B 0178APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY _
178
CITY DF CUI'ERTINO BUILDING - ELECTRICAL PERMIT NO'�j 0
ISUILDINGDIVISION APPLICATION/PI+,KNIT , ,�'�dLN!'INbi ME'HvN. .AL,rr.v 150001 � L`
OrARCHITECT/ENGINHIik:
LIAR
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El
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CONTACT: PHONE:
BUILDING PERMIT INFO
BLDG ELECT / PLUMB / MECH /
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTORS DECLARATION
I hereby i form mal I stn licensed under pnwi,im s of Cb.pter 9 (usmmendng
with Swtbn9000)sf Division 3 arms nosiness and Pmfcedoas Cale.anamy limalis
in full force and cffc
License QP _ _ _ Lic.a O
nate Comrecntr
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL ❑KITCHEN RF.MODI:1,
El ADDITION ❑ PLUMBING RE PIPE
C3 MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
Ll INTERIOR El CHIMNEY REPAIR
IMPROVEMENT C3SWIMMING POOLS
❑ BATH REMODEUREPAIR C3 DEMOLITION
❑OTHER
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VIiHMIT ISSUANCIi .JJ Ste-//
APPLIANCES -RESIDENTIAL.
ARCHIT[CTS DEC ATI)N
I understand my plana shall he used as public record.v
PANELS
UP TO 20X1 AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License law for the
following m.wn. Socha. 7031.5. Business and Professions Cale: Any city or county
HIL-RCOAM'S
OVER 1010AMPS
SIGNS ELECTRICAL
OH
'}
00
I., M
' ts'
'Zy
iSQp
;F,
which requires a ,.air, mrewet, .act, improve, demolish, or repair any sunmare
prionnia issuance. also requires the applicant fur sucM1 perinnlilen signed nmlermend
mat he is licensed pursmnuothe provisions of me Conuacdor, Littnse Lew (Chapmr9
(commencing wfor Section 90(IB)of Division 3o(the Business and ProfesslonscadO or
mat he is exempt therefrom and the basis for me alleged cxonption. Any violation of
Section]031.5 by any applicantfor a permit subjects the applicant to a civil penalty of
.,it more than five hundred dollars (5500).
❑Lay. s net of the many or my employees with wages as their sole compensation.
will Jo the work. and lheslructc is not intended or offered for sale (Sm. 904, Business
m
and Pmfes,lom Code: The Contractors License Law docs not apply to on owner of
property who builds or improves thereon, and who docs such work himself or through
his own employees, provided that such improvements ore not intended or offered for
sale. If. however the building or improvement is sold within one year ofmmpletion,the
SPECIAL CIRCUITIMISC.
G- C
TIiMI3NHl'IiR OR POLO INS'1'
MM R I L:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENAM1T El FOOL) S17RVICH
IMPROVEMENT
❑OTHCR
POWER DEVICES
SWIMMING ELECTRIC
OUTI.Iffti -: I XTUp FS
Q FE
NEW RI.. 1 E :L 4n51&
SQ. FT. FLOOR AREA
SISQ. Inf.
mer -Wilder will have the burden of proving that he did not build or improve for pur-
U TOTAL: /.00)
Free oRak.1
❑ 1, as owner of the pmpeny, am exclusively contracting with licensed contractors to
,muuer the pmjecd (Sec. 9(94, Business and Possessions Cade:) no Contractor's Li-
cense Lnwdoes not apply toanowner ofprepcnywho build, or improves thereon, and
QTY. PI,UMBING PERMIT FEE
woo contracic for such projects with a aontracto"s) licensed parsoand tothe Contrucdoh
License Law.
I am exempt under Sm. . H & P C for this reason
PERMIT ISSUANCE
z 3S50
VALUATION
ALTER - DRAIN & VENT - WATER (EA)
Date
Owner
WORKER'S COM P17NSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Cenifcatanf Commauoself-inare lou Workers Ompcn-
sation, as provided for by Section 3701 of the Labor Code, for the perfmmence of the
work far which this permit is issued
Xhave and will maintain Worker's Compensation le urine. a, required by Section
)ofmc LaMarCade for the performance ofthe work for whichmi,mat i,ls,acd.
BACK PLOW PROI'ECf DEVICE
DRAINS- FLOOR. BOOT. AREA. TONE).
STORIES
OCC. GROUP
TYPE CONSTRUCT ION
APN
FIXTURES - PER TRAP
GAS - EA. SYSTEM -I INCA OUTLETS
GAS - EA. SYSI'1?M-OVEk4(1?A)
My Wnrk d,C at madamIi,marie carrier and Polley '' S',�
Currier: 11 T4� Policy Ns.: IyA LI
CERTIFICA'T'E. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GHIiASI%INDUS'1'HL WASTIiIMI}RCEFIOR
BUILDING DIVISION FEES
GR17ASIT TRAP
PLANCHECK PEIi
f"iswaimumdnothemmplaod if the Permit Ls for nnclmndresldullms D10o)
or Icesd
I certify that in the pcdonnancc of the work for which this permit is is.wcJ,Inh;Jl
not employ any Penna in any manner so as m became suhjocl to the Workers' Compen-
Slow]:R-SANITARY-STORMEA.2(H)f .
ENERGY FEF.
WAI'BK HEAfIiK W/VENT/EL.ECTR
GRADING FEE
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saloon Laws of Clifamia Date
A,licam I
should
NOTICE 10 APPIACANT: If, afl-ataklny this Ccnilioncnf Esentption, you. s
became abj a m the W ..kcr's Csngwm,ntlon Provtmms of tha Lobo Cade, you roust
litnhwilb comply with sorb pmvi,ions or this peril shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is unmstmnion lending agency for the performance of
the work for which this pends is issued (Sm. 3099, Cls. C.)
Lender's Name
W TER SYS] FNLOREATING
SOILS FEE
WNIER SERVICE
-Dale Receipt
NEW RESIDENTIAL FLME.
-"
TOTAL.
FEE
TOTAL:
Under's Address
I certify that I have real this application and state that lie.Mme infl num.... is
cared. l agree tocnmply with all city andcounty ordinances and nfare laws relatingto
building<on.amction. and hereby molorim represemulives alhis city loenmr.,or the
above-mentioned propeny for inspection purposes.
(We) agree to rove, indemnify and keep harmless the City of Cupenlmt against
Iiahilides.judgmenls.costs and expenses which may in anyway accrue ugainsl said City
QTY.
rV,r2DMIT EE
E
t r5o
PERMIT IS. ,li
ALTER OR )ME i,
FEE
ICONSTRU�10.
PLUMBING F. Q
in consequence of the granting of this permit.
API'LICAN'f UNDIik S'T'ANDS AND WILL COMPLY WI'lI1 ALL. NONI'OIN'T
Allt HANDL. CFM)
AL
SOUR ' iGU1.AT10N ^ _I _�
(7j
AIR HANDLING UNII'IOVER IILIKKt CFM)
f10, i'A%.
gn ur at AppBonVCondmcmr Date
HAZARDOUS MATERIALS pmDISCLOSURE, mrd
Will the applicant or future Wilding nccunslom or handle haous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and me Health and Safely
Cala Section 25532(.)!
EXHAUST HOOD(W/DUC)
MITI TION FEE
X)
HEATING UNIT 0 U 1110.10 BTU a.ao
HEATING UNIT (OVER I W.(Xlfl BTU)
VENTI LATION PAN (SINGLE RESID)
E3Yex Fl No
PAID
Dale Rcceiptp
40,
Will me applicant a future building occupatn use equipment or devices which
emit Mesar s air contaminants as defined by the Bay Area Air Quality Management
/
BOILER (Bill OR 100.000 BTU) /
TOT ,
BOILER -COMP (OVER 10(.(00 BTU)
Yes ❑Nsase
AIR CONDITIONER
ISSSUUANCE DATE
read me hvaNtusmaterial, requirements under Chapterfi95 of the Cali-
lth & Safety Cade. Sections 255115.25533 and 25534.1 umkrsmnd that if the
NEW RESIDENTIAL. MECH. SQ. PT.e,
nod cunendy have a tanaL that it is my re,rytmibilidy m omify the necti ircmends which must be met prim to examem of a Cenifirnte of tRcuputcy.aumorimd
L
ISSUEDD � ��
TOTAL:
agent Dae
OFFICE