30035 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ^(
CITY OF COPERTINO BUILDING-ELEC'I'RICAh PERMIT NO. 30035
�O O V
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. 3
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
EN G�2 EE
OW 'R'SN ME: O - C RACfOR'S NAME: 'LIC NO'.
D N/C CONTROL#
IMPRCHITECT/ENGINEER: LIC NO. ADDRESS•. ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
l79 ❑ ❑
LICENSRDCONsed under
ORS rpreviCons of I IONChap QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under previsions of Chapter 9(commencing - JOB DESCRIPTION
OaZ with Stttion]1180)of DivisionJofthe Business and Professions Cale.end my license is
k 00 .n PERMIT ISSUANCE REFDWL IAL:
t fene Class
effect. ❑SFDWL [I KITCHEN REMODEL
�U j License Class � o
Dam Contractor APPLIANCES—RESIDENTIAL ❑ADDITION C]PLUMBING RE-PIPE
ntr
f.Ow ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z Orfs Z I understand my plans shall be used as public rtcaNs CHIMNEY
REPAIR O,n +n UPTO 2(IBAMPS �IiNI'ERIOR ' ❑CHIMNEY REPAIR
[-�Iqal Licensed ProfessionalOWNE201-1000AMPS IMPROVEMENT
S a 2 that I o-BUILDER m the ARATION OVER IBM AMPS ❑HATH REMOVE REPAIR DEMOLITION
y LLLLCC1l 1 hereby affirm that 1 1. exempt from the Comore,Cas License Law native a�
x a i F following reason(Sudan]871.5,Rosiness and Professions CoNe:Any city or county SIGNS ELECTRICAL ❑OTHER
E, I+„� which requires a permit m consuuo,ober,Improve.demolish,ser repair any strncwm
lq'-�+y� prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
2a� that he is licensed pursuama theprovisitnsofthe Commove,License Law(CmEec,9
uuCCll l) (commencing with Section 70M)of Division J ofthe Business and Professions Cole)m TEMP.METER OR POLE INST COMMERCIAL'
INq m m tet he is eaempi menta.and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W..y
Section 7031.5 by mynppliem,far.pem,itsubPeta the npplicanLtoa evil penalty of POWER DEVICES
} (try mom Nan five hundred dollars(8500). ❑TENANT ❑FOOD SCRVICE
f0a IA 1,.... et mepapart,mmy employees win wages as thei...lie compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
Svi do the work,and the structure is not intended oraffend for sale(Sec.]614,Business ❑OTHER
L3§ and Professions Code:The Comranor's License law docs not upply to an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves thereon,and who does such work himself or,through
his own employees,provided Nat such improvemems am not intended or uttered for I NI!W RESIDENT E -CTR SQ FT.
sale.If.however.the building or improvement issnldwithin one yearofecmpletion,the SQ.FT.FLOOR AREA VSQ.F-r
er-builder will have the burden of proving that he did not build or improve for put
Ease,of sale.). X4 m s + n
❑ 1,m owner of the property,on exclusively contracting with licensed emensT rs Is, MAL: 7�
construct the project(Su.704bl,Business and Professions Cade:?The Contractors Li-
censer law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PER MI FEF. A� O
who contracts for emKs)such projects with a cemmlicensed pursuant to the Coronaries n
License law. PERMIT ISSUANCEJ� s tet UAv.l
Iam cx. un Sec. ,All B&PCT this
Owner Data seALTER—DRAIN&VENT—WATER(EA) U�\+ VALUATION
WORKERS COMPENSATI N DECLARATION BACK FLOW PROTECT,DEVICE Q d
I hereby affirm under penalty ofperjury one ofthe following declarmions: - i
❑ I have and will mortamaCerificateofConsent toself-insure for WorksmsCampen. DRAINS—FLOOR,ROOF,AREA,GOND, STORES 11 TYPECONSTRUCDON
senna,as provided for by Section 37W of the Labor Code,for the performance of the
work far which this permit is issued. FIXTURES—PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Cade,for the performance of the work for which this Permit is issued. GAS—G.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy nmoher are:
Cartier. Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPLON FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR
(Thissecti...red net be compinW ifthe Permit is for one hundreddollais(SIM) - BUILDING DIVISION FEES
or less. GREASETRAP
PLANCHECK FEB
Icenify that in the performance ofth ark njIvInIt his permit is issuN.IsMII
not employ any, , m,,.vmnnerca h,n b' coo Ne Workers'Cnm rn- SEWER—SANITARY—STORM BA.288 FT.
p ENIiROY FEE
Z urian laws an;
i 1.. WATER HEATER WNENn?LECIR
O Applicant 0 6�,LF GRADING FEE
'y NOTICE TO
PLIC NP otter nuking his mficam of l:xnnpnon WATER SYST17MNREATING
become subject to the Worker's Compensation provisions of she labor Code,you must SOILS PER
forthwith comply with such provisions or Nis permit shot[be,deemed revoked. WATER SERVICE
CONSTRUCT ION LENDING AGENCY NEW RESIDENTIACPLMB. SQ.FT. PAID
L) Ihereby mfirm that hem is u construction lending agency torte performance. Data Receipt# i
U. F Ne work for whichthis penait is issued(See7091,Cie C.)
Lender's Name TOTAL:
O W Lenders Address r' TOTAL:
G 1 certify that 1 have read this application end stain that the above information is BUILDING FEE
ti fq correct.1 agree in comply with all city and county ondinonav and sate laws nlmingm QTY MECHANICAL PERMIT FEE
building construction,and hereby authorire representatives of this city a enur upon the SEISMIC FEE
ebner-mentioned property for inspection purpouv.
(We)agree a save,indemnify and keep harmless the City of Captain.again. PERMIT ISSUANCE ELECTRIC FEE
liabilitie,pilEmme,costs andexpenus which any in any wayaceroe against said City ALTER OR ADD TO MUCH.
in consequence of the granting of this permit/ PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITOM 18,8118 CFM)
SOURCE REGULATIONS. MECHANICAL FEF.
AIR HANDLING UNIT(OVER 10,888 CPM) CONSTRUCTION TAX
Signature of AppliarmConuactor Date EXHAUST HOOD(WMUCp HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant share or handle h teardous material I IEATING ON[r(TO 100,0 0()BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100.00)BTU)
❑Yes ❑Nn PAID
VENTILATION FAN(SINGLE RESIDE
Will the applicant or future building occupant use equipment or devices which Dam Receipt#
emit haradous air contaminants utas defined by the Bay Area Air Quality Management BOILER—COMP(3HP OR 1W,gq DN)
District? TOTAL:
❑Yes ❑No BOILER—COMP(OVER 1010,000 BTU)
I have read the hawdous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
6,.ia Health&Safety Cade,Sections 25585,25517 and 25534,1 undersand that if the NEW RESIDENTIAL MECH, SQ.FT.
building does n.currently have o mman,that it is my responsibility to nuf,fy the camper ofthe requirements which must be met prior to issuance of u Certificau of 0ecupancy.
Owner or authorised agent Date TOTAL: ISSUED BY:
OFFICE