S 1938 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PF: ITNO q
BUu,DING DIVISION APPLICATION/PF,RMIT vl.unlxlNr.-nlEcxnmcAl. 1
ItU11.DINL'PROJECT IDENTIFICATION
BUILDING ADDRESS; SANITARY NO. APPLICATION SUBMITTAL DATE
ioa3� c2Esaro+4 -DcvP�l�'T) N0 -3a - 2r
OWNER NAME: PHONE: CONT CINAM':'OR'SLIC NO. ,
NIC CONTROLp
NCII TEC f/P GINGER: N LI NO�/1 ADDRESS: ❑ '''(((���y 3
CON'TAC'L PHONE: G BUILDING PERMIT INTO
/��i
El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECCH
El
/'�Q ?6fLICENSED CONTRACIORS DECLARAPON (� QTY. EI.ECI'RIC PERMT'IFET: 1y�y
I hereby affirm the'1 am Iicensod under provisions of Chapter 9(Mmntenaing JOB DESCRIPTION
FIZZwith Section71"Aof Division 3 ofthc Husinms and ProfessiannCod<,and my license is PERMIT ISSUANCE
RR IDENTIAL:
+4 1 O p
ty.- in full force,and en act. DSFDWL D KITCHEN REMODEL
�UV License Class Lic.N APPLIANCIES—RESIDENTIAL. [s}RUDITION D PLUMBING REPIPF.
FZW Done Contractor
ARCHITECTS DECLARATION IDMULTI-UNIT ❑STRUCTURAL
F 5 y PANELS MODIFICATION
O Z�Z I understand my plans shall be used as public records
UP TO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
F=k WW Licensed Professional 401-1000AMPS IMPROVEMENT El SWIMMING POOLS
S a47d OWNER-BUILDER DECLARATION UVER 10pa AMPS D BATH REMODEUREPAIR 0DP.MOLTI[ON
LL C a 6 I hereby affimt the,I am uempt from the Contractor's License Law for the
x0( y U following reason.(Section 71131.5.Business and Professions Code:Any city or wumySIGNS ELECTRICAL DOfHER
fx7 3 C y< which requires a Permit to Maintain.alter,improve,demolish,or repair any structure
u .
pri t ' ' nc 1 9 .th appl tf hPem,i fl 'g rm
Isenrnd SPECIAL CIRCUITIMISC.
�Qf
the,he'.licensed p .. th Po ftM1 C r t I 1 (Chapmr9 COMMERCIAL,
C��pO (commenting with Section]00()of Division 3ol'the BusinesslandPr fc,si.Code)or TEMP.METER OR POLE INST.
q y m q that he is ewmpr therefrom and the haais for the alleged exemption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
LLXi li
Section 7031,5 by any applicantfor a pennit.suhjecrsthea,plicumm a civil penalty of POWER DEVICIS [I TENANT ❑FOOD SERVICE
of more than five hundred dollars SS(X1.
1- 6 1,as owner of the en,orm laces with season their lok,cum tion. SWIMMING FOUL ELECTRIC
IMPROVEMENT
£ property. Yer'W Y 6 ,cost ❑OTHER
settdoth¢work,andlhenmmomure isnnl,Liecom Ls.als no,osaic(Sea
1.an. wneress'
and I'rolessium Code:'rho Contrucmr's licence,Law does not aPPIY to an owner of UUTLe'rS—SWITCHES—PI%TIIRIES
propeny who builds or imponas thereon,and who does such work himself or through
his own empinyws,provided chat such improvements arc not intended or offered for NEW RESIDENTIAL IELECTR SQ Pr.
sale.If.however,the building or improvement k old within ane,ycarofsmplaina the SQ FCI'LO///QQQRARIEA SISQ.FT.
owner f o budder will have the hunlen of proving that he did not build or improve for par- "`Z
-
pn1.se,ole.).
1,us owner of the Sea 70y,nm exdusi and contracting with:)sensed contractors to
alma rust the project(Sec.]044,Business and Professions Code:)The Convector's U. `//
cause Lowdoes not apply to an owner of propeny who builds or improves thereon.and QTY Pt, MBIN ERMIT FEE 7
wo contracts for such project,with a eommetm(s)licensed potential to the Contractor's Il
License Law. PHRMI'r IS ANC /e
Dlat—mc ,under SM. .B&P C fill this reason
Own hate ALTER—DRAIN NT—WATER(EA) VALUATION
.
WORKER'S COMPENSATION DECLARATION lmang RACK FE IECT. )EVICE � � D
1 lonelytiff rte under Penalty ofperjuryone
,, the I'olbw log Workers Co
❑Iheve onal will praviddlforbineCmixcute of the Labor
Cod i,for the rommecu ofer,the DRAINS—ROOR,RWP,AREA.CON❑, S'rURlfiS TYPIi CONSTRUCTION
worn,at provided for byI,Section.. 3]Iq of the Labor CnJq for the luformance of the
work for which this permit i.a issued. FIXTURES—PER TRAP
❑1 hoveand will maintheerkcrn'x Compeiby Section
3]IX of talc Code.for the perfrnlararof[tic workfor which this Permit
is issued, GAS—EA.SYSTIEM-I INC.40Ir1'LETS OCC.GROUP APN
My Worker's Compenstown Insurance currier trod Policy randier are:
Carrier: Policy No.: GAS—HA,SYSTEM.OVER 4 NA)
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASIMNDUSTRL WASTE INT'ERCE17OR
COMPENSATION INSURANCE BUILDING DIVISION FOES
r less) 1'LANCHECK REU
)(I'hi ,ronin eared not be completed ifthe permit is fromm hudlred dollaa(S IW) GREASETRAP r
I can ify that in the perfomtonce afthe work for whichda,permit is isoed.l shall SEWER—SANITARY—STORM EA.2010 T. �J
t mnpiny any parson in any ma : r me dlje�u the Worker'Campeau- ENERGY FIEF L.
7 Iicont s c ifnmig,I ' _/ WATER HEATER WNENTIELECOt GRADING
G y OTICIi TO Ill ICANN1 f,after making Ih�Cenificme of exemption,you should WATER SYS'I F.M/fRIEATING SOILS FE
(~ become subjecua the W me,Compensation provisions althe Labor Cute,you muss
Rr�, forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
J Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PENCILSQ.1T. PAID
(
U 'Z' Ihcreby affirm that then is a Connotation lending agency lorthe performance of v( Uatc Recciptp
the work for which this permit is issued(Sec.3097,Civ.C.) r^ O'rA L.
U Lender's Name,
nders Address TOTAL:
bo
y I certify that I have read this application and sum-tits'the-have information is BUILD G FIEL ¢
rF. rn correct,l agree m comply with.11 city end coonry ordinances and tuna taws relatinsm QTY. MECHANICAL PERMIT FF.E SKIS IC FEE J D
C.) building construction,and hereby unbridle representatives of this city no enter upon the
above-mentlonedPoland,fill inspection Purposes PERMIT ISSUANCE E.L. 'RIC FLEE 3 O
(We)agrm m save,mommunhy and keep hamdcas the City of Ca,mro against
Ii-bllillavjudgmem,emus and expenses which may in any way Microcopies,said City AhrFR OR ADD It)MECH. PLUMB GPEE
in consequensm of the groaning of this permit.
APPLICANT UNOERS'LANDS AND WI LL COMPLY WITH ALL NON-POINT' AIR HANDLING LIN IT 0010""CFM) EC LF[iE
SOURCE.REGULATIONS,
JUL AIR HANDLING UNIT(OVER I0,100 CPM) CONSTRUCTION TAX
Signature of Applicant/Cotnmcmr Date EXHAUST HOOD(W/DUCT) GIIT Vl 40)9IINGMI1IGATION PEE
HAZARDOUS MATERIAL S DISCLOSURE
Will the applicant or future building«eaPant store or handle hazmdous material HEATING UNIT(TO I f10,D'ld B'IT)
as car tel by the Cupertino Municipal Cak,Chapter 9.12.and the Health end Safety
Crede,Section 25532(a)? HEATING UNIT(OVER 100,0(10 BTU)
❑Yes No VENTILATION PAN(SINGLE RISID) PAID -
M
Will the nppliesm or future building ocenpaol use equipmmt or devices which BOILER—COMP(314POR 100,000 BTU) Dare In
emit hazardous air contaminants as defined by the Buy Area Air Quality Management T L
DiarictY BOILER—COMP(OVER I(IOWHTV)
❑Vcs C]No
I have mad the hazardous mmedals requirenmms under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE/
fnmiu Health&Safety Code,Sections 25505.25533 uad 25534.1 understand that if the NEW RESIDENTIAL MECIL SQ.EL
Molding does not currently have atenank Lleyn is my respmsibillty in unity the occupant ( O
oftherequlrements which m nbe met prior o lssuunce nfe Certificmu of Oeeepanq. O� n _
Owncrorunr
uorizedagent Dote TOTAL: ISSUED BY: `„ � `"1
OFFICE