29568 (2) APPLICANT TO FILL IN INFORMATION WITHIN REP LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO,2 9 6 8
RUII,UING DIVISION APPLICATION/PERMIT 1•LUMIIINC-MECHANICAL L�l•J� V(-l�J k}J(
BUILDING PROJECTIDENTIFICATION
BUILDING ADDR121S: / SANITARY NO. APPLICATION SUBMITTAL DATE
NER:S NAME,: `1 g[h�(" PHONE: ):STRACfOR'S N E: LIC NO:
N/C CONTROL#
ECT/EN (NEER: LIC NO: UDRESS: ❑
t l C
LSIIIAYU1U PHONE: ILDING PERMIT INFO
L �s-?4?57-5,^(W
❑ Consultant Fees Paid by Applicant(Initial) RLD6 ELECT PLL MEC,
UK A
LICENSED CONTRACTOR'SDECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Mzzve vx 3ofle,Im,ier,'and Prnfineions Coda,into my license is
a'Z IIM1 Scetinn]qxq elD"'
F 100- ..'OH force and effect. PERMIT ISSUANCE
V License Class Lic.# WL El KITCHEN REMODEL
tF�a Dare Contractor APPLIANCIS-RESIDENTIALSCb ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECT"S DECLARATION PANELS ❑MUCrI-UNIT ❑STRUCTURAL.
Ow Z I mlderswd my plans shall heaved u public meme, MODIFICATION UPT02MAMPS
Z�� ❑INTERIOR ❑CHIMNfiY REPAIR
F�2t:ly hicenseJ l'ndm'sionai 2111-I Wf1AMP$ IMPROVEMENT
<SeOWNER-BUILDER DECLARATION OVER 10100 AMPS
E3 BATH REMODEUREPAIR El DEMOLITION
�tY C Q 1 hereby affirm that I am exempt Bram the Contractors License Law for the
iqLi5$O y U following mason.(Section]0315.Business and Professions Code'.Any city or county SIGNS ELECTRICAL. ❑OTHER
I+s 3 V.Ot which requires a permit to conswc6 alter.improve,demolish,or repair any slmmo
am
F"LL�g prior to its issuance,also requites the applicant for such Permit o file a signedstatement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant o the provisions of the Contractor's License Use(Chapter 9
a aQSimmemorial,with Smmo.700)of Division 3 ol'the Business and Profc,slmu C,de)or T'1!MP MLTKR OR POLE INST. COMMERCIAL'
cy not he is exempt thcrefmm middle basis far the alleged exemption.Any vinhoma of ❑NEW BLDG/AUDITION ❑DEMOLITION
�yLL Section 7031.5 byany applic.rtfar.pe wit subjms theapplicamm a civil penalty of POWER DEVICES ❑TENANT ❑FWD SERVICE
n more than five hundred dollars($5001.
Z IMPROVEMENT -
Q ❑ Las awnerofthv pestres nr employees wages astheiNce,compcnwian, SWIMMING POOL ELECTRIC
will do Ne work,and theswaum is not intended Or nffereJfor sale lSee.]Opi.Business ❑DTHGR
uixgl and Professions Code:The Contractors License Law dues not apply to an owner of OUTLETS-SWITCHES-FIXTURES
�'3 property who builds or improve,Ihuroon,and who does such work hi..self or Ihrongh
his own employees.provided that such improvements am not intended or uffeeJ for NEW RESIDENTIAL FLECTR SQ FT.
sale.If,however.the building or improvement is sold within one year ofcompletion,the . SQ.pT.IFLOOR A A 11 Q FT.
owner-builder will have the burden ofprnving that he did not build or improve for pun- 105^1 1 88A3
"aid'Zin). TOTAL: J� 1 1
I.as owner Of the Pmpsrl,man exclusively cnmrecting with licensed comm.tors to -s Q
comwa the project(See.7 FI.nosiness wd Profession,Code:)The Conwnars Li-
ase Low does not apply In an owner of proper who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who convects fornuch projects with a contracmrts)RcenseJ pirsoanl tothe Contractors
License Law. PERMIT ISSUANCE
I am exempt under Sec. .B @ P C for this reason
ACT[#-DRAINk VW- ATER LEA) VALUATION
Owner Date,
WORKERS COMPENSATION DECLARATION RACK FLOW PROTECT. E II
Ihcreby alEnn under penalty ap�
(it of the following Acdamtinns: L.� `
I have and will maintain a Certificate ofConscnt toself-inmre for Worker's Confer. DRAINS FLOOR.H( .A.0 STORIES, -'+ '1'YPECONS'LRUC'DON
sation,as provided for by Section 3701 of the Labor Cade,for the perfamunce of the a ..
work for which this permit is issued, FI%TURES-PER TRAY
Cl I have and will maintain Worker's Compensation Inwmnce,as required by Section
37M of the labor Code.forthe perGmnancc offle work for which this pem ,i,issued. GAS-EA.SYSTEM-I INCA Ol1TL'TS GRUI,Fj4 AI'N
My Worker's Cmnpemation Insurance carrier and Policy number are: OA 99
Carrier Policy No.: GAS-EA.SYSTEM-OVER 4(EA) Gil V
CHICTIFICATEOFEXEMP'NON FROM WORKERS' GRFASFJINDUSTRL WASTE INTERCEPTOR V
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Takov,ion need not be emmpletnd Hire permit is for uallumueddollars($100) GREASETRAP
or less.) PLANCHECK FEE $'L L90
Ieimify that in the perfammuccof the work fonwhicladd,permit is issued.10.11 SEWER-SANITARY-STORM EA.200
not employ any Amnon in any manner so as m become subject t0 the markers'Compels- ENERGY FEE 7e"/k$>C to
OZ sauou Lows of Caldron!,Dem WATER HHATER W/VI?NT/EI.ECTR GRADING RiIi
Applicant
NOTICE TO APPLICANT:.If.afoamaking this Cenificme of Exemption.you should WATER SYSTEMFBOATING
a become subject m the Workers Compemaenn provisions of the Lab,Code,you must SOILS FEE
forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT, PAID Dae Receipt p
L) 0 Ihcr.Fy allirm thauhere lsaumstmnion lending ngcncy for the p.dinmunce Of
f•" Ore weak for which this pcwil is issued IScc.3097.Civ.CJ
Lenders Name TOTAL:
V Lenders Address TOTAL:
sus Wry , BUILDING FEE flu
1' 1 crnify that I have mail upPlicvnnn and etam Ibm the'Entre infnnwtion is
h correct.l agree m comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT [ZEE
LJ IZa building mmmmlim,Znd hembyamharim represeconwexofthis city menteruponthe SEISMIC FEE ASO
above-nenrioned property for ii,,pection purposes PERMIT ISSUANCE
(We)zgrce to use.indemnify ad keep hoandessthe City of Cupertino against CLF.CI'RIC PEE 143,41%
Iiabilitio,judgments.costs andexpenses which may inanywayacerveagoinst said City ALTER OR ADD TO MECH.
m.cimmee of the gmming of this permit. PLUMBING FEE 14141
APPLICANT UNDERSTANDS AND WILL COMPLY WITH WITH A AIR HANDLING UNIT(TOR 10.JCFM)
SOURC :CUNDERS MECHANICAL F[E 4 O\
AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCDON TAX
Sigmt eof Applicam'2U Or
- Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEF.
HAlAR OUS MATERIALS DISCLOSU E
Willthevpplicamorl lure building occupant store or handle haeardors material HEATING UNIT ITO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the lfealth and Safety
Code.Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
E]yes El NO PAID
VENTILATION FAN(SINGLE RESIDI Dat. Receipt#
Will the applicant or furore building by the Bum.Ail Qu or devices which
emit hazvduus air contaminants as dcfinW by the Bay Arta Am Quality Management BOILER-COMP(3HP OR 100.000 ITT U)
TOTAL:
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
I have man the har.urdous mdenZA,receiremant,under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Ileullh 6 Safety Code,Seen ons 25505,25533..,1255$4.1 wdentunJ that d ue, NEW RESIDENTIAL.MECIL SQ.FT.
buildingdms not currently have a tenant,that it is my responsibility m notify the rceupant
of the requirements which must be met prim to issuance of a Certificate of Occupancy.
Owner or autharieed agent [)ate TOTAL: ISSUIiI)BY:
OFFICE
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