29665 APPLICANTTO FILL IN INFORMATION'WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPEi RTINOBUILDING.ELECTRICAL � � ••PERMIT NO. '
BUILDING DIVISION APPLICATION/PERMIT- PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION 9 96 v
65
BUILDINGADDRESS: R - SANITARYNO. APPLICATIONSUBMITFALDAH
_ OWNER'S7 PHONE: `(w CON O '. N LIC NO,
CONTROL# -
ARCHITECT/ENGINEER: ADDRESS: ,❑
CONTACT. PRONE: '- BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial)- BLDG 'ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY. ELECTRICPERMIT FEE ❑ - ❑
1 hereby amen that 1 licensed a p ' (c
f Chapter r 9 .mme 'ng JOB DESCRIPTION
�"Z'with Section 7000).fD"ei.0 3oftha Bindric,sund Profeent.n.0 e,.ed mylcen.e it - - RESIDENTIAL,
0 0 PERMIT ISSUANCE ',
CWF to full force and effect "❑SFDWL. ❑KITCHEN REMODEL
QUzU License Class Lia# APPLIANCES-RESIDEN'T'IAL
HQ� Dare Contractor �. ❑ADDITION ❑PLUMBING RE-PIPE
ARClf1'I'ECT'S DECLARATION ❑MHLTIANIT' - ❑STRUCTURAL
PANELS
Z O y z I understand my plans shall he used as public records r MODIFICATION
oz-, t UP TO 200 AMPS El INTERIOR, El CHIMNEY REPAIR
[•.4 ; LicensedPr fc:'.nal 201-I1100AMPS_ IMPROVEMENT ^
iC .4 d OWNER BUILDER m the Control.,',
OVER 1000AMPS' ' ❑BATH REMQZIJwn IRr+❑�Mi LITTON
W w Q I hereby ffirm that 1 em exempt form the C Nrmtor. I cense Law far the wJ �
34FU
following .(Section 9H3L5 Business dP pooch sC d Any any or county SIGNS ELECTRICAL ❑OTHER �M=
W 0 which y permit construct, It 'mph demolish, repair' y stmcture
E�k7y Q, p6m t ' " I q th ...Ireland formah,o it fl g dstntc Hent SPECIAL CIRCUIT/MISC;
p+
that he licensed ptt th p r. f(he Commerce, La (Chapter 9
Q'0 (soar nein,with Sectt 9000)of Davi,mr 3 f the Holmes, oilP f gCode)or TEMP.METER OR POLE I COMMERCIAL, _
that he is exempt therefrom and the breis for the alleged exemption.Any variation of ❑NEW BLDG/ADDITION ❑DEMOLITION
rSanl.n 9031.5 by any applicant for permit subjects the applicant tan civil penalty of POWERDEVICESt• '.
of mom than rive handout dollars($5W). []TENANT ❑FOODSERVICE
� 6 1,as owner of the norm - IMPROVEMENT '
❑ grapey, my sere 044,8 sim.,s SWIMMING POOL ELEC'T'RIC
Qo will dnthework,node: ha Cormorant's
Livens Lawcdforsalc(,], of to mei ref ❑OTHER
a ti and properly
who
C.tic The Conimetor's License Low docs not apply t.lf .cams of OUTLETS-SWITCHES-PIXY'
222 progeny who.,cess or improverthereon,andwho vemnts such tintk himself or through,. for
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR
sale.If,however the building.,impmstnorminaold withinoneyem.fcompletion,they. SQ.FF.FLOOR AREW A ®
p nnu-builder will h rvenhe bung.of,..in,that he did not build or Improve for par-
' : ) .. TIL..
fth p ,eny 1 .' elY t tig 'd 1 . d van no ,TOTAL: ��g n .,
st uhe p ] t(S ]Ui4-D . '.a d P f: 'Co."Th C t e lar.Li
meL d r apply mi n fp p ty h builds p thereon,and QTry, PLUMBING PERMIT FEE C�IyV [r 9g
who contracts for.suchpideel,vvithacmv lues)lcensed pars a tto the tar ,t rs V I �
- License Low. /ww - • PERMIT ISSUANCE � VU�C��ler •
❑Irmexem funder /// ,B&PCforthisreason
C DoteALTER-GRAIN&VENT-WATER(EA) VALUATION
W R ERS COMPF.NSA3'ION DECLARA ION BACK PLOW PROTECT.DEVICE
herI hereby affirm under penalty cfp jury one ofthe fallowing declarations
❑,IM1ave and will maintuinn Cenifica¢ofC.nsennoxelf-insure for Worker's Cnmpen-• DRAINS-FLOOR,ROOF,AREA,COND, STORIES TYPE CONSTRUCTION
action,as provided for by Section 39tH)of the Labor Code,for the,performance of the - ,
ark for which th.,i n rt claimed. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation I rmarmee;us required by Section
3900 of the labor Code,for tltoperfonnance ofthework forwhich tht.permit is issued. OAS-EA.SYST[?M-I',INC.40UTLETS � OCC.GROUP APN
My Workers Compensation Insurance carrier add Policy number are:
') r Curia: - Policy No GAS-EA.SYSTEM-OVER 4(CA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF✓INDUSTRL WASTE INTERCEPTOR V'
COMPENSATION INSURANCE I
.(Tbissectiou need urn he wmplemd if thepemdtls for ono hundredrlollars($100) GREASETRAP
,BUIL`DING DIVISION FEES
or les..) � PLANCHECK FEE
Icertifythm in performance ofthe work far which this permit is issued,lshall SEWGR-SANITARY-STORM f?A.2W FT.
not employ any person in any.tanner so as to become subject to the Workers'Compeo- ENERGY FEE
Z. it..Lawsof Calif...I.,Dem
WATER HEATFR'WIVENT/ELECpR
GRADING FC
NOTICE
TO APPLICANT If,after making this Ccnificam of Exemption,you should WATER SYSTEMITREATING
F become subjed,to the Worker's Compensation pr..id.m of the Labor Code,you rout - SOILS NEC
forthwith comply with such provisions.rbc,pconat,hall be deemedmvaked. WATER SERVICE
Q .
� 7. 1_ CONSTRUCT ION LENDING AGENCY' t NEW RGSIDENTIALPLMB. SQ.Ff. PAID
U p Ihereby affirm that them is a combustion landingagency Lai the performance of " _ Data oeipt
W H; Ne work for which this pumit is issued(Sec.3119],Civ.CJ - - -
Q U Lender's Name
TOTAL
W Lender's Addreae 1 cenlfyihat I have real this application and slate thatthe above information is M'VN4
FEB lky correct.I agree to comply withcH city and county ordinances and state laws rela0ng to' QTY. MECHANICAL PERMIbuilding conswction,and hereby nuthoriee representatives of this city to enter upon the EB aove-mandongd proeny for inspection purposesP2RMiT ISSUANCE(We)agree to save,indemnify and keep harmless the City of Cuponln.against FEE•Iinbllidw,judgarem..00stsand extremes which muy`in ady way accrue against said City ALTER OR ADD TO MECH.in .sequence of the graming of this permit.. ' FEEo „APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(7010,000 CPSOURCE REGULATIONS. AL F'EEAIR HANDLING UNIT fOVM 10,000TIONT
Signature of Applicant/Contm.mo-• - - Dale EXHAUST HOOD(W/DUCT)
HOUSING MITIGA ON FEE
HAZARDOUS MATERIALS DISCLOSURE
'
Will
yteCupemoo fumrcipal ode,Chaptsbre2r handle h eanoand Safety HEATING UNIT(TO 100,000 BTU)
m defined io the Cupertino Municipal Qnlc,Chapter 9.12,and the Health and Safety - -
' Code,Section 25532(.)? HEATING UNIT(OVER I00,000 BTU) '
[]Yes No
VENTILATION PAN(SINGLE R25ID) PAID Data Rueipt
Will the applicant or future building awupom sc equipment or devices which NOILER-COMP(3HPOR IOO,WO BTU)d".'
emit hazardous air contaminants as defined by the Bay Area Air Quallly Management
District? TONE:
F-1 Yes FINo - BOILER-COME(OVER 1111,000 BTU)
Ihave mad th M1 d u. t AIRCONDITIONER
rcq Hent, d Chapter fi95 of Ch ISSUANCE
from.Health&Sab ty C de Sections 255115 25533 d 255341 understand th t It the +'a
.,alma d t u tl h t nam that t NEW RESIDENTIAL MECH. ''SQ.Ft. -
6 Y Y pons'Elty0 notify occupant
of the q irements which most bear tpmrt ssuance ma Cen'feam of Occupancy
Owner or numeric, a,em Date TOTAL ISSUED BYf
OFFICE.