� Dale Contractor APPLIANCES-RESIDENTIAL IML)\I'L-
F c /! El UMBING RE-PIPE
pypw ARCHITECT'S]DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
OZp v-Z I undemnnd my plans shell he asM az public records MODIFICATION
UPT02WAMPS ]OR El CHIMNEY REPAIR
�WXW Lmcensed Pmfcsannel %I PROVEMENT
.J OVER
ySX�...4I OWNER-BUILDER DECLARATION _ [I SWIMMING POOLS
C W 6 1 hereby affirm that 1 am exempt from the Contractors License Law for the OVER 1000 AMPS TH REMODELAtEPAIR ❑DEMOLITION
'3 F following reason,(Section 70315,Business and Professions Calc:Any City or county :SPECIAL
ECTRICAL ❑OTHER
F`O which requires a permit m Conswn,alter.improve,demolish,or repair any museum
y
Prior to its issuance,also requires the applicant for such Permit to file a signed statement CIRCUIT/MISC.
that he is licensed pursuant the provisions of the Contractors License Law(Chapter 9
W ADO (commencing with Section 9(IIIU)of Division 3 of the Business and Professions Code)or TER OR POLE INST. OMM R IAthat he is exempttherefrom and the basis for the allege)exemption.My violation ofSection 9031.5b anyr licant fora NEW BLDG/ADDITION ❑DEMOLITION
yY re permit subject the rpPlicammacivil penalty of EVICfiSno[mnrc than five hundred Jolles 18300). ❑TENANT ❑I'OOD SERVICE
a Ol,es owner of the propeny,mmy<mployas with waes as maim Cole comtiG POOL ELECTRIC IMPROVEMENT
will do the woretnd the structure is not intended or affertd forsule(Sec.JM4,Business ❑OTHER
and Pmlessioms Code:Thu Contractors License Law does not apply m un owneroT -SWITCHES-FIXTURES
properly who builds or improves therene.and who docs such work himself or through
his own employees,provided that such improvements are nolintended or otiered far NEW RESIDENTIAL ELECTR SQ FT.
sale.ll',however,the building or improvement in sold within one year al'cnmpletion,the SQ,,ppIl''.FLOOR AREA $/SQ.Ff
.
oweowner-builder will have the M1urden of proving that he tliJ not build or improve for Dur ��A
ofsalde. sY
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construe'the project(Seo.70,H1,Business and Professions Code:)The Contractorls Li-
wave yflyf
se Law does wt apply to an owner of properly who builds or improves thereon,and QTY. PLU G PERMI FEE �'V 4 �'Atps
who contracts for such projecus with a contmemr(s)licensed pursuant the Contractor's / a1L(X Xn
License Law. Y
❑Iamexemptunder Sec. PERMIT ISSUANCE,B&PCforthisreason ryOh �UYGIi
Owner Date ALTER-DRAIN ) ON
WORKER'S COMPENSATION DECLARATION EV
T.U ICEIhereby alf'm'under penalty of perjury one of the following decorations: L I have and will maintain a Certificate of Consentto sel6insum farWorker's Compcn- R ARI ,GOND. STORIES '1'YPE CONSTRUCf10N
around us provided fur by Sec'ino 370 0 of the Labor Code,for the pmunn umn,of theCork far which this permit is issued, PQ 1 have and will maintain Workrs Compensation Insurance,as m shed by Section
3]W of the Labor Cale,for the performance of the work fur which this permit is issued. -I INC.4 EftOCC.GROUP APN
M Wmk$/'sC mpensation lnsumnce certier andPolicy num -
Plicy,No, GAS-EAS -OVER4(F
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCE
(Dossection need not W Completed ifthepenNt is foronehundred dollars(SIM) BUILD I ON FEES _
or less.) GREASE,TRAP PLANCHF.CK FIiE r ,
Ireadily'hot in the perfommanceofine work liar which this permit is issued, .
not employ any Person in any manner so as to become subject to the Workers Comped SEWER-SANITARY-STORM EA.200 FI'
ENERGY FEE
,Z sided Lrwsof Cvlifnmta.Dam
zta
O AppliCmI I WATER HEATER WNENT/F.LECI'R GRADING FE
y NOTICE TO APPLICANT.If,after,making this Ceralste of Bxemp'ian,you should WATER SYST'ENUTREATING
aM1ecnrr'e subject to the Workers Compensation provisions of the Labor Code,you must SOILS FF.
forthwith comply with such Provisions or this permit shall he deemed revoked.
0. Q WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Pf. PAID
U O Thereby affirm that is a contraction lending agency for the performance of Date Receipt
Duh the work for which this permit is issued(Sec.309],Civ.C.) '
Leader'sName
O W Lenders Address TOTAL: TOTAL:
y I certify that 1 have rend this application and amte that tM uhove information is BUILDING PEG
In correct,I agree m comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE oi
Uz building construction.and herebyau'hotize upoxnntativeso(thus city menterupan the SEISMIC FEE
above-momim red Pmpeny for imi anion pompoms.
(We)agree,to save,indemnify and keep Warless the City of Caperton against PERMIT ISSUANCE ,ELECTRIC FEE
liabilities.judgments.costs and expenses which may in any way accmeagrimat said City ALTER OR ADD TO MECH.in asequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTAIR HANDLING UNIT(TO 10,0X10 CFM)
SOUR ULATIONS. / MECHANICAL F.F. _
AIR HANDLING UNIT(OVER Mooli CPM) CONSTRUCTIO TAX
Siguamre of ApplicanJContmnor I Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS IfISCLOSURE HOUSING MITIGATION
Will the applicant or future building occupant slum or handle hazardous material HEATING ON IT(TO 100.000 BTU)
as defined by me Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255320)? HEATING UNIT(OVER 100,000 BTU)
❑Yes 7 N
VP.NTILATION PAN(SINGLE RESID) PAID
Will the applicant or futu'n building by the B use .Ail Qu or devices which Date Receipt X
Mil hazardous air romaminems as Jcfined by the Bay Area Air Quality Management BOILER-COMP CHP OR 100,001)PTU)
)istrict? TOTAL
❑Yes ❑No BOILER-COMP(OVER 100,000 BTU)
I have rend the haenrdous materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
fomin Heald&Safety Code Sectiom 25505.25533 and 25534.1 undersdval that if the NEW RESIDENTIAL MECH. SQ.Ff.
building does not currently have a tenant,that it is my reaponsibilay to notify the Com plan'
of the requirements which must be mem prior to issuance of a Cenifcate of Occupancy.
Owner or aumonred agent Date TOTAL: - ISSUED BY
OFFICE —