28489 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 8 89
BUILDING PROJECT IDENTIFICATION V V V
UILDINGgADDRESSQQ: /� / SANITARY NO. APPLICATION SUBMITTAL DATE
2.�� VVCo��1n U(
t R' NAME: PHONE: - CqNTRACTORS NA E: LICNO: V
I ^
NIC CONTROL p
4RCHITECf/ENGINEER: LIC NO: ADDRESS: A ❑
Z �
CONTACT,. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
a�f ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby arfirm that 1 am licensed under prosdsions.f chapter 9(commehdng JOB DESCRIPTION
Cz ith Section]000)olDivisinn 3.f the Businessnnd Profesxi.ns Cade,.ndor license is RECIDENTIAI-
F�C 'nfullfor it affect. y PERMIT ISSUANCE �SFDWL D KITCHEN REMODEL
c License Class Contractor
APPLIANCES-RESIDENTIAL ❑ADDHWN [I PLUMBING RE-PIPE
t;Z<1a�0. Date ContDECL
I„ay ARCHITECTS DECLARATION. PANELS - ❑MULTI-UNIT ❑STRUCTURAL
!/1 {undentn J h ha116e used un�p(�blit rccuNs MODIFICATION
OZ a �1etlf.A p.�iw -,�C�]s/� UP'1'0200 AMPS '0 INTERIOR ❑CHIMNEY REPAIR'
L¢cnser Professronel 201-10(10AMPS - IMPROVEMENT
CCC OWNER-BUILDER DECLARATION OVER 1000"I's ❑BATH REWDEUREPAIR C3 DEMOLITION
yyx 6 I hereby affirm that 1 am este p,from the Contortive s License Iaw far the
W L U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER �tA
al O�j which requires a permit to construct,alter,improve,demolish,or repair any structure
.Ql prior to its issuance,also requires the applicant for such permit o File a signed statement SPECIAL CIRCUIT/MISC.
yNm he is licensed pursuant to the provisions or the Commcmrs License Law(Chapter 9
(commencing with Section7000)of Dwist.Oof the Businessand Pmfessions Code)m 'TEMP.METER OR POLE INS'T. COMMERCIAL,
d c shot he is exempt therefrom and me basis forme alleged exemption.Any violation of ❑NEW BLDG/ADDITION []DEMOLITION
Senion]OI LS by any upplicemforepermit subjecw the upplicammacivil penalty of POWER DEVICES CTENANT ❑FOOD SERVICE
5. amore than Eve hundred dollars($500f. - - IMPROVEMENT
�pQ ❑I,azowner ofthe properly.or my cmpl.yceswith wagesazMeir s.lecompcnsati.n, SWIMMING POOL ELECTRIC
E C wdldo the work.and me structure is not intended oroffered forsake(Sec.]W ,Business ❑OTHER
W3 and Profesrions Calc:The Con.ucans License Lew does not apply t.an owner of OUTLETS-SWITCHES-FIXTURES
a' proputy who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR
sale.IL however,the building.,improvement is sold withirtow,cinaf complenco,the SQ.FT.FLOOR AREA M.FT
ner-builder will have ma burden of proving that he did not build or improve for pur-
pow of sale.). _ to
TOTAL:
❑1,as owner of the property,am exclusively contracting with licensed contractorsors to Y" p
construct me project(Sec.]044.Business end Professions Cade:)The Continuous Li-
ceruse Law does not apply to an owner of property who builds or improvm themon,and QTY PLUMBING PERMIT FEE
who comment for projects with a contactors)licensed pursuant to the Contractors �•/1
License I. PERMIT ISSUANCE. /s n
f um exempt under Scc. .B&P C for this reason C 9g
tuner - Data
ALTER-GRAIN&VENT-WAT (EA) 2le(;,,1`UAII1
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEV E f r/7
1 hereby affirm under penalty of perjury one of the following dedaations:
❑iheve and will truinuin aCenificrte ofConwnuo self-insure for Workers Compeer- DRAINS-FLOOR.ROOF.AS ,COND. STORIES TYPE CONSTRUCTION
.firm,as provided for by Section 37M of the labor Code,for me perfam..c of the
work for which this perndt is issued. FI%TURES-PER TRAP /
❑I have and will maintain Worker's Compensation Insurance,m require]by Secsion
37M of the Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.$YSTEM-I INC.40UTL S OCC.GROUP APN
C.Workerp Gyne talon i9svmnce eurtier and Policy num�er.4re:
Carrier:514ts/cn{�t{, Policy No.: 12A 1L4�^9S GAS-EA.SYSTEM-OVER EA)
CERTIFlC O OF EXEMPTION FROM WORKERS' GREASFANDUSTRL WASTE INTERCEI'1'O
COMPENSATION INSURANCE BUILDING DI SIGN
(Thissection orad notlxcompletW iflhepemJtuf.ranehundred dollars(Slgll GREASE TRAP
or It..) P NCHECK FEE
ail I certify that in the performance of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 W.
not employ any person in any ner su as to become subject m the Workers'Compen- ERGY FEE
man
Z
cation Laws of California.Date WATER HEATER WNENT/ELECfR
7�7 Applicant GRADING FEE
Gy NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING
abecome subject to the Worker's Compensation provisions of the Labor Cade,you most SOILS FEE
W foMwith comply with such provisimsor this .is shall be donned!revoker, WATER SERVICE
0
D,Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Dae Receipt p
V Q l hereby affithi th Permit
i is sued x.30 lending agency fonhe pert.rtnance of
[~ the work for,which this permit is issued Sex.709],Civ.C)
u" Lender's Name TOTAL'
O V Lender's Address TOTAL: , -
W BUILDING FEE
I certify that 1 have reed this application untl state that the nerve information is
rA coned.l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
V Z building construction,and hereby authorize representatives of this city to ether upon me SEISMICFEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agren
e to save,indemnify and keep Innersole.,the City of Catania.again. ELECTRIC FEE
liabilitiesjudgments,exits and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
inconsequence.fine grating of this permit. PLUMBING FEE
APPULCANT(UNDERSTANI,ES AND WILL COMPLY WITH ALI,NO -P01 pIR HANDLING UNIT(TO 10,000 CFM)
'RF. ULA IONS.
SOUR MECHANICAL 'F.
AIR HANDLING Loci r(OVER 10.000 CFM) CONSTRUCTTO TAX
Sign ore of ApPlicaMComordaor - ¢ EXHAUST HOLD(W/DUCD HOUSING MITI ON FEE
HAZARDOUS MATERIALS DISCLGROWS-
Will me applicant or future building oecuprnutore orhandle hazadous material HEATING UNIT TIO IN,"BTU)
defined as by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety aw
Code,Section 25532m)? HEATING UNIT(OVER 100.000 BTU)
[]Yes No VENTILATION FAN(SINGLE RESID) PAID -
t Date Receipt#
Will the applicants future building occupant use equipments devices which
'it hackman.ser contaminants as defined by the Bay Area'Air Quality Management BOILER-COMP UHP OR 100,000 BTU) TMA
),sires, BOILER-COME(OVER IW.000 BTU)
0Yes El No
I have wad the hauadons materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fumia Health&Sarny Cade,Sections 2"05,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Fr.
building does not currently have amount,that it is my nesport Miliry to notify the occupant
of me req.iremenls which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE