S 0699 APPL1 ANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPRRTINO BUILDING-ELECT RICA], PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT IDENTIFICATION
S 0699
BUILDING PROJECT IDENTIFICATION
BUILD I ,ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATE
erg Lb Q,
WrN 'S A PHONE: C CTMeOR' N�.MG� /LCNO: NIC CONTROL#
ARCC/HHITECI'/ENGINEER: LIC NO: JDI{B$5 J� 44 Sy- L) t ❑
CONTACT: PHONE: GVC (U/ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ 4!5� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby amrm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
"Z with Section of Division 3 ofthe Business and Professions Code.and my license lc RESIDENTIAL:
04OO in full farce and efi PERMIT ISSUANCE
Iy ❑SFDWI. ❑KITCHEN REMODEL
aV[J Lwanm Class Ue. AppL1ANCE;-RESIDENTIAL ❑ADDITION L1 PLUMBING RE-PIPE
H Q� Date Consmcmr -
VARC ITECT'SDECLARATION ❑MULTI-UNIT ❑STRUCUURAL
i,,,D an PANELS MODIFICATION
Zorn ZJ lunderstand my plans shall he used oc public records
02130 UIs TO 200 AMPS ❑INTERIOR ❑CHIMN17Y REPAIR
413,FJ til Licensed Professional 201-1000AMPS - IMPROVEMENT E]SWIMMING POOLS
.•]] OWNER-BUILDER DECLARATION
IY4'� OVER 1000AMPS ❑BATH REM DEIIRF.P DEMOLITION
y 6 1 hereby affirm that 1 oro exempt from the Contractor's License Law for the
x O d U following reason.(Section 7031.5,Business and Professions Code:Any city nr county SIGNS ELECTRICAL ❑OTHER
W a G.F which requires a permit to construct,alter improve,demolish,or repair any structure prior to its issueaer.da..qujres theeppllennt mrsuch permit n,file aslgrednudearm SPECIAL CIRCUITIMISC.
ythat he is licensed pursuant to the provisions ofthe Ctmtmemrs License Law(Chapter 4
(commencing with Section 9fgNBof Division 3 rfm.Bualness and Professions Codi TEMP.METER OR POLE INS'C COMMERCIAL'
g, c that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
Xm
Section 7011.1 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
❑TENANT C1 FOOD SERVICE
FZ6not more than five hundred dollers($500}
IMPROVEMENT
D Les owner df the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
O will do the work,and the structure is not intended farmland for sale(See 7044,Business El OTHER
�.1 a and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended m offered for N17W RESIDENTIAL ELECTR SQ FT.
sale.If,however the building orimprovement,,sold within one year efcompletion.the SQ PF 'O@ARRA SISQ.Ur
ter-builder will have the harden of proving that he did net build or improve for put- V
pose ofeeleJ' , TOTA ' ■Ry}
[-] 1,as owner or the property,am exclusively con meting wise licensed commit rs m LWWW 06 f,a4._
construct the project(Seo.9044,Business and Professions Guide)Me Contractors Li-
cars e Law does not apply to an owner ofpmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE CIT
whocontral for such pro]mts with a comramor(s)licensed pursuant m T.the Contractor's t-
License Law. PERMIT ISSUANCE LVY[H O/y
I1 I NV
I am exempt under Sec. ,B&P C for this reason
. Owner Date ALTER-DRAIN&VENT-WATER(EA) ^ VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE V 7
I hereby offinn under penalty of perjury one of the following doelarnti am,
❑Ihave and will maintains Cedificme of Cnnsenuo self-in.curc for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. 1-S TYPE CONSTRUCTION
sation,as provided for by Section 3900 of the Labor Code,for the performance of the
work for which this permit js issued FIX'T'URES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
37M film Labor Code,for the performonceof the work far whichthis permit as issued. GAS-EA.SYSTEM-1 INC.40UTI.ETS OCC.GROUP AfN
My W0r ,Cpmpensnti Insum_nI�center and Palley n�i
Carver JR'� Uri Cr policyffic CAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORK ftS' GREASPIINUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE, BUILDING DIVISION PEES
(Thissection need not ba completed Hine pcomit is Refund hundred dollars 1$100) GREASETRAP
-
or less) PhANCHECK PBC
I coni fy that in the performance of the work far which this permit is issued;I shall SEWER-SANITARY-STORM EA.200 FT
oat marjoram person any manner sn -rxag b t r Workers'Compen- ENERGY FEE
,z sation Law, CelifN'1 — b WATER HEATER WNENT/F,LECUR
z� Affluent ��f -- GRADING FEE
y NOTIC A NT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
f"t became. est to the Worker's Com tion Ione of the Labor Code, en mull SOILS FEE
1 pens. provision, y
Wforthwith comply with sucM1 provisions or this permit shall be deemed revoked WATER SERVICE
Q
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,EU. PAID
U z Date RecelptN
UQ k for
rwhichitm the there issued Nenetion Tentiis,urgency tar performonceof
h the wore Na which this permit is issued(Sat.stn],Civ.C.)
Dr Fit Leaders Name TOTAL:
V rs Address 'DOTAL:
Lende
fill 1 codify that I have read this application and state that the above information is BUILDING
[meq correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC HE
building conmmeion,and hereby emhonae repmsematives of this city to enter.,,at the
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree m save.indemnify and keep harmless the Cay of Capitol.agelns ELECTRIC PE
Iiabilides,judgmenLs.,mis sad expenses whlchmay in any way aernsuro.instmid City ALTER OR AILD TO MECH. PLUMBING F.F.
in asequence of the grant g of his permit.
APPLICANT UNDE NO WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANI ALFEE
SOURCE '',ULA
AIR HANDLING UNIT(OVER 10,100 CFM) CONSTRIc'TION TAX
S(at .nV onaacmr DateVVVV ! EXHAUST HOOD(WIDUCT) HOUSIN MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will andi.alor future building occupant srore or handle Incantations material HL'ATING UNIT(TO I N0,00)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,anti the Health and Safety
Cede,Section 25532(1)! HEATING UNIT(OVER 100,000 BTU)
Yes No E] VENTILATION FAN(SINGLE REBID) PAID Data Receipt q
Will the applicant or future building occupant use equipment or devices which
emit hazardous air cum ardaants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 1(10,000 BTU) TOP
District? BOILER-COME(OVER 100,000 BTU)
E-1 Yes FIN.
I have read the Incautious materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANC ATE
fomie Health&Safedy Cade,Sections 25505,25533 rad 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building does net currently have.tenons,that It Is my responsibility to reify the edrmpaat
of the requirements which must Ise met porno issuance urn Certificate of Occupancy. _
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE