00020026 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLYvV 0
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CITY VE COPERTINO BUILDING-ELECTRICAPER�/IT NO,
BUILDING DIVISION APPIACATION/PERMIT PING FROG CTIDENNICAI, le//
(WILDING PR(IJECt'IUENTIFICA'fil1N
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
ZZU , Ca-rokne.
OW AME -7 3TN� s �O' CONTRACTOR'S NAME LIC NO.
O NEC CONTNOLN
FA HI'IF: 1'/EN i I _L{C NO' TM
SO _ O \ ❑ 7
CON'TAC'c rHONE: _1 BUILDING I'eRM IT INFO
1t._1 �Og'I��!-�0��� ❑ Consullanl Fces Paid by Applicant(Initial) BLDG I:LIiC9' PLUMB MECH
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LICENSED CONTRACTOR'S DECIARAf10NQTY , .ELECTRICPERMIT FEES
I hereby affirm mat I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
�OO PERMIT ISSUANCE a2. with Section 7000)of Division 3 ofthe Businessand Professions Code.andmy licensees RESIDENTIAL:
W
F 41� in Tulle C, and<R t. O ❑SFDWL ❑KITCHCN REMODEL
� Lmcnx -s Lie. 7/h
F Z APPLIANCES-RESIDENTIAL ❑ADDITION C3 PLUMBING RE-PIPE
zw W Ua¢ Cnntmmm
hQG ARCHITECTS D[CLANATION CIrJS ❑MULTI-UNIT CI STRUCTURAL
Z 01=Z I understand my plans shall be osW es public rtwsds I'ANEIS MODIFICATION
OZ=n UPT0200AMPS El INTERIOR El CHIMNEY REPAIR
Licensed Professional - 201-1000AMPS IMPROVEMENT E)SWIMMING POOLS
CCC_• �; OWNER-BUILDER DECLARATION OVER HXX)AMI'S ❑BATH RI?�ODIi1JR1iI'AIR DEMOLITION
C Q 1 hereby affirm that 1 am exempt from the Com rumor's Lacree Law for the
L V following,canon.(Section]031.5,Business and 1'r ieWona CMe:Any city or coumy SIGNS[LCCT'NICAIFIN A ❑OTHER
Iy a LL y which mquims a permit to construct,alter,improve,demm
olish.or repair any ar crc
O pr. I,,it, ot v.iio)re, .th,.,plican It,, I I 11o ate admed shch,ment SPECIALCIRCUIT/MISC. a"
that lie is licensedpursuant tthe previsions orrl Contractor K Ltecose L (Chapter9 a
W0 (w cn th6 IFS ci ]000) fD' T fIh B : JI Ir,:' nsCMc)or TFIORMINERORPOLEIAPR 3 COMMERCIAL;
a p, C that he a exc mat mcn,frnm and me basis for the alleged exempti n Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4X1 w Section70315byaayapplicantforapennitsunjens meapplicannoaava perulty of EIOWIiR DEVICES El TENANT ❑FOOD SERVICE
^
t more than five hundred doll.,($500).} � IMPROVEMENT
=Q ❑has owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELE
W p.,O will do the work,and the structure is not intended or offered fo...le(Sec.7044,Business ❑OTHCR
W 3 m and Professions CMe:The Contractors License Law docs not apply to sr owner of OUTLETS-SWITCHES-FIXTURES
prapeny who humid,or improves thereon,and who does such work himself..rough
his own employees,provided that such improvements me not intended or offered for NEW RESIDENTIAL ELECIR SQ Ff.
sale.If,however,the building or improvement is sold within one year of completion.the SQ.Fr.FLUOR AREA $/SQ.Ff.
tovia,lnildc,will have the burden of proo in,th t he did nal build th improve far aur-
,so I' ),
1 f the property,am exclos ely contracting with licensed contractors to TOTAL:
.momel l Ih project(Sec 7044.Baa ne,s mid Podco,i Podis Cada;)ThC tmcl f.Li-
censc
Lawdoes,not applyman ownerefp ply n build. p mere nd QTY. PLUMBING IT FEE C.--
whnwnbnmsl'or such projects with neenademr(s)Itwnsed pursmmna the Contractor's
Li.rov Law, PERMIT ISSUANCE '700
❑ I umeomptundef Sec. ,B&PCfimmisreasun ee
Owner Date AL'fliR-DRAIN&V -WATER(EA) VALUAHON
WORKER'S COMPENSATION DECLARATION BACK PIA CT.DEVICE /�� OA'A'1
1 herchy affirm under penalty of pc Jury one of the following declarations:
�Q I have and will maimaina Certificate of Consent tool(-insure for Worker's Comped- DRAINS-1 R. REA,COED. STORIES TYP UCf10N
sdtion,use provided for by Section 37M of the Labor Cure.for the performance of the
wod far which this pcB m'tisissued, FIXTURES-PER
JVY 44011
❑1 have and will tadimain Workers Compensation Insurance,as required by Section
3100 of the Linor Cade,for the performance of the work for whichthispemut is issued. GAS-PA.SYS' N . O OCC.GROUT' APN 0�
Cam r��J+�l un Insurance ca¢rriecrlla ll'tk'y Nrr,Y 9y(�(•c��y I ( O AS-EA.SYSTEM-O E h� Ti--'
CERTIPIC OE ENSA I IP ,ION FRANCE KERS' t0 GRBASE/INDUSTRL WASTE IN EROYYrt) '{
COMPENSATION INSUNANCI? B1111.IlING DIVISION FEF",S
-(fhissatinn nein not bewmpleted if the pcnnB is for one hundred Jolla"($100) OR BASH TRAP
or less.) PLANCHF.CK LEG �-
Iready matinthe performance ufthework for which this permit isissued.[shall SEWER-SANITARY-STORM EA.caj ET.
n.employ any pecten in any manner m as to Femme suhjen to the Workers'Comped- ENERGY PEE
Q Z uhen Laws of Cul bmia.Date WATER HEATER W/VENT/ELECTR GRADING FEE
Z O Apphcam
y NOTICE TO APPLICANT:If,after nuking this Cenificme of Exemption,you should WATER SYSTEMGREATING
a ; become subject m the Workers Campensatiod avvkin.of the Labor Code,you mux SOILS FF.E
forthwith comply with such provisions m this pcmtit shall he deemed revoked. WATER SERVICE
LYz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID��
Z - - Date kcceipt p Sfu
U O (hereby affum mm there is a concoction lending agency forthe performance of the work for which this permit is issued(Sec.3097,Civ.CJ
U. F-' Lender's Name TOTAL
U Leaders Address '1'tyl'AL,
s?t W BUILDING ETI?
I cmify that I have read this apNmminn and state that Ota above mfonnaiom is _
.�'i h correct.I agree In comply withal]city and county ordinances and stale laws miming In QTY MECHANICAL PERMIT FEE
V Z building construction,and hereby authorize representatives ofthls city In enter aped the SEISMIC FEE
shove-mentioned pmpehy for inspection purposes. PERMITISSUANCE.
Odl0 agree nr save,indemnify add keep harmless the City of Coachman against ELECTRIC FEF.
liahilitics,judgmcros,cants and expenses which they in any accrue againx said City ALTER OR ADD TO MECH.
in"""_Nuance OO�NSF��(
oiPLUMBING FF.F,
APPLICANT ,Nf HALL ON-POINT Alµ1{ANDLING UNIT(TO 10.(10(ICFM)
MECHANICAL PEI?
SOUR 1W .
AIR HANDLING UNIT(OVER IQ000 CPM) CONSTRUCTION TAX
ate EXHAUST HOOD OKMUC) HOUSING MITIGATION FEE
HAZA ding ads SCLOSUNE
Will the applicanmrfumre building l¢cupam smrc or handlehazardous material HIiA'ONG UNIT(TO IW.001)RTU)
us do ed by the Cupertino Municipal Code.Chapter 9,12,amd the Health add Safety
CMe,.action 25532(a)1 HRATING UNIT(OVER 100,010 BTU)
(]Vcs KCNo PAID
r" VIIN'1'lLA'fION PAN(SINGLERBSID) pros Iteccipttt
Will me upplicam or future hullding oecupunl usa equipment ter devices which
mit httanlaus air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP CHPOR 100,000 BT U)
'1'O'1'AI:
Dis¢icYp BOILER-COMP(OVER 100,000 BTU)
oYe, m
I have read me hazardous materials m tr mnu under Chapter 6.95, ale- CONDITIONER ISSUANCE DATE.
fomia Health&Safer e,Sections 25545 255" 25534.I understand at if AL MECH. S0.FI'.
ildingm tl have. a y "lily. ' the m
'.best p to eofaC fOc ry.
wher r dami'm age. TOTALFE: ISSUEDBY:
OFFICE