S 0894 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CU
BUILDING-ELECTRICAL PE�HT NO. 0894
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL J
HULLOING PNUJIiCI'IINEN'TIFICATION
' UILDING/
Y1l SANITARY NO, APPLICATION SUBMITTAL HATE
I'll CONTRAC'IUR'SN MP.: LIC NO: VL
N/C CONTROL Or
• ARCHITECTIENGINEER: I.ICNO: ..'T ❑
CA �j�•� /jFlpy�� BUILDING PERMIT INFO
/ GL7 �J ❑ Consultant Fees Paid by Applicant(Initial) BO ELECT PLUMB MO 1
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that ran licensed under provixinm nl Chapter 9 Icammencing JOB DESCRIPTION
Oax wiOhscetioa70(spafDM,ior3ofinelluainws and Pndusxlons Cndo.and my llcenseia RESIDENTIAL;
4 O p PURMIT ISSUANCG
Fht full force andeffect. ❑sFDWL ❑KITCHIiN REMODELly
aUV Licence Class Lic.M APPLIANCES-RF_SIDENTIAL C1 ADDITION El PLUMBING RB-PIPE
Zpy ARCEI'fECI'S Date CDF.CIARATION-0oncom
fn6a ❑MUI:rl-UNIT ❑STRUCTURAL.
Fpm PANELS MODIFICATION
Z O 4 Z I underhand my plans shall he used as public records
0--4-0O UI'T02110 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
P�ntW Licensed Pmfexsiowl NII-ICMAMPS IMPROVEMENT []SWIMMING POLIS
Oat I am exempt
U rapt fir DECLARATION CountON OVER IM)AMPS ❑BATH REMWII;IIIi" IR EEMOLITION
1 hereby affirm that I urn exempt from the Contmoter's License Law for the -r411�_ (�
kO L U which iwr reason(section c...am,Business and Pmfessiana Code:Any city o lcounty SIGNS ELECTRICAL ❑OTHER
fR�1I�O 1, which requires o permit In umslruct.alter,improve,demolish,or repair any xtrucwra
.:7} prinno its issuance,also rc9nims the applicant forstich permitto titan signed momment SI1I7C1AI,CIRCUIT/MISC.
"y that he is licensed pursuant m the provisions of the Contractor's license Law(Chapter 9
tl
H
00 (conmacing with Section 7050)of Division 3 ofthe Business and Profession,Code)or TP.EMMETER OR POLE INS'T.
COMMERCIAL
y m K that he is exempt therefrom end the Iasis for the alleged exemption,Any violation of El NEW BLDGIADDITION [I DEMOLITION
m
4.X7 li Section 703 L5 by any applicant for a pent subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Fy} act tome than five hundred dollars(S500L IMPROVEMENT t
=CI.m nwna of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC ❑OTHER
F- will do the wark,and thesmactare isn.I intendedaraRered for 11,(11,71X4,1,Business
3 and Professions Com de:The Conlmaner,License Law does napply man owner of OUTLETS-SWITCHES-FIXTURESOf
propcny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements ate hat Intanded or offered for NEW RESIDENTIAL.ELECTR SQ fT.
,ale.IL howaven the building or improvement is sold within one year ofcompletion.the [f • .I ORAREA
owner-builder will have the huNen of proving that he did not build or improve for Puy-
pow of sale.).
r7 1,ns owner of the property,am exclusively contracting with licensed contractors to TOTAL: ` EC e Q Mn
construct the project(Sec.70,14.Business and Professions Coxii 1Oe Cantmotoa Li-
cense Law does not apply to an owner tit property who builds or improves thereon,and QTY PLUMBING PERMIT FEE f�
who contracts for such projects with a contractar(s)licensed pursuantto the Contractors Ur 11 ur uurrhou
Licence PERIOD r ISSUANCE.
❑la mnorder Se .Ba&1'C fmhia a
Owner ate son ALTER-DRAIN&VENT-WAI'HR(EA) VALUA'T'ION
WORKEIIIS CBMPENSA ION DECLARATION BACK FLOW PROTECT DEVICE?
1 hereby affirm under penalty,of perjury one of the I'olhnving declarations:
.n I have and will maintain a Certificate of Consent to self-insure for Worker's Compete DRAINS-FLOOR ROOF,ARBA_.COND. STORIES TYPE CONST RUCTION
s lion,as provided for by Section 37UI of the Labor Code,for the performance of the
work for which this permit is issued FIXTURES-PCR TRAP
1 have and will maintain Worker%Compensation Insurance,m required by Section
370(1 of the Labor Code,for the perfonwace of the work for which this permit is issued. GAS-EA.SYSTEM I INC.4 OUTLETS OCC.GROUP AM
My Workers Compensation Insurance currier and Policy number arc:
Carrier: Policy No.: GAS-FA.SYSTEMOVER 41EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRCASFJINDUSTRI.WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION PEES
Thiaxection inedoot M completedlfthe permit la ionone hundred dollars Is lmq GREASE'TRAP
nr less.) [ENERGY
NCIiHCK FEE
I certify Natio the perfismmnce of thework forwhich this permit ixissued,l shall SEWER-SANITARY-STORM RA.2W IT.
not employ any person in any manner so ax to hecame subject to the Workers'Compen- FEE
Z smian Lows of California.Date WATER HEATER WNENT?:LECfR GRADING hEF.
y NOTICE TO APPLICANT.If.Offer making this Cenificate of Exemption,you should WATER SYSTENUTRF.ATING
f" become subject to the Workers Compensation provisions of the Lubnr Code,you mu.a SOILS FEE
Lakl fnnhwith comply with such provisions or this permit shall be deemed v.km. WATER SERVICE
Q
razz CONSIAUCf10N LENDING AGENCY NEW RIiSIDCNf1ALPhM O, SQ.F. PAID Date Rece
LJ O I hereby affirm that there is a conhmenon lending agency liar We performance of
OE~ the work for which this permit is issued(Sec.3097,Civ.C.)lenders Name VTPAL:
LU11 lender's Address TOTAL"
6t 1 certify that I have read this application Oad state thauhe above information is BUILDING FEE
N correct l agree to comply with all cityand county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V Z building ronswction,aml lumbyauthodm representatives ofthis city to enter upon the SEISMIC FEE {
r above-mentioned pmperty for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC PEE
Iiahilities,judgmems,costs and expenses which may in anyway accme against said City ALTER ORADUTOMECII.
in con. yncnce a fthcgmntingefthiapcnnh, PLUMBING PEE
APP' ANT UNDERSTANDS AD WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT f10 10,M)CFM)S EREGUL ' IONS, CONSTRUCT
ION i
'7. AIR HANDLING UNIT(OVER IB,INN)CPM) CONSTRUCI'ION'1'AX
Signature of Applic t/Catnracusr tat P.XHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupens more or handle hiallous material HEATING UNIT(TO ElBoo08'TIT,
as defined by the Carleton.Municipal Cab,Chapter 9.12,and the Health and Safety
Code,Section 25532m)P 1117ATI NO UNIT(OVER 100.00)BTU)
E]Yes ❑N. VENTILATION FAN(SINGLE RPSIDI PAID
Uute kwiltM
Will the opplicam or fnmre budding rempenl arae equipment III devices Which
snit bazardmis air mnwmimma tis derined by the Buy AraAir Quality Management IIOLBR-COMP(3HPOR 100.000BTU)
IOTAL:
Dutra"? BOILER-COMP(OVER 100,0001111)
❑Yes [7 No
I have read the havardou%nmtenala requirements under Chapter 6,95 of the Cali- AIRCONDITIONER ISSUANCE DATE
fomia Health&Safety Cats,Sections 11101,25533 and 2.5134,1 undorsmnd that if the NEW RESIDENTIAL MECIL SQ.PT.
building does not currently have a mount,that it is my reaperaibiliry m mnify the..,tit
of the mgairemeris which most barium, no,m issuance"I.Campeau,of Occupancy. V aI P
Owner or authorized agent Dam TOTAL: ISSUED BY
OFFICE