99080110APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPE RTINO BUILDING - ELECTRICAL I'IiRM
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL
BUILDING PROJEC7P IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. J APPLICATION SU15MIITAL. DATE
OFFICE
C{II Tli GINEIiR: LIC NO. ADDRfSSJ W TIO 6
❑
944G+6
CON'IAC. PHONE: I
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MUCH
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LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am E=enxd miner providons of Chapter 9 (emnntenciag
JOB DESCRIPTION
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RESIDENTIAL:
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PERMIT ISSUANCE
in full force sort stint. /
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❑ $FTJWI, ❑ KITCHEN REMODEL
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Loren l Lica APPLIANCES - RESIDENTIAL
[] ADDITION ❑PLUMBING RE -PIPE
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ARCHI'IF,C'1'S DECLARATION
❑MULTI -UNIT []STRUCTURAL
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PANELS
I understand my plans shall heated as public natures
MODIFICATION
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GP'T02g1AMPS
❑INTERIOR El REPAIR
CquiveJ Profc,,onal 201.1(HIBAMPS
( vlFTod
IMPROVEMENT C]SWIMMING POOIS
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OWNER -BUILDER DECLARATION OVER I"AMPS
❑ BATH REMQDEURFP R ❑ ' OLI N
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1 hereby affirm that I am exempt from the Contractor's License Law for the
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Ballow ing reason. (Section ]031.5. Business and Professions Code: Any city or county SIGNS ELECTRICAL
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which requires a permit 10 CnOSVYCt. alter, improve, demolish, or repair any structure
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prior Oa its issuance, vko requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
(nal he is licensed wrsuanrlu the prosinions of the Commoriai s License Law (Chapter9
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(commencing with Section 7()()()),,f Division 3ol'the Business unit Profession, G.IcAu TEMP. METER OR POLE I NST.
COMMERCIAL:
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her he is exempt therefrom and the basis for the alleged exemption. Any violation Of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
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Section 9031.5 by any applicant for a permit subjeel"m applicant na a civil peraltvof POWER DEVICES
❑TENANT ❑ FOOD SERVICE
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n more than file hundred dollars ($500),
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IMPROVEMENT
01, as owner Formal or my employees with wages as thci=sole compcmatlon, SWIMM INC, POOL ELECTR IC +- ^
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DO'tHBR'
will do the work, and the structure is nmf mended ouaffvmdfofmle1 we744,Bmines,
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and Professions Cede: Tne Cantmnor's Liana Law doer not apNY la an wvner of OUTLETS-SWIICUES-FIXTURES
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who builds or improves thereon, and who does such work himself or through j
property
his own employces, provided that .such improvemenk am not intended or offered for NEW RESIDENTIAL ELECTR SQ FI'.
♦ SQ FT. Fl.00R R.A
7 6 j999 U
9SQ. Ff.
sale. If. however . the building or impnwermnt is sold within one year ofcompledon.the r,
mer -builder will have IhebuNun of proving Ihat he did nor build or Improve for par- I H
pose of salt ). J
TOTAL:
1, as Owner of the property, am exclusively contracting with licensed convenors to
on,vun the project (Sec. 7044, Business and Professions Code:) The Contractors Li
vense Lawdtes not apply man Owner ufpropcny who nuildsm improtxn Hereon. wd QTY. PLUMBING PERMIT
who nnnraaa' for such pmjm¢ with a mntmnnr(s) lianxd pumuunt na IM1e Commaor,
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License law. PERMIT ISSUANCE
❑ I am exempt under Sec. . B M P C far this reason
— DRAIN&VENT — WATER HTIA)
VALUATION
Owner DateALTER
WOR KI? R'S COM PENSXrION DECLARATION BACK FLOW PROTI.CT. DEVICE
I hereby affirm under penally of perjury one of the following declarations:
STORIES TYPE CONSTRUCTION
I have and will maintain a Certificate of Coeenunxll-imme lir Worker's Gnnpcn- DRAINS— FLOOR, ROOF, AREA. COND,
nation, to, provided for by Section 37M Of the Lahr Cade, for the performance of the
work for which this permit i,,,,.cd FIXTURES—PER TRAP
i have and will mountain Worker's Rmgmnvation houmueo, as required by Section
. Apofthjee..Labopermit n issued. GAS— EA. SYSTEM-( INC. 4 OUTLGI S
CPPraddkee� fou�r t�he performaaonncce of the work far
DCC. GROUP ♦ APN
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' �OObititJOhis
MY Carrier: rkest "rA—rmy ;6A pnlmyNo.it yX:5WkD� Ie18 GAS — HA. SYSTEM -OVER 4(EA)
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CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASEIINDUSTRh WASTE INTERCEPTOR
BUILDING DIVISIONFEM
•
COMPENSATION INSURANCE
(Ihiase,tom needsnl be completed ifthe permit is Torun hundred dollars (SIW) GREASE PRAY
or less.)PLANCI{ECK
FF.F:
lath, lbmlnthcpceferromme ofthctywork (orcywhIichrpntisa pabermit is issued, l shall SEWER — SANITARY — STORM EA. 2011 FT.
ENERGY FEE
not employ any pc non Our, mannersoas a Wmiters'Comlen-
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GRADING FEE
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try (aT
wou.law (Cu_b�fY� �D le iS O' [ WATER HEATER WNENTRiLECIk
ApplicantaQ P T S
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NOTICE TO APPLICANT: If, ufier making this Cenilicax of Exemption, you should WATER SYS' 1'17mr]BEATING
y
become mbjal to the Wnrkurs Corisam aGnn provisions of the labor Cmle. you mux
SOILS FEE
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forthwith comply withsuch provisions or this permit shall be deemed resuked. WATER S17RVICE
W
0zCONSTRUCTION
LENDING AGENCY NEW RESIDENTIAL PLMH. SQ, IT.
PAID
Ualn Receipt
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I hereby uffimt thathem is a construction lending agency for the performance of
TOTAL:
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the work for which This pcona is issued (Sec. 309), Civ. C.)
IsWer'a Name
Under's Address TOTAL:
BUILDING FEE
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I ccnify that I have reM this application and state that he above information is
SEISMIC PIiG
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sennet lagmemennply wnh all city and county ordinances and torte lows reluungm QTY. MECHANICALPERMIT FEE
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buildingconarmima and hereby minimize representatives oflhis city to enter upon the
ELECTRIC PEE
aMvemoniiored propcny br inspection purposes. PERMIT ISSUANCE
(We) agree m s ,indemnify and kap h:rmlcss the Chy of Cupertino against
PLUMBING FEE
Ilubl.....v 'uNA
parents as- swhich may in an'x'ay actors ageinx said City ALTER OR AUUTO MECH.
nxquencc' I gr go his pc
MECHANICAL PEF,
APP LIC NT O h AND AND II . CO Y WITH ALL NON -POINT AIR HANDLING UNIT (TO IO,BW CFM)
gOU .' F S.
CONSTRUCTION TAX
6_ AIR HANDLING UNIT (OVER IBM) CIM)
CS
in of ApplicnntlConlr Uitc IiXHq UST HOOD(W/DUCT(
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will to applicant or future building accupanl store or handle hawnlous mammal HEATING UNTT(TO 10000) BI' U)
as defined by the Copern Municipal Calc, Chapter 9.12, and the Health and Safety
Code, Section 25532(x)^ HEATING UNIT (OVER IW.000 BTU)
i]Yes �N^ n
VUNnLATION PAN (SINGLE RES ID)
PAID
Date Raei a _
%District,
Will the applicant or future building occupant use equipment or devices which ROLLER — COMP CHIP OR IOO,WO BTU)
emil h scrommus air commitmentsas defined by Ole Huy Arca Air Quality Managemet
BOILER — COMP (OVER 100,0110 BTU)
p Yes )<No
1 hove read l lavard muteriak rtquixllmmz under Chapter 6.95 0l Use Cali- AIR CONDITIONER
ISSUANCE DATE
liamia Beahh & S y (' . S tions 2.5115 2$SJJ 125534.1 uudcrxmnA ,hat if he NI?W RESIDUNI'1A1. MECH. $Q. FT,
huil"a', sn hat ur mnl.lha 1 y .iMliry to notify the occupant
of the h m he m pd f f u Cenificate Ot O`vaparay3
Owns or ZIhonv. nt are 'i(YfAL:
ISSUED BY: /
OFFICE