30539 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
EGA
"Up"'
I1I111.U1NG-ELECTRICAh PERMITNO 0
n 1PPLICA'1'ION/PERMIT PLUMBING.-MECHANICAL
1 DIVISION - BUILDING PROJECT IDENTIFICATION
«9 539
: - _"� ` V�.� SANITARY NU, APPLICATION SUBMI ITAL DATI
g . PHONE: ONT �CTORS AMf: C LIC NO
J7L J 41 S� NIC CONTROL#
RCHITECTNNGINEER:�6 t 1 Q S
ICN �O/. OORI9 ml omc J -1� �ZS, ❑ /��
COM' CT: PHONE: BUILDING PERMIT INFO
!Z�&`.-(v Zg ❑ Consultant Fees Paid by Applicant(Initial) BLDG
ELECT PLUMB MEECIIH
LICENSED that I CO,va,ld IOR'S DECLARATION QTY. ELBCfRIC PERMIT FSE
1 neem arum that I ant banxca ander pmvixn�n of Chapter 9(commencing JOB DESCRIPTION
ADO with Sation]IX0)nf DivixionJnf ma Business end Profeaions Crde,and myliow is PERMIT ISSUANCE
F-�.. infull fu-and ct-_N Nr<f WL ❑KITCHEN REMODEL
are las l:� Lica J APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE:
NGW DmCantrzcom
ARCHITECTS DECLARATION ❑MUIThUNIT ❑STRUCTURAL
Z O ti Z I understand my plans shall be toed a.public.ecords PANEIS MODIFICATION
OZ-p UP102WAMPS ❑INTERIORq ❑CHIMNEY REPAIR
F4LW Licensed Pmfesaonal 201-10MAMPS INIPROVEMMA //��
�0P OWNIiR-BUILDIiR ULCI,ARAI'ION OVER 1000AMPS OBATHREMODEL/REPPAfM❑DEMOLITION
5 d Q 1 hereby affirm that I ton exempt from the Contractors License Law for the
xe.QaU following reason.lSecticn703L5,Business and Profusions Code:Any city or poorly SIGNS ELECTRICAL OOT
n.1 a W N which requires a permit to ouromo t,abed,Improv.,dannakh,or repair any onamre
FLLO¢ piionoitsnaaancc,also requires theit,licant foeauch penin#,fleasignxdmammem SPECIAL CIRCUIT/MISC. Y
fay that he is licrnxJ pursuanuothc provision of the Comracmrs Licenu Law(Chapter9
uaia�C hwrion acing with Section7000)of Division 3ofthe Barinccs and Pmle,ions Code)m 'TEMP.MP,TER OR POLI:INST. R _
�/.(/�'m
el�y that he is exempt thercfmm and the basis for the alleged exemption.Any violation of 01,112WBLDG/ADDIT � W'DEMOLITION
X�N Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FWD SERVICE
I„zy not more than live hundred claims s5mp' IMPROVEMENT
G ❑Las owner of the pmpeny.or mycmployecs with wages as their solecomcensation. SWIMMING POOL ELECTRIC
FD wilLdmhework.and thecwmure is not intended motored formic(Se,70,W.Business ❑OTHER
'^roand Pnmf cions Come:'De Ccom aha's License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6 3 property who builds or improves therm,and who does such work himself or&rough
his own employees,provided that such improvements we not intended or offered for NEW RESIDENTIAL ELEC R SQ FT.
sale.If,however,the building or improvement is sold within one year ol'compIchou,me SQ.F1'.I LOON AREA 8/SQ.FT.
cr-builder,will have the buNen of proving that he did trod build or improve far par- \ V l
,socnfsale.),
I,us owner of the propcny,um allusively cnnvaming with IicenseJ nmoaenoo m ` J
construct the project(Sec.70A,Business aryl Professions Code:)The Comrecmrs Li-
riseLowdoesnotapplyroanownerofpropcnywhobuildsorimprovesthereon,and QTY, PLUMBING PERMIT FEE
whoeontrecks forsuch projects with acnntmctods)licensed pursuant to the Commend _
License law. PERMIT ISSUANCE
❑ 1 am exempt under Sec. ,H&P C far this reason
ALTER-DRAIN&VIiN'1'-WKI ER(EA) VN.UN'IUN
O rDae
WORKER'S COMPfiPSATIODECLARATION BACK FLOW PROTECT. E r,—
1 hereby affirm under penalty of perjury ane of the following declarations:
I have and will mnboom a Certifcacof Cnnedeaself-insure for Worker'sCompel- DR N LOOR.R R, C D. STORIES TYPE CONSTRUCTION
onion,as provided for by Section 3]1X1 of the Lobar Come,for the performanc.oT the
work for which Nis permit is issued. F r PER TRAP
I have and will maintain Wolaw's Compensation Inaararce,as required by Section
3700of the Labor Cadc.for the perfannoncc ofthe work far which this pcnnit is issued. En. -IIN(7.SOUTL S OCC.GROUP APN
My Worker's Compensation Insurance westward Policy mother are:
Cartier: Policy No.:
CURL[FICATH OF EXEMPTION FROM WORKERS' GRGS s L WASTE ERCEI'1'OR
COMPENSATION INSURANCE BUILDING IVISION FEES
(This xecaimrin edian be completed if he permit is furore hundred dollars(SIM) GREASETRAI'
nr
It,,.) PLANCIIECK FEE #r
I certify th in the Performance of is work for which pemmitisiseuN.10.11 SEWER-SANITARY-STORM EA.200 F`E
not employ any p in any manner r s h me 1[ t the Workers Compcn- ENERGY FEG �+
,z scion Laws ofq m�inn', Dmc WATER HEATER W/VENT/ELECI'R
Applipant /_ 1� GRADING MtIi
z NOTICE TO A13 LICAN7Tr:If,after m':ing this Cenifnte of Exemption,you ehnuld WAT17R SYSTEMO`REATING
ac( a subject to the Workers Compensation provisions of the Labor Code,you 'a., SOILS FEE
forthwith comply with such provisions or this Permit shall be Deemed revoked. WATER SERVICE
7z CONS IRUC'I'ION LENDING AGENCY NEW RESIDEM'IAl.P1.M B. SQ,PT. PAID Dam Receipt#
U C) I hereby affirm thatthem is adonsumction lending agency for the Performers,of
,tet the weak for which this permit is issued(Set.3097,Civ.C.)
W Fit IxnJcr'x Name TOTAL:
Lenders AddressX
fy 1 certify that 1 have read this application and state that the above information is
BUILDING PEI: l
Tri correct.l agree to comply with all city and county ordinances and smmlaws renting to QTY. MECHANICAL PERMIT FEE
V z builiirt,emtraetion.and hereby aumorizc mpreunmtives of Nis city townw.pon the SEISMIC IEE
above-mentioned proppny for inspection pugmm, PERMIT ISSUANCEELECfRIG FV'
` \
(We)agree to save indemnify and kap hmmless the City of C.,i ino againt
Iwbilitics.judgmems.msts avdexcerscswhich may in anywayaccme against mid City ALTERORADDTOMECH. 1
in asequence ofthe granfingofthis cern:¢ 1'LUMHIN 'L K
APPLICANT UNDERSTANDS AND WILT,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('1'0 10.000 CFM
SOURCE REGULATIONS. MECHANIC E 1
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION T X
Signatumo'Applicant/Contraaor Dec EXHAUST HOOD, W/DUCT) HOUSING MITIGA ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fnum hiildingacepant snucorhandle htiamous material HEATING UNI'L UPO 100.010 BTU)
as defred by me Cupertino Municipal Code.Chapter 9.12,and the Health and Safely
Cade,Section 255320)? HEATING HILL'T(OVER 100,000 BTU)
❑Yes C]No VENTILATION FAN(SINGLE RESID) PAID
Drtc Receipt
Will the applicant or future building by the 8 ave equipment nr dMana which
. it hazallous air contartdnantx n Defined by the BaY Area Air Quality Management ❑OII,IiR-GGMP(3111'DR IINLIXI)H'PI/)
TOTAL:
'vias BOILER-COMP(OVER 110,010 BTU)
❑Yes C]No
I have read the hazuNous mamrulsrequiremcm¢under Chapmr 6.95 of ds Cnlh AIR CONDITIONER ISS UANCE DATE
Ra
mie Health&Safety Calc.Suctions 25505,25533 and 25534.1 understand that if the NEW R F.SIDEN'1'IAl.MECH. SQ.14.
buildingdoes nee currently have a motor,mat it is my responsibility to notify the occupant
of me requirements which must he met prior to issuance of a Certificate of Occupancy
Owner or amhorized a gent Dam N ISSUED By. •-� ��
OFFICE