S 2039 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING.ELECTRICAI. PE IT NO.
BW 'DING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL 2039
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPPLLIICAU NSUBMITTTAAL DATE
/0 -flyp o L
NGR:S NAME: HONE: i CONTRACTOR'S NAME: LIC NO:
A4Lt/1)OrvN'Y rii-A a 5-33 NIC CONTR 3Lp
ARCHITECT/ENGINEER; LIC NO: ADDRESS:
CONTACT: - PHONE: BUILDING PERMIT INFO'
$ON /A-/_I_A� 10W SV I 2���3 3 El Consultant Fees Paid by Applicant(Initial) BLDG ELEG'T PLUMB ME❑CH
/LICENSED CONTRACTOR'S DECLARA'T'ION 0 QTY ELECTRIC PERMIT FEE �/
1 hereby it inn that I am Incensed under provisions of Chapter 9(cnmmcnciug JOB DESCRIPTION
DC'Z with Section 7000)or Division 3 ofthe Business and Pavlovian,Cede,and my license is RESIDENTIAL:
Fw� in full forceandeffed. PERMIT ISSUANCE
�UF` License Class Lic.0 ❑SIT WL ❑KITCHEN REMODEL
Nae Datc Contn,v, APPLIANCES-RESIDENTIAL L]ADDITION ❑PLUMBING REPIPE
ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAL
E"m I understand m PANELS
o Z,4 my aM1,ll he used os public records MODIFICATION
UP TO 2110 AMPS
F,'�.1"'Q�1 hmensed Pmfesponnl [I INTERIOR
El CHIMNEY REPAIR
s'Is`�.J4I OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT SWIMMING POOLS
a, 6 I hereby mfilm Thar I am exempt from the Cialoc n',License Low for the OVER I WOAMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
X d U following reason.(Section 90315,Business and Professions Code:Any city orenemy ❑OWER
W 3 F- which rc SIGNS ELECTRICAI.
01 more,a permh ar con,wet,aper.hnprove,demolish,t or roped,am awment D U
HN prionn usinuancB,also requires W.appliwnl for such permit to flea signed statement SPECIAL CIRCUIT/M1SC. % i
ecGg flatbe islicensedpursuunnotbeprovismacofthe Centruemrsl.ieense Law(Chapter9
CGpO (commencing with Suction 7000)of Dlvhinn 3ofihe Boston„and Profeesiom 1(1,),, TP.MP.METER OR POLE INST. COMMERCIAL
6i y m y that he is exempt Omrcfrom and the basis for the alleged exemption.Any violation of El NEW BLDGIADDITION [:1 DEMOLITION
iLLCI k• Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑_TENANT ❑FOODSERVICE
5m re than Five hundred dollop(8500).
<rCt as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
Fm will du the work,and the strardmi nal intended m WErrel for sale(Site W
c.] 4,Bmimcc; DOTTER
w ^ and Professions Code:The Contra"-"'License Lo,ones act apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own entployce.v,provided that such improvements are not intendedor offered for NEW RESIDENTIAL ELECTR SO Cr
sale.If,however,the building or improvement is veld within one year ofmmplehoo,the SQ.FT.FLOOR AREA $/SQ.PT.
reancobarlder will have the burden of proving that he did not build or improve for
put-
p
seJ.
7 1,asessential propertyexclusively coni nwith licensedni-
Construct the protein(Sec7044,Business and Professions Codc:)The Cmplaiots
Li-
verso Law does not apply man owneroflroper,who builds.,improve,mcons,and QTY PLUMBING PERMIT FEE /
who contracts for such pmjeds with a comocums)licenced putsuunuo the Contractors /
License law. PERMIT ISSUANCE
❑ 1 1m nxempl under ec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) A pT}pN
nor • pale LfL
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE D
I herehy affirm under penally of perjury oneofthe following declarations: o
❑ i have and will maintain u Certificate of Consent in self-insure mrWodrere Compen- DRAINS-FLOOR,RODE AREA,GOND. STORIES TYPE CONSTRUCTION
salion,as provided for by Section 37W of the Leber Code.for the performance of the
work for which this permit is issued, FIXTURES-PER TRAP
❑1 have and will maintain Worker',Compensation Insurance,as required by Section
3700 of the Labor Code,for the verfermanm of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP ARK
My Worker',Compensation Insurance carrier and Policy number am:
Cork,: Poli,No.: GAS-RA.SYSTEMOVER 4 CA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
(This section need not bernmpleted iftnepermit ix for ane hundrod dollar.,(8100) BUILDING DIVISION FEES
or less.) GREASE TRAP'
PLANCHF.CK PEE
1 comfy that in the performance of the work for which this permit is issued,1 shall
not employan SF,WER-SANITARY-STORM F:A.2W IT.
any in manner su usmbumme.cubjen to the Workcrv'Cnmpen- ENERGY PEG
O Z ,pion Laws of California.Date WATER HEATER WNENT/ELECTR
Z 0 Applicant GRADING FHB
r., y NOTICE TO APPLICANT.Workers
rs after Compensation
this Cionprovisions
of Exempting you should WATER SVSTEMlfRF:AI'INC
a
become subject m the Workers Cmmpeor this pmvisihal of the deemed
Code you pup SOILS FEE
fin forthwith comply with such provision,or this permit Shull be deemed revoked WATER SERVICE
aQ '
U 'z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID ��'.
GO that i isawawcti30[coding ugeasy for the perfermeneeor m Receipts
lbs de work for which this pumlil i,issued(Sec 309],Cie.CJ
U Lender,Name TOTAL
D.l Lender's Address TOTAL:
Fd 1 conlry that l have read this applicalinn Imo slate that the above information is BUILDING FE '
.. m coreetl agree to comply win all city and county ordinances and state laws renting m QTY. MECHANICAL PERMIT FEE
U '7Z building Bonmmcann.and herebyauthorize reprewmatwe, tflaird,to emernpon the SEISMIC FEE
abmctnendoned open,rnr inspemion yurpo,cv.
(Wel agree to save,Indemnity and keep harmless the Guy of Cupertino agoinsl PERMIT ISSUANCE' ELECTRIC 'G
Iiubililies,judgmenp costsand expenses which may in any wayaccmcoichartvoid City ALTER OR ADD TO MGCH.
con,equenw of the granting of this permit. PLUMBING FE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
S,,mameof Applicant/Cmhddahr Date EXHAUST HOOD OVMUCT) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE
Will theupplicant or future building oceupam minvor handle hartrdoosmamrial HEATING UNIT(TO IW,OW BTU)
us defined by the Cupertino Municipal Corp.Chapter 9.12,and the Health and Sera,
Code,Section 2.5532001 LIGATING UNIT(OVER 10f1,0W BTU)
El steel ❑No PAID
VENTILATION PAN(SINGLE RP.SIU) Dole Recessa
WIII the air contaminants
or future a buildi d by the B use equipment or devices when BOILER-COMP(3HP OR 100,000 BTU)
Buil led I nus air conmminante as defined by the Bay Area Air Quality Management OTA .
DicOicT!
E]Y. E]No BOILER-COME-(OVER 100,00)BTU) � I
I have mad the hoordous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
2533p ISSUANCE DA E
Ratio Health A,Safety Aden Section,25505,is toy and 25534,I to unity th that if the NEW RF.SIUENTIAL M[CH. SQ.FT `
buildingsorenetcurrency have meant,than it ismytespf.Cilitymis of o o e,.
once req.iremrma wmnn most 1w ma pdonn i„aanBe ofa ceniamte nr GRapaney.
Owner.,authorized agent Date TOTAL: ISSUED BY: or �-
OFFICE
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BLCG.INSP�TiOePNHnwcn
�I CITY OF COPEATINO
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