S 2082 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPLi RTINO BUILDING-ELECTRICAL PE]SIT NO
BUILDING PROJECT IDENTIFICATION
BUILDING DIVISION APPLICATIOWPERMIT PLUMBING-MECHANICAL, v 2082
BUILDINGADDRESS I SANITARY NO. APPLICATION SUBMITTAL DATE
Qu no Cct•R5o1 S-� g
O 'S AMB: 11y�' nI PHON&. NTRA TO 'S NAME: LI
I� 11 4-Irl
/ �0� 1 st CONTROL#
• ARC(II ECT/ENGINEER: I LIC NO: I A DRBIS9: 10 ❑
G , AAeell
CONTACT: PHONE: dU ILDING PERMIT INFO
(YIICheJ8 roe ✓Q ❑ CatifeaftcratF¢eSPaidbyAPP1IC3Of(IOilldl) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby alarm hoof 1 am licensed had er....idem of Chopor9(ee innarr lag JOB DESCRIPTION
HOZ with Section Division 3ofthe Bmineasand Picfeasiens codo,aadmy hcame is RESIDENTIAL'
ix'y infull force en [� FERMI MI'1'ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
QUV Lice Cl'ss Lic# APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE PIPE
N�un
�L Dpla Com r,ou
SCUD DLCLARATION ❑MCLTI-UNIT ❑STRUCTURAL
PANELS
p m Z 1 mamm my pluns,hall be used m Im�rec�_rds MODIFICATION
OZ4", I Q UP TO 2h0 AMPS
eclz¢e¢¢ 7+r ❑IN IiR10R ❑CHIMNEY REPAIR
a�E'ty] Ltcensel Pmfessmml 201-I0)OAMPS IMPROVEMENT C]SWIMMING POOLS
I•..I1
OWNER-BUILDER DECLARATION
W Q 1 homby slLrm dualOW R-min exempt from the OOr'4 Llcemc Lew for the OVER IOW AMPS El BATH REMODEUREPAIR F1 DEMOLITION
WWO 0.U following reason.(Section 70315,Ban,ince and Pndevom,Cale:Any city or chanty SIGNS ELECTRICAL. ❑OTHER
W y which requires o P:,,air to mmlruel,alter,improve,demolish,or repair ony slmcmre Q
�Q prior to its issuance,also requires lie applicant forsuch permit to file a signed.statement SPECIAL CIRCUIT/MISC.
d that he is licensed pursuanunlhe pnrvi,inns"far,Contmcfoh LinVare Lose(Cbopmr9
W�qO (commencing with Section 90m0)of Division 3 ofthe Basinessand Professions Cri,)or 'TEM R ME TER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the allaged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Why Section 70315 by any applicant fare permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
FZYtart more than five hundred dollars($500). IMPROVEMENT
e,' 0 ❑L as owner ofthe proton,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
22 will do Newuk,;md decimation,islmt infendedoroEemd Russia(See.]044,Uusinms ❑OTHER _
W�m vnd Padcssions Calc:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpary who builds e,improves Ilworem,and who docs such week himself m branch
his own employees,provided(hal such improvement,are not intended or offered far NEW RESIDENTIAL P.LECTR SQ IT. _
sole.If.however,the building nrimpmvemem issold within oneyearol contpinlon,the S LFT.FLOOR AREA k '
owear-budder will have the hurdcnofpmvimg that he did not bnildnrimprove for pur- ILli
,,a.f^ale, WAY 0 4 19! 9
1.as owner of the n y contracting with TOTAL:
f
❑ pope y,am and tonin Ih licensed aerates m i
msamn the pmjecl(Sec.]U44,Business and Pmfussian.v CndeJ The Commemrs LI- 11 JI
the Low does not apply to an owner ofpropeny who huih6 or improves thereon,and QTY. PLUMBING PERMIT PEE
who rantmcl,for such projects wilt a conaucmr(s)licensed purauanl In the Conracmis
License I.aw. PERMIT'ISSUANCE O
Ellomexcmmnndcr See .Bre PCmrf1a,Acmr By
owner
Date ALTER-DRAIN&VEND-WA'I'HR(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penally of pe jury one of the following declarations:
❑ (have and will maintains Car iivore of Consent m self-insure for Whrke's Cheapen- DRAINS-FLOOR,SOUP,AREA,COND. STORIES TVP F.CONSTRUCTION
shihn,t,proper
vided Inrhy Section 3]00 of Labor Cade,fur the famtanceof the
KI
which this permit is issued. FIX'I USES-PER TRAP
have and will mainhan Worker's Compensation Insurance,as required by Section
of the Labor
lCode,for the tperfamonce at t the w��Iorrr'kk forwhichthis permit its isssueedd. GAS-EA.SYSTEM-I INC.4 OUTLETS OCG GROUP APN
MyWtae' lal� Gv [�i .5��-�.• GAS-EA.SYSTEM OVER 4 CA)
Coni
CERTIFICATE OF EXEMPTION TRWWORK[RS'
COMPENSATION INSURANCE. GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION PEGS
(This section need not becompleted ifthe permit is Income hundred dollars($100) GREASETRAP nr less) PLANCHECK PEE
I certify halon the pelfortaanceofthe work for which this penin is issued,[,hall SEWER-SANITARY-STORM EA.203 FE.
not employ any person in any mmmner so lie to became misread In the Waders'Compton- ENERGY FEE
O z soften Laws of California.Data WATER HEATER WNENTULECUt
z Applicant GRADING FEE
sr to NOTICE TO APPLICANT:If,after making(his Cenifietne of Exemption,you should WATER SYS')EMIfREAT1NG( SOILS FEE�~I live he It, he Worker's Compensation provisions film Labor Code,you must
forthwith comply With-such provisions or his prep ilshall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LEND INC ng agency
NEW RESIDENTIAL PLMB. SQ.Ff. PAID )me Receipt#
U O I to,by Which
ren this permiat t
in
sued me.30 lending Egency oar the Perfnnnanuo of
W thewofk far sublet,this pclmi[ia issued(Sca.3U9],etas CJ
O Lender's Nemo 'fOT'AL:
Lender's Address ]DIAL:
ly 1 certify that I have read this npplimfion vnd emm(hal the unnve infnrmutien is BU1
Imo.fn correct.lagree to comply with all city vnd county ordinances and state lawsremhng to QTY. MECHANICAL PERMIT FEE
UZ building enmauClion,and hereby auturiza representatives of this city to enter upon the SEI IC E
above-mentioned pai for m,,,t hit p.,,,a,,
(We)agree lnsove,indemnify and keep licamess the City of Caperton against k
PERMIT ISSUANCE O ELE 1 EE
Iiab11'nies,judgment,.costs and activates which may in anyway account against said City ALTER OR ADD TO MECH.
in PLOMBI GLEE
wnICAN ce UNDERSTANDS
ANpermit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNITfI'O IU,WOCPM) MECH CAI,FEE
O
SOURCE REGULATIONS.
AIR HANDLING ON]'1'(OVER 10,003 CFM)
CONS TRU ION TAX
Signature of Applic4nt/Comlmrlor Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE � �O
Will the applicant or future building occupant store or handle hazarinus material HEATING UNIT G 0100.00)BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Stomion 25532(a)'/ HEATING UNH(OVER 100,000 BTU)
E]Yes ❑Nh VF.NT'ILATION FAN(SINGLE RESID) PAID
Dote Becalm is
Will the t,tianan sitfumes building by theausee.AirQuaitment or devices Manawhich BOILER-COMP OHPOR 100,0001BTU) O
mil hazardous air anuaminuno as defined by the Bay Area Air Quality Management OT
District'
❑Yea ❑Nh BOILER-COM Y(OVER 1(q.000 BTU)
I have read the hteraliusmaters,rcyuiremenle ander Chapter 6.95 ofthe Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET.
building does no currently have a tenant,that it is my responsibilitym notify the occupant S- ��
of the reyuiremenis which mmlMmq Alarm issnane o nCeniOc en10c pis
caner or am urized agemsae Tb L ISSUED BY: heD
OFFICE