S 2325 —APPLICANT TOFILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF COPERTINO INILI)ING-ELECTRICAL PERMIT NO.
CAL
BUILDING DIVISION APPLICATION/PERMIT PINGPRNJECCIDIANIFICA
GAL
BUILDING PR(1JF:CUMBERS '1'IDN:NTIF'ICATIIIN
BUILDING ADDRESS: - SANITARY NO. API'LICAI'ION SUHMI'I'TAI.IIAI'I
7tJ o
O 'SNAM PI1O E: CO ACT'OR'SryAME: LIC NO.
` / l'-e J N/C CONI ROL4
•;ARCHITECT'/ENGINEER: (J ' LIC NO'. A DR : l/ ❑
CONTACT: PHONE: /114
` O BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial)' RLIIG ELECT' PLUMB MEECHH
❑ ❑ ❑ `CJ
LICENSED C(INTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensW under provisions of Chapter 9(commencing JOB DESCRIPTION
O='Z with Sea,inn]Illxp of Division)nrthe B.6moand Professions Calc,and ntylictriwis RFSIDENTIAL-
FO full force and eB PERMIT ISSUANCE ❑SFDWI. ❑KITCHEN REMODEL
�UU License Class LIC.X APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
F z yl Date Contractor
m 6 M ❑MULTI-UNIT ❑STRUCTURAL.
ARCHITECTS DECLARATION MODIFICATION
F❑ti PANELS
z O in 2 I understood my plans shall be used as public records
OZ-p
UP TO 200 AMPS E3 INTERIOR []CHIMNEY REPAIR
F+C4.Ix', J.,,wd Prnlessionul 20I-101xlAMPS IMPROVEMENT 0SWIMMING POOLS
G 2� OWNER-BUILDER DECLARATION
25 9,x�-1 OVER Iqp AMPS 001014ELREPAIR ODEMOLITION
L W 1 oear .(Sect the 11. exempt frim the Comracmrs License Law fur the 06U following reason.(Sectinn]onsim Businessand vs,,de io li Code:Any cityof county SIGNS ITLECTRICALLLO ywhich requires a permit m construct,alcor.improve,Demolish,nr repair nny mrudumprior to its lewamce,thorequire%the ippli,em lbrsnch Kamm dile uslgnedmacrulat SPIiCIAL CIRCUITIMISC.y fed he is licensed pursuant m the provisions of the Contractors License Law(Chapter96� (mtnntuncing with 9cc,ion](BIB nr Dlvision3 of dhc❑usinus and Professions Code)or TAMP.M ETER OR POLE INST.o CDITION ❑DEMOLITION
LL Semion703 LS by ay applicant fur a parron,unceathe applicant m a civil peoetyof POWERDEVICES ❑FOODSERVICE
y ,mote Than five hundred did...($500).I,as ovarr ofThe propenY.or my employees with wages as their sale asmpnsmion, SWI E ICT
willdothework,.oaths stmemru is not imm�dW or nlTercd far sole ISec.]M4,Itusine%.
gsad Professions Coxic The Contractor's License Low does nu,apply to an owner of ETS-S 113- ES
property who builds or intprnvex thereon,and who does such work himself or through
his own employees,provided,had such improvements me not intended or offered for F:NTC'! 14.
,.It.IL howevea the bail or'umprovcment is sold within one year of asmpletion.the SQ.IT.FLOOR AREA $3Q,def.
owner-h oll will have the burden of proving that he did urn huild nr improve fur par
pox of sale.).
I,in owner of the p oacri,ren exclusively contuaftc with IleenseJ comrnctnrs ut TOTAL:
construct the pmjea(Sec.7094.Business and Professions C-0 Centrum.'.
cense Law does not apply to an owner of property%bit builds or improve%thereon,and QTY. PLUMBING PERMIT FEE
who eontmets forsuch projects with a eonoaaor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑ I an exemP,under Sec BAPCtln thkars.on
Owner Deco ALTER-DRAIN&VT:NT-WATER(EA) yf�'1 I.GATED
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTFCf.DEVICE I 1
I hcrchy.(ire under penalty of perjury mo of The following declarations: u
❑ I havemul will mui,a.m.Cemifiansa(Cooxnttosel4insure far Workers Compte- DRAINS-FLOOR,Rl AREA,GOND. STflRll:. TYPE CONSTRUCTIOI
sadion,as provided for by Section 371x1 of the Labor Code,for the performance of the
work for which,his permit is issued. FIX'ITRES-PER TRAP L ! ry
ave and will maintain Workers Compensation Insurance,as required by Section `
371x1 offela,Mu Code,6n the parfor ounce of the work for which this Permit is issued. GAS-I:A.SYSTEM-I INC.4 OUTLETS OCC. APN
Mywmla SCo pcnsation lnot ixrand Pnlicynmrit 4, GAS-EA.$YSTEM OVER4(EA)
Carrier: -�/a� t+GCOr✓ Policy Nm:
CERTIFICATE OF EXEMPTION FROM RKF.RS' GREASI'JINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE s HUILDING DIVISION fEF3
(Thissu,inn noel no,hcatnplctW lftheµnnhisfuronehmamddi(Into GREASETRAP
or IcssJ PLANCI{ECK FEE
I certify that in the pertimnewo of the work for which this permit is issued,IshalI SHWER-SANITARY-S'I'ORM ITA.21x1 IT.
not employ any pamun army manner so es to heeonm subject to the Workers'Compen- ENERGY FEIi
,Z, smiun laws of Cidifi mi..Dem WATER HEATER WNENTMLECTR
Q GRAVING FFEEApplicant
NOTICE T'O APPLICANT:IL after making this Certificate of Exemption,yon should WATER SYSTENUTREATING SOILS FEE A
(~ ; become huhyst to the Worker's Compensation provisions of the lather Core.you muss
{R Q forthwith comply with such provisions or this permit shall he deemed revoked WATER SERVICE
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.IT. PAID
VQ (hereby aftirmthm there is a cansmseion lendird,,arcy for the performance of 1 at Receipt
f-' the work far which this pemtit is issued(Sec.3097,Co,C.)
C) Lender's No= TOTAL
r Lenders Address TOTAL:
y hE
1 certify that I have rend this application and Imre Thad the above information is BUILD(
h
correct.I agree it)comply withill city and county oolilooas and state luws relming to QTY. MECHANICALPERMIT FEE
V Z building convection,and hereby motorize representatives Ofthls city to enter upon the SEISMIC FF.P
above mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cuperin t against ELECTRIC .E
hahilities,judgmends,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECIL PLUMBING
in consequence of the granting of'his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIN'r AIR HANDLING UNIT(T'O 10,000 CFM) MECHANICAL E
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 1400x1 CFM) CONSTRUCT10N'TAX.
Signature of AppIi1Qmx7.mmnof Doc EXHAUST HOOD(W/DUCT) HOUSING MERGAT10N FEE
HAZARDOUS MATERIALS DISCLOSURE
Will dheappllaanf or future btlldingoccoDan store or handle hemati material HEATING UNIT(101011.0X)H 1'U)
F--
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Header and Salary
Cuda.Section 25532(n)9 HEATING UNIT(OVER 100,000 BTU)
O Yes ❑Nu VENTILATION FAN(SINGLE RESIDE PAH)
Doc Rmcipd X
• Will the applicant or fears,lwilding acupent use equipment or devices which BOIL12R-COME LiHP OR 100.0 0 H'I'U)
emit hrea hazardous air contaminants as defined by the Bay AAir Quality Management TO f
DisminP BOILER-COMP(OVER 100.1%x1 BTU)
p Yes ❑No
I have mad me hamrdnus mamdu6 rtquimmems under Clefour 6.95ofthe Cul,- AIR CONDITIONER ISSUANCE DATE n
feria lleahh di Safety Code,Sections 25505,25533 and 25534.1 undcomad tbm if the NEW RESIDENTIAL MECH. SQ.FT.
huildmg dr snomurendy aveate."i that it is my resrymslbi lily to notify ffirocupant
nrme m emswhi tmbe t eenfa Cert(cm r /}A27
Onvacror ,honmd;t 'nam T( 'AL: ISSUED RY: V _ �/ Tv
OFFICE