S 1549APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO BUILDING - ELIECI'RICAL
NU 14r C, DIVISION APPLICATION/PBRMIT DING PROJECT IDHANICAI.
BUILDING I'RfURCI'IDFNTIFIGTIUF
1'F. IT NO,
1549
'I BUILDING ADDRESS / ��
10673 W Z—s-lo 4-r D,-,;,,)
SANITARY NO.
APPLICATION SUBMITTAL DATI
- �6
' iR'S NAM': nn //////�yyyyy..r�ar PIIONIi:
1 r"'14�111* /L!/./ J -SG
'-%% 7
CONTRA DR'S NAME: LIC NO'.
N�
NIC
❑
CO 'IPHIL M
\RCHITECT/ENGINEER: LIC'INOOE:
ICON'EACT:
ADDRESS:
PHONE:
BUILDING PERMIT INFO
a/a!/ -p"
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MUCH
1wiC(��j
/ IDRRrs rV +cC�
N DR ❑ ❑
LICENSED CONI'RAC 'I'OR:S DECLARATION
1 hamby affirm mal 1 am licensed under pros5dons of chapter a (emnmculleg
with Section7Ngy.fDivision 3ofthe Business and l'mfcsslnre Codeand in, he,., i.
infellClassACRca.
[)are Class Lim p
Oma C9rllDECL
QTY ELECTRIC PERMIT FEE
O0Z
X00
a❑)f•
U
6 V
v�iQi
F � N
Z O y Z
JOB DESCRIPTION
RESIDENTIAL:
❑$FDWL El KITCHEN REMODEL
❑ADDITION El PLUMBING RE -PIPE
❑MULThUNII' ❑STRUCTURAL.
MODIFICATION
FIRM Ir ISSUANCE r'
AI'I'LIANCf:S-k1iS1UENl'IAL
ARCHI TECTS DECLARATION
I understand my plans skull be used az public rttttNs
PANELS
OZ --M
GNF m.,1
Xy7E
L a
X a U
y
F u•�a
}�
W�00
d a e ¢
xm'h
f=C
p -u
It `m
6'3 ^
UPT0200AMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMINGPOOLS
❑HA'I'R HIiM Dlillkhl'AIH El DE LITIO1v'
rY �. ) .� l %1 J/ fs''i
qI OTHER i�<%i(7i I,e /1
--�a•�,Q��oiJl
Licensed Pefic,amul
OWNER-BU1LUER DECLARATION
1 hereby affirm teat I am esmnpt from the Ciminero— Ijer n, how for he
hdbwing mason. (Section 71031,5, Business and Professions Code: Any city or county
ve, dentou.h. or repair any rrr
whichmyuires:r perrnh u. consu na, neer. nttproamm
Prion, its issuance. also reyuims the applicant for such permit to file a signed statement
I list he is I sen.scd personal o the provisions (if [lie Contractor s License Law (Chapter 9
(commencing with Section flNp)af Diviniun 3 ofthe BEsiri and Proesvons Codc)nr
that he is cxanpt therefrom and the basis for the alleged exemption. Any violation of-::�9
Section70315 by anyappli,ma tie a permit erhj,,,, the npplicanl In a civil penalty of
t northern Eve hundred dollars (SSW).
;4 Lav ownend the property, or try employees with wages as their sme compihear.
ill Jo the well, and the%muclum is not imcnded or opened forsule(Set. 9014. Broinms
and Profexsionx Cwlc: the Commctors License taw lines nm apply et an owner of
pmpeny who builds or it.pnrves thee....., End wen dares such work himvcE or through
201-IINNIAMPS
OVER I(XNIAMPS
SIGNS ELECfRICAI.
SPICI AL CI RCU n]M ISC.
'1'1?MP. METER OR POLE INSI'.
/—
COMMERCIAL;
ElNEW BLDG/ADLI ZION ❑ DEMOIJTION
El TENANT ❑ FOOD SERVICE
IMPROVEMENT
OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUtLETS- SWITCI{ES-IIXTURES
his own cmNoyces. provided that num improvements are not intended or offered for
NEW R17SIDENIIAL EITC` R SQ FC
,ale. IL however the buildingor improvement i,. wild within ane yeafofcumpletinn, the
FT. FLOOR AREA
SISQ. Fr
e,huJder will have the burden of proving thin he her our hard or improve fnr par
ryes of sale.).
❑ I. us owner of the putpeny, our exclusivdy contracting with licensed contractors In
consume, the project (See 70,G. B.,iii and Professions CE.lc:) The Comm"ot_s LL
TOTAL O
serve Law docs not apply to an owner of property wen builds or improves thereon, and
QTY.. PLUMBING PERMIT FEE
who.onuens far such prnjeYIs wrh a conlracwoP) licensed pursuanuo the Conuuetah
PERMIT ISSUANCE
License law.
L
Ise . u tendo Sec. .B&PC hr this reawn
ALTER-DRAIN&VENT-WA' ' (1: _ II
NQ
Owner _ 6
VALUATION
WORKIiR'S CO PENSAI'ION DEiCLARATION
BACK FLOW PRODUCT DEVI j
-
1 hereby off tin under penally of perjury nuc ortba folbtwing dedmatinac.
I have and wi 11 maintain a Cenitieam of Corwin mself-in curator Worker's C9mpen-
as provided for by Section 391X1 of tire Labor Gdper
Core for ma fre orof Its
c
DRAWS- FLOOR. ROOF, AREA, COND.
5'rORll?S
TYPE CONS'rRUCTIOS
FIXTURES - PER TRAP
work fnr which this permit is issued.
❑ I have .,,it will naintain Worker's Gtm,us. ion hnuraw, , as mt,m rd by Section
-00ofthc laMn GWc, for prrfennummaof he work fill wMrh,hi, l+vintir is imucd,
Worker's Cnrnpnvtlon eInsurance canter and Policy number art:
GAS - EA. SY'S']IiM-I INC 4 OUTLETS
OCC. GROUT'
AMMy
Canine Poliey N.:
I GAS -HA. SYS'T'EM -OVER 4 TEA)
CERTIFICATE OF EXEMPr EON FROM WORKERS'
C)
z O
COMPIiNSAI'ION INSURANCE
('Itis section need not u completed lithe pcmm'n is for one hundred dollors(EIIX)
or revs.)
I terifymat in the Parfurmmtecof the � /w�o'r}k'��for,`,b�ymWit'bis pero.if is issued, Is bell
nntemploy an5'pens n any sy -o /S'O to the Workers Compen-
salon haws t f P Ij/11 1, aUa c heli a 1/r'� '/G
Applicant `/K(/ s�/�
GRFASUINDUS'I'RL WASTE INTERCEPTOR
BUI(.D ;DIVISION
FEES _
GREASE TRAP
PLANCHECK FEE
SEWER -SANITARY -STORM F.A. o_fNl Fr.
ENERGY li
WATER HEATER WNENVELECfH
GRADE ,F i
NOI ICE tU APPLICAN I: IL after rearkirgirfit, Certificate of Fi wr,Jnn, you should
Emi,orm, hice, a, the W ..ken's Contpemminn ptovisiom ofthe LaMtr, Code. you oma
forthwith comply wltb ruch provisions or this permit shell he deemed revoker.
WATER SYSTENVIREA'E'IN'G
N
W
SOIL.b T'
WATER SERVICE
NEW RESIDENTIAL I'hMB. SQ. FI'.
aQ
7 z
V O
CONSen iso cION LEND] tionle G AGENCY
IMrehy affirm that isaronamction lending agency Tones performance of
PAID
Dae Emery,9
t•+
he work for which his pcunil is ic,ard (See 309]. Civ. C.)
Leni Name
TOTAL:
O FU'
M
N a
Lender's Add....
1 certify mut 1 have mad hie i,ilieation and Iam robe the above irdennaeon iv
TOTAL.
BUILT 1.'G FEE
QTY. MECHANICAL PERMIT FjP '
y
V Z
correct. l agree to comply with all city and county ordinances and state laws elatin,to
buildingconstructiuonnA herchyau imiec reuv,rumIivasofthi,aEym im—,emtbe
abcn'c-mentioned property for inspemion purrynes.
1 We) agree to.save, indemnify p Carol M gain,
6 y unit kec hxrmlcas the Cn 1'Cu nines again,,
Iiabilices,judgments, cnsm unit asperses which may ill say voy... me again I.said City
In c9 nsayuence of the graining ohhis permit.
,Ii1SMICl'E
PERMIT ISSUANCE
LLECBLG ill f
ALTER OR ADD In MLCH.
Mein
ING F'L
AIR HANDLING UNIT(TO 10,000CFM)
APPLICANT' UNDLRSTANDS AND WILE. COMPLY WI HE ALL NON -POINT
SOURCE REGULATIONS.
MECHANICAL FEL'
AIR HANDLING UNIT 10,0X) CEM) v
CONSTRUCT ION TAX
Signature of ApPlicam/Commcutr Dale
I IAZ RDOUS MATERIALS DISCLOS URF.
EXHAUST HOOD IW/DUCT)
HOUSING MITIGATION FEF;
I IISA'L'ING UNIT ('In I W,0) B'I'U)
Will me applicant or future building occupant stere or hand lc horardnus rnacrial
;is defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Serino 25532Ia1P
❑Ycx �No
HL'AI'ING UNIT (OVER HiMME BTU)
V ENTILAI'ION FAN (SINGLERI51U)
Will the applicant or future huili ing occupant use cyuiporent in devices which
it heard... air conmminan, as defined by the Bary Arca Air Quality Management
PAID
[)am Reccipt p
BOILER -COMP QHP OR 10t BTU)
"ricy'f
❑Ycx KII No
'rOT
BOILER- COMP (OVER I(NI,(N)RTIII
AIR CONDITIONER
I Lave read the hazardous nmmdalsm to cuter Chapter 6,95 at Elie Cul i-
15533 n
I'nmia Heart & Saleun CNa a miou 25505. 2553] and 25534.1 undemanA dim if the
caret notify lbutseupant
huihlingc us enc randy Ntrcelenarrt•nmminvuanrc
ISSUANCE DATF.
(/
N'IiW RESIDENT IN, MILI1. SQ. Fr.
pfa C.nylo
nftM i mmrs inch m�/e��� ��y Celtic r q�cu :umy.
�r�
Ow coli uulM1oniW agrut
TOTAL