99110071 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY �_1 J��
.._.. .. . .._. ..-..,. I ..-
I CITY OF C[)PE R•rINO RUi1:D1NG-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERAIIT PLUMPING.MECHANICAL IDEM
I•:^ ' ',/.,EIUILDING PROJF.CI'.IDEM'EFICAT[ON; IU
BUILDING ADD LESS.+ SANE TARY NO APPLIQ�ION SUBMITTAL DATE
21�`- � I ELI z�r ��CE• �v►�r`�'np q s of
N' R'S NAME&s I PHONE C NTHACTn �S NAME LIC NO N/C CONTROL
��)e C,i�.CLY1 2 Z-�g$-� one�l �4�►r �f ❑
' ARCIIITECFNGINIEIER. � IC NO DD HSS
^;: ('ids-P, 4�Iman five �Cam�ll
CONTACT: 'BUILDINGTHRMI.1'INFO,'
❑ Consultant Fees Paid by Applicant(Initial) r BLDG ELECT PLUMB MUCH
❑ ❑ ❑ d
LICENSED CONTRACTOR DECLARATION QTY iy ',?f,ELECTRIC PERMIT:'•!I,,: . !(I+FBE 'f)L
I haehy affirm mat 1 am hccnad node,pro—a..of chapter 9 b,anmenamg ',if .'I. :I� l ' JOB DESCRIPTION
Z with Secti on 7000)of1).vuum 3ofthe Bmmess and Pafcevom Code,and my lirenwrs
�Op PERMIT ISSUANCE RESIDENTIAL'
j1FFa,_ is fall force turd eRcct 1 n Lie# f Z •-,� ❑SFDWL ❑KITCHEN REMODEL
vyZW Date Contrac �I•h A1J`pIr APPLIANCES-RE5IDENTIAI. I El ADDITION ❑PLUh101NG RE-PIPE
ARCHITECTS DECLARATION El MULTI-UNIT L1 STRUCTURAL
F m PANELS Z O y 3 ` n I nnJ.�frmd my�Jnn.sPnbLr Icenrds MODIFICATION
OZ—O- d/ f) It l„ UPTn:W AA1P5 ❑INTERIOR El CHIMNEY REPAIR
h+�F'j Lt se tai csstonal 201-Im10AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IINFIAMiI'S 1:1 BATH RF:M1iD EIIREPAIk ❑DIihIDLI'TIDN
Q 1 hereby affimr that 1 am exempt front We Comment is License Law for the ..�
�0 a.0 following reason on 7031 5,Business and Professions C+de An t t ❑OTHER ralzi7C/Ch.noG'hwvl t�Ue.-H
3kF-' whub re e uncmnruu.ulmi, Any count SIGNS ELECTRICAL
y quire,a penal + imp..we,danolnh,fir repau any shnnem
prior to Issuance.also re9uime the applicant for such perms to file a signed statement SPECIAL Cl RCUIT/M ISC
��. that he is licensed pursuant o the provisions of the Contractor's License law(Chapter 9
X00 Icmmttenemg wnh Section 90000 of Dl vmmn 9 of rha Busm...and Prolesaom Code)or I FOR SIFTER OR Po INS, COMMERCIAL:
a a e C that he rs exempt therefrom and the bass for he alleged nemptiar Any violation al ❑NEW BLDG/ADDITION ❑DEMOLITION
uk.,m Section 70315 by any applicant fart perms subjects the applicant to a civil Penalty of POWER DEVICES , /`
not nurse man eve hundred Dollar.(RS(xn ,�.✓ []TENANT El FOOD SHRVICF.
=C ❑ neaowantivehundred ours S50(f nyem wnh xegecu mar sale cnmpensaunn, SWIMMING POOL ELECTRIC / IMPROVEMENT
will if,) work.and the structure is not intended or offered for sale 70414[business []OTHER
W 3 and Professions Code The Contractor's License Law dies not apply to an owner of OUTLETS-SWITCHES
�/
property who builds or improves thereon,and who dins such wink himself or through T1
his own employees,provided that such Improvements are not intenJCJ or offered for NEW RESIDENTIAL ELECfR SQ<J
sale 1f,boweveq the huJd.ng nnmpmwmem is sold uilhnn fine year of n+mplcho11 the ` SO ET FLOORAREA 5/SQ.IT
owner-builder xdi have the burden of pm.mg,hat he did iii.build or Impave arm, !�
pnse of sale.),
❑Las owner of the property,am exclusively contracting with licensed contractors m TOTAL,
construct the project(Sec 7(W,Bestows and Professions Code')The Contmi Lt- ,. r r'.1., ,. . ) + 1.
nsc Law discs not apply tonnawnarnfpropaty who hmldsarunpfnvos meeon,a I, l'QTY. :f.t, PLUMBING PERM1II - I!�il, r{�,i FEff', ,
whornntrams.or such pro)emv with aeontramngs)licensed pursuanttothe Contractors ' '
License Law. I PERMIT ISSUANCE
❑ I:in exnnp.und ..o
.,,,fee Se, .13&P C for tho,cn
ALTER-DRAIN&VIENT-WATER(EA) I VALUATION
WORKER'S COMI'fPenneI on DI:Cefollo following BACK FLOW PRUI'HCT DEVICE �I✓1 /
IherMy atlimi under penalty of penury one of the follinvmg dedamuons
❑I have and x ill maintain a Certificate of Cononuo self-insure for Worker's COmpeml DRAINS-FLUOR.ROOF,AREA.COND Yftyfe(Ff TYPE CONSTRUCTION
salon,as pmvWed for by Section Oup or the Labor Cale,Inv the partnmiance of the
wink for wheh MS mm,w lssucd MIXTURES-PER TRAP
d�I Mme and x JI mamma.Worker's Compensation 1nw,ao e,ac reported by'Section
7,xlnl me LUMnCxle,lorfhr pedmman cmotthe work for whmhrhnpvm(nnwed. IGAS-IEA S`t STEM-I INC 40UTLTS OCC.GROUP JAyM^��
My Worker.Compepcanon Inwonce tamer and Policy���!b�faa� i/
Canter ST. YAUL Pnhcy No: 614"300527 IGAS-F-A SYSTEM-OVER 4(EA)
CUM IFICA'1 IE OF E%LMPI'UN FROM WORKERS'
COMPENSATION INSURANCE GREASI%INDUSTRL WASTE INTERCEPTOR
(This,.coon.tied not N,,m.plcteddthe perm..n ronme hundreldellam OHpt BUILDING DIVISION FEES
or Ica) GktiASli[RAP PLANCHECK FEE I
],entry thor the peifnnnarcrofthe work finwhaht his peimnn ,wed,Khalil $EN[iR-SANITARY-STOHM1I EA 2(00 FT
cor employ,u.y pervnn In any manncno as m Mcome sub)ec.n+the Widen'Camper- ENERGY FEE
Z saran Laws of California Dare WATER HEATER W/VENT/IELECTR
Anthem • GRAVING FEE
NO[ICE rO APPLICANT.IL after making his Ceri icate of Exemption,
r~N-t g p Ion,You should WATER SYS'1'lIM/rR1EATING
a , become subject m the Worker's Condensation this provisions of.he Lahr Coke,you man SOILS PF.E
(11 ti
forthwith comply xnh such provisions unhn perms shall be Deemed rtvoAed WgiT:R SERVICE
Q
Z) z
CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL 1'LA1B SQ,FT. PAID
U I hereby affirm that there n a construction lending agency for the performance of Date R¢eiptp
Da f'" the work for which Inn pennil n.awed(Sec.3047,Cs C I
0 U Lender's Nam° TOTAL
Lenders Addr,• TOTAL:
E certify that I have mud III...tpplem i and state that the ahnue mfinmatan Is r t, t.n t BUILDING PER -
F' N coned l agree m comply wnh all city and county entrances and sure too rcmung to TY.I'•• MECHANICAL-PERMIT(' I i t''•FEIr'
U z barking ttntam.eon,and heeby author.representatives olm.scuy no enter upon the Q f t _ t 1. SEISMIC FEE
above-mentioned property lot mspecuan purposes PERMIT ISSUANCE
(We)agree m v, ,indemnify and keep hwlnlea the City of Cuperhnn agar... BLEC'TRIC FEE
Indal es.pulgmenn,castsunJ c,cews which maymmyway.,woi Om,t,aid C,ty AL'EIER ORADD TO MECH
in eonsepueace of the granting of this permit PLUMBING PEE.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT A IR HANDLING UNIT(TO IB.WO CFM)
SOUHC fEGULAT10N5 . MECHANICAL FEE
wi /I- ,-99 AIR HANDLING ON[I'(OVER 10,0m)CFAD CONSTRUCTION TAX
SmnAuureul Apph.wn/Contrncmr-G�— Ddre EXHAUST HOOD(W/DUC) HOUSING MI FIGATION FEE
HAZARDOUS MAI HRIALS DISCLOSURE
Will the applicant(it future building occupant%lore or handle hazardom material HEATING LINE F(TY,100.000 RTU)
as deem d by the Cupertino Alumcipal CnJe,Chaplin 9 12,and the Health and Safety - t
Code,Section 25532all BEAT ING UNI'I'(OVER Pol lxi BTU) �
❑Ycs ❑No PAID
VENTILATION FAN(SINGLE RESIDE Date Ric#
Will the air contaminants m future building by the B use equipment sir Mane which t
ems hazmdous air cunmm,nnnts as defined by the Bey Area At Qmhry Management BDILIiR-COMP(JI3POR Ifp,(N)n BTU) 14'.1`,3
TO"1'AI: I 41
Dnnst❑Yes El No BOILEER-COMP(OVIER 100.1K I
AIR CONDITII
I have read the hwerrom melcnals equ,emcnn under Chapter n 95 of the Cali- - ISSUANCE DATE
bandit Health ek Safety Cade,Sectmm 25505.25533 and 25534.1 undonWnd that dune NEW RESIDENTIAL MECH. SQ,FT
huddle.dke> tromontly have a event.math ks my rcspmsibtlily to nnufy the ktacupam
of me reyutiyt firs whah nwsl M reel p/or o nsvance of a Cmmfime of Occupancy
as
Owners lnuhnnznfEgenf Du,e L TOTAL ISSDED B"
OFFICE