B 0116 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO W'J'CATION
UILDING.ELECTRICAL PERMIT
BUILDING DIVISION APPLICATION/PF.RMITPLUMBING-pIRCNANICAI• Ct�GGA 01LDING PROJECT IDENTIFICATION J�BUILDING ADDRESS: SANITARY NO. APPLICA'190N SUPMITTAI.DATE
1 f� 01 OWNF1@' NAME' ' Py(Iro: �_- COMAME: LI[[JO: NIC r CON1'ROLpsIT V /I vV �A, `f/K1JARCHITECT/ENGINI?Ek: LIC NO: ADDR ❑41 CONTACT: - PHONE: BUILDING PF MITINFO
���� 3pg_n ❑ Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
'1 ❑ ❑LICENSED CON'I'RACfOR'S DECLARATION QTY. ELECTRIC PERMIT FEE1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencinglOB DESCRIPTION
OoZ ith Section 9000)of Division 3 of the Busineas and Professions Cale and my license isn R IF�DFNTIAL:1,100 u' LLq^1 SUANCE09W nPollBrrccandcRecr. . IJI ❑SFDWL ❑KITCHEN RIiMODF.L
ULicense ClayslN Lick ES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
ZW Dare 1 ICU Conructor
Qa ❑hfULTI-UNIT ❑STRUCTURAL
Dtn ARCHIT[C'T'S DECLARA N PANELS
F - MODIFICATION
zOy,Z� IundersmnJ my planssMll be used ats public rooms UPT02WAMP5
OZ—O ❑INTERIOR El CHIMNEY REPAIR
;:�nLW Licensed Ymfirmienal 201-10WAMPS - - - IMPROVEMENT EjSWIMMING POOLS
gw$, affirmOWNER-BUILDER DECLARATION OVER IIMXIAMPS
W following El BATH REMODEUT[TAIR [I DEMOLITION
O U 1 hereby arm that I am exempt from the Contractor's License Law far the El^ r}�r
qx W ng mason (Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL pppppTTTTTHq
x1'3 W N which requires a permit m construct,alter,improve,demolish,or repair any structure
��0 prior as its issuance,also requires the applicant Joe such permit to file o signed statement SPECIAL CIRCUIT/MISC. �r
y� that he is licensed pursuant to the pros isionsof the Committees License Law(Chapter 9 COMMERCIAL P
CQD (commencingwith Section 9fM1U)ef Divisinn3of the Busine,lead Professions Coda)., TEMII METER OR POLE INFI
6 a p mat he is exempt therefrom and the basis for the alleged exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit iubjects the applarat to a civil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
�=0 not more than five handmaidens.($500). IMPROVEMENT
❑i,us owner of the property,mr my cmpleyecs with wages as their wlc compensation, SWIMMING POOL ELECTRIC .
.f. will do the work,ond the seure is not intended or offered far sale 7044,Business ❑OTHER
w
W and Professions Code:The Commmors License law does not apply to an owner of OIITLBTS—SWITCHES—FIXTl1RFS
propeny who builds or improves thereon,and who does such work himulf of through
his own employees,pnrvideJ that such improvements ort not intended m offered for NEW RESIDENTIAL ELECTR SQ IT.
sale.If,however.the building or improvement is sold within one ywum completion.the SQ.FT.Fl.WtIAREA SISQ.FT.
owner-builder will have the burden of proving that he did not build a impure for pur-
,se of sam.), TOTA '
1,v owner of the lropetty,am exclusively contracting with licensed contmetnrs to
odswn me project(Sec.7044 Business and Professions Co he)The Connector's Li-
coarm Law does not apply to an owner of property who builda or improves therson.and QTY. PLUMBING PERMIT FEE _
who cancans for such projects with a centracurt(s)licensed pur meat in the Contrxcem's
License Low. PERMIT ISSUANCE
Ej I am exempt under Sec. ,B&PCforthismason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
`� ..I hereby reffird uWe,penalty of perjury mnedfthe following declarations:
Ell have and will maintain a Certificate of Consent o self-inure for Workers Comped- DRAINS—FLOOR.ROOF,AREA,COND. STORIES TYPECONSTRUC-DON
cation,as provided for by Section 3II0 of the Labor Code,for the performance of Ne
work for which this peemit is issued. FIXTURES—PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37Mof the Labor Code.far the perf...of the work for which his patron is issued. GAS—EA.SYSTEM-I INC.40UTLETS OCC.GROUT' APN
My Workersx in aaionI more career and Policy main at are: , Ica
Cartier Palmy No.: GAS—HA.SYSTEM-OVER 0.I
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFJINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES _
Oris sctimarial not becompleud ifthe pe am[is force,hundred dollars(SIM)
IL
lca. GREASE TRAP
P KI Eloss.)
Loy an,persnthe ina,faemaneeofthe work for which Pettitisiss'ConimI SEWER—SANITARY—S'fORM FiA.2W Fr. �/ Vv �NERGYFEE
not employ any person in any manner sal as m become subjen rd the Workers Cnmpen-
Z cation Laws of Calif.mi..Data WATER HEATER WNFNT/F.LECTR
z0 Applicant 1 GRADI GFF:E
y NOTICE TO APPLICANT:If,after making this Cerni cate of Exemption,you should WATER SYSTENUTREiATING SOILS FEE
F hetmne svhject in the Wmkers Compensation previsions of the labor Cade,You mast
I11 forthwith comply wlthoah provisions.,his peardinall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.PI'. PAID
L)� Iherehy alErm that there isaconstmction lending agenry for the performance of Date it eiptk
44 F the work for cal i,h dais permit is issued(Site 3097,Civ.C.) TOTAL:
OU Lenders Name TOTAL:
Gil lenders Address UIIAING FEE
I certify that 1 have read this application and smote that the advice bef n make.is B
i.. to dame'.?.'exam comply with all city and county ordinances and sure laws minting to QTY, MECHANICAL PERMIT FEE SEISMIC
V Z buildingcooswetion.and hereby authorize representatiersafmiscitymenteruponme
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC EE
(We)agree m save,indemnify and keep hamtless the City of Calamine against
Iiabilmes,judgmenw.costs and expenses which may in any way acme against mid City APER OR ADD TO MECH. PLUMBIN FEE
in Consequence of me granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10,1101 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,010 CFM) CONSTRUCTION TAX
Signaur of Applicant/Corimctnr One EXHAUST HOOD(WMUCO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or future building occupant store or handle baerdous material HEATING UNIT(TO USMI1(I BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER W,Op BTU)
Curia.Section 25532my?
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER—COMP(3HP OR I W,11f10 BTUI
emit hmnNous air contaminants as defined by the Bay Area Air Quality Management TOTAL
District? BOILER—COMP(OVER IMTM PTU)
❑Yes ❑No
I have real me harrumous materials mquidements under Chapter 6.95 of me Cali- AIR CONDITIONER ISSUANCE DATE
Tome Health&Safety Cods,Sections 25505,M533 and 8534.I undersand that if the NEW RESIDENTIAL MECH. SQ.ET. / // _
building mKs not currently have a our that it is my rtspansibility to notify the occupant
of me requimmons whichour he met pdsa m is.car.oft Centric.of Occupancy. Ass �y
Owner or autlerized agent Dau TOTAL: ISSUED BY, „�„
OFFICE