S 3275r
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITT.OF COPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
rBUILDING PROJECT IDENTIFICATION
PE' ITNO.
3275
BU LDINO AD RI
o 12, s,,
SANITARY NO.
APPLICATION SUBMMAI. DATE
l�-ii_4
ERS NAME PHONE:
✓ 72g-07
CONTRACTOR'S NAME: - LIC NO:
NEC
❑
CONTROLN
I / 2,
CHITS /ENCINLER: LIC NO:
ADDRESS:
ONTACT. PHONE:
BUILDING PERMIT INFO
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❑ CAD6DR3D[ FC¢H Paid by APPIi¢3Dt (IN[I21)
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LICENSED CONTRACTOR'S DECLARATION -
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section]000)of Division 3m he Business and Profession. Cade. and my license is
full force and effect.
License Class Lip. it
Dam Camraaer
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL [:1 KITCHEN REMODEL
❑ADDITION El PLUMBING RE -PIPE
❑MUL1iiNFT Fl UCTURAf.
MO,Ik3,f`j',
Zj�O CHyv,1. EYR P
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHI'TECT'S DECLARATION
1 understand my plans shall be used as public records
PANELS
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Licensed Potassium]
OWNER -BUILDER DECLARATION
1 hereby off rut that 1 am exempt from the Contract License Low for the
following reason. (Section 9031.5, Businessand Professions Coda: Any city or county
reywreso permit to cons olcer,improvo, demolish, nr repair any structure
prior to ib issuance, aim requi for such permit In fileasigned statement
that he ie licensed pursuam tat mvivo r eCan actors License Low(Chapter9
(commencing with Seclinn] of Division. tM1 Pndesslous Code) nr
that he is exempt therefrom Is for ml . A violation of
Section ]113 LS by any apple Ifor rmits Is the Plicvn a tip t of
no tut rc than live hundred Ilurs (85nq.
w ser of the prop yrrm alp ithw s m nsun
201-1000AMPS
ENT ❑SW INC 5
JBATD EPAIR 0 DEMOLII'10
OVER IOOOAMP5
SIGNS ELECTRICAL -
SPECIAL CIRCUIT'/MISC.
TEMP. METER OR POLE ST.
H
❑TENANT ❑ FOOD SERVICE
❑OTH RVEMENT
POWER DEVICES _
IMMING POOL ELEC.TR
G
m
"
coil Bothe work vnJlhesOuca de nR l3 0 Business
and Prol@sninre Cade: The Cunlactn . Licen rraonnt op to or s
propeny who builds nr improves thereon, and cosh war h
his own employeese buildr ed r a such improvements am not int f nfferc Ir
svle.lf. howeveg the building or imprnvemem is sold within oney of pletio he
OU'fL ITCHB TXTURES
'W :SIDE IAL ELEC. SQ
SQ. FT. FLOOR AREA
$ISQ. PT.
ner4mider will Once, the hideout pmving that he did not build or improve ft ur
14 AL
pose of sale.).
I, as owner of the propeny, ass exclusively contracting with licensed wmmmua to
Q
QTY. PLUMBING PER FEE
nnama the project (Sec. 7044, Business and Professions Cash:) The Cnnuudora Li -
use Law does maripply to an owner of propeny who bonds or improves thereon, and
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who commets for such pmjecta w da. crearwha s) Iicansed pumuum m the, Gmvucmrs
PERMIT ISSUANCE
License Law.
❑ 1 am exempt under Sec. _ . B & P C for this r axon
Ownert
ALTER-DRAIN&VENT -WATS h A
RACK PLOW PROTECT. )EVICP.
RKF.R'S OMPENSATION DGCLARA'ION
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I hereby of to underp nvllyof pcjury a far the following mulumtions:
I hvvemal will maintain a Cenifcide of Consent mself-insure for Worker's Campers-
TO IES IF TYPE CONSTRUCTION
DRAINS -FLOOR, ROD .... COND,
as pnrvided Im by Section 3900 of the Labor Code, for the pert ndarowo of the
Is f or which this permit is issued.
FIXTURES - PER TRAP
1 have and will maintain Worker's Compensation Insurance, as required by Section
of the LlhurCotlq far the performanceof the work for which this permit is issued.
GAS -EA. SYSTEM -1 INC. 4 OUTLETS
OCC. GROU APN
y Workers Comparr adu r Insurance carrier and Policy number arc:
uee Policy Na:
GAS - EA. SYSTEM -OVER 4 (EA)
GREASUINDOS'IRL WASTE IN' I'RCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS
- COMPENSATION INSURANCE
UILDINODIVISLONFRES
(Thixsudon need sol M1e completed if the permit is forme haaJmA dollars($100)
or less)
GREASET'RAP
_
PLANCI{' E r
SEWER -SANITARY -STORM EA. 200 PT.
-
ENE 'B. Z_0
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I certify that in the Performance of the work for which this permit is issued, Ishali
not employ any person inanypreare past lubjeeno the Workeru G�mpen-
sateen LawsofC o is {'
Applies
NOTIC AP 1C! C lir a cr wk g II hnifcate o mption, you should
become subjeetto the 'orkers Compensate provisions of the Labor Code, ynumust
WATIiR HEATER WNENT/ELECTR
WATER SYSTEAUT BEATING
GRAD .E
SO P E
WATER SERVICE
fonhevithcomplywith sucbprovisiom ort N.. shall be damned revoked.
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CONSTRUCTION LENDING AGENCY
I thatis conduction lending agency for the performance of
the work for which this pearrit is issued (Sec, 09]. Civ. CJ
Lenders NameTOTAt
PAID
Receipt It
NEW RESIDENTIAL PCMB. SQ. FT
TOTAL:
Lender's Address
is
BUILDING PEE
clause infoetlon
1 certify that 1 have read This applicaon tianti state that the abmt
correct. 1 age m recomply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
shove -mentioned property for inspection purposes.
(We) agmato save, Indemnify and keep harmless the City of Cupertino against
QTY. MECHANICAL PERMIT FEE
SEISMIC FhELj
PERMIT ISSUANCE.
6
ALTF.RORADDTOMECH.
E
IMICHICAL
liabilities,judgments, costs and expenses which may in any way uccrueagainsl said City
inconsequence of the gaming of this permit.
APPLICA 'UNDERSTANDS A' WILL MPLY WITH ALL NON -POINT
SOURC CATIONS
AIR HANDLING UNIT (TO 10,00OCIIND
FEE
AIR HANDLING UNIT (OVER IO,OOB CFM)
CONSTR CTION TAX
4f
Signal re of can Couaacter Data
LXIIAUST HOOD(W/DUCE)
HOUSING MITIGATION FEE
HAZARDOUS ATERIALS DISCLOSURE
Will a applicant or future iilding�upanlsmreorliandlehazardousmaierial
HEA'T'ING UNIT (TO 1100,0010 BTU)
as defined the Cupertino Man dial Code. Chapter V12, and the Health and Safety
Cod c, Seaton 25532(a)IHEATING
Yes WK,
ON] f (OVER 1011,001 BI U)
PAID Date RcceiplN
VENTILATION PAN (SINGLE RESID)
Will the applicant or future building occupant use equipment OL&VI S which
air hazardous air contaminants us defined by the Bay Area Air Quality Management
BOILER -COMP (3HP OR IOO,lg11 BTU)
BOILER -
O
Istficl4/
❑Yes E;/
BOILER- COVE (OVER 100,000 B U)
AIR CONDITIONER
ISSUANCE DATE �]
.- 7
I haveread the huzanlous materAl requirements um r Chapter has of the Cali-
fomia Health & Safety Gude, Semimis 25505, 2553. m 534. 1 understand that Othe
NEW RESIDENI'IAI: MECH. SQ. FR
buildmildoesn c vemly ha tenant m lis wOulhy 1. many the necaphal
of erequi n cm p' afa CertiBaem ofnp u
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TOTAL:
cr r Carr a gem i late
ISSUED BY: O
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