S 0513 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C[TY OF LUPE'RTINO BUILDING-ELECTRICAL PERM
IT NO.
BUILDINCDIVIS10N APPLICATIONMEFt1t r1NGPROJECT IDHANIFIC S 0513
BUILDING PRfkJF.CT IDENI'IF'll'ATION
IIUILDING ADDRESS: SANT TARV NO. APPLICATION SUBMII'I'AI.UA'1'li
fG fir. Sari
NFR'S NAME: ONH:3�3[��, C)N'TRACIDR'S NAM.: LIC NO
NIC CONTHOLN
�ARCH]'FECT/r GINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG EL 17
PLUME MILCH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT [TEE JOB DESCRIPTION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(enumerating
Op.'Z with Secrion](XI81 of Division Sof rhe Business and Professionz Csafe,and mylicensei.s RESIDENTIAL
WOO PERMIT ISSUANCE
F O full foom.nd effect. ❑SFDWL ❑KI'I'CHEN REMODEL
-CUV License Class Lic.N APPLIANCES-RESIDENTIAL. []ADDITION El PLUMBING RE-PIPE
L.Z W Datc Cmtnxrl r
yap. ❑MULTIUNIT ❑STRUCITRAL
5H ARCHITECTS DECLARATION PANELS
z b n 4 l umden teal my plans Shull he used a&Publie records MODIFICATION
OZ—p UPT0200AMPS [I INTERIOR [I CHIMNEY REPAIR
,CSE-ly Licensed Professional 281-1010AMPS IMPROVEMENT F]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 10p AMPS ❑BATH REMODE ' A 'A LITTON
jj a I hereby effort that I am exempt from the Contractor's License Law for the D E
p.O p.U following reason.(Section 7831 S,Business and Professions Craft:Any city or county SIGNS ELECTRICAL,
3 W(me"' whirl,requires a permit m construct.idler,improve,demolish,or repair any mmmurc
,Ff,LLO.i priono its issuance,also requires the applicant for such Permitto rile a signed statement SP17CIAL CIRCUIT/MISC.
F,Ox that he is licensed pursuant to the provisions of the Commerce&License Low(Chapter 9
W (commencing with Section7000)of Division 3 of the Business end Prefesiom Cut I,r TEM P.MHIS OR POLE.INSTl OMMFR IA e' that he is exempt therefrom:ted the basis far the alleged exemption.Any violation of ❑NIiW BLDG/ADDITION ❑DEMOLITION
LL• Section 101 Ll by any applicant fora permitwbjects the applicant to a civil penally.( POWER DEVICES ❑TENANT ❑FOOD SERVICE
Q t more than five hundred dollars MILADY
CLae owner of the n IMPROVEMENT
❑ pmpe )sur isms uucnJ,o1 ithwagfmw0eirsnl.7044. miner. SWIMMING POOL ELECTRIC []OTHER
_ will d.thewons andel,The Cure iatnei kende Law
of apply JH W,Business
4'3� and Professions Cede:The Conwnoes License Imw docs not apply to an owner of OVfLETS-SWITCHGS-FIXtVRF_S
property who build.or Improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ f?.
sale.R,however,the building or improvement iswidwithin one year.fenmpletion.the SQf$P.@f.0(IR/¢EA SISQ.FT.
owner builder will have the burden of proving that he did not build or improve for par- P' {� 1 1./
pose of sole.. TOTA. en
�
❑has owner of the propene,am exclusively c.mmning wilt licensed convacmm to AUS �u
construct the pmjern(See.7844,Badness and Professions Cale:)The Cemarel-II Li- ®�S RE
.P
Law does not apply it)an owner of propeny who builds or improves thereof,and QTY. PLUMBING PERMIT
who contracts for such projects with a commemrfs)licensed pursuant o the Contractor's Ty
Ur
License Law. PENMITISSUANCF. V ' 1 UUrtHIIIVU
I amcxenl m Scu. - ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION'
�a)w tare r7—C76
RAT Dole BACK FLOW PROTECT DEVICE k
�. here ollirmure,peralt f rjurycn the following deelamti.m:
a and will maintain a Cent f- of Cone elf-ii fm W asNs Camper- DRAINS-FLOOR.ROOF.AREA,COND. STORIES TYPE CONST'RUCTION
x n,as provided for by Section 3700 of the L Code,for the perfommnce mf the
work for which this permit is issued FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,m required!by Section GAS-EA.SYSTEM-I INC.40VILEI'S
37M of the Labor Code,for the periamance of the work for which this permit is issued OCC.GROUT' AI'N
My Worker's Compensation Insurance carrier and Policy number art:
Carrier: Policy No.: GAS-EA.SYS'G1M-OVER 4(F/G
CHRTIFTCATEOFEXEMPHON FROM WORKERS' ORI:ASDINDIJSTRI.WASTI?INTI;RCI;l TMR
COMPENSATION INSURANCE BUILDING DIVISION PliliS
Oris section need not W completed if the permit is for one hundred dollars(S 11x) GREASETRAP
or less)(This FEE
I rectify thin in the performance of the work for which thio,permit is i,sued,lxhull SEW BR-SANITARY-STORM HA.001 IT.
not employ any person in any manner eco as m become subject to the Workers Cumpen- ENERGYME
,Z, nation Law&of California.Date WATER HEA'1TR WNENT/ELEC R
zApplic:un GRADING PGI?
r .N. NOTICE TO APPLICANT:If.ager making this Cenif,i a ur Exemption,you should WAT17R SYS'IENUTREATINC
h Wc.me subject m the Worker'&Compcnsmlon provisions cf Ne Isbor Code,you man SOILS FTE
Wforthwith comply with such Provisions ar this pertain shall be deemmd revoked. WATER SERVICE
0
.a7. zCONSTRUCf10NLENDING AGENCY NEW RESIDENTIAL PLMO. SQ.FT. PAID
Date Receipl
I hereby uffum that there iso construction lending agency fornhe performance of p
LUIaO thework forwhleb thispermit lx issued(See 7097,01 CJ
OU Lender's Name TOTAL..
W Lendees Address TOTAL'
y I certify that 1 have read dr,applicmin rand sate that the above information is BUILDING MH
rA correct.Ialreemcomply wiNall city unit county ordinances income lewsrelaaagm QTY, MECHANICAL PERMIT FEE
UZ buildingnmswcti.n,and hereby umhorizerepreematives ofthincitymenter upon the SEISMIC FEE
shove-mmadoned property for Inspection purposes. PERMH ISSUANCE
(We)spo e m save,indemnify and keep harmless the City of Cupertino against ELECTRIC PCI:
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FTE
in consequence of the granting of this permit.
'APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,M)CFM) MECHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 18,(00 CFM) CONS'I'RUC'I ION TAX
Signature of ApplicanVCmnracmr Date EXHAUST HOOD(W/DUCT) HOUSING MFGOATION FTE
HAZARDOUS MATERIALS DISCLOSURE
Willnhe applicant or future Infido,orce pantwaeor handle hmzardousmuler'ml HEATING UNI'T(TO 100,W01f1'U)
as defined by the Caperton Municipal Code.Chapter 9.12.and the Health and Safety
Code.Section 25532(x)'! HEATING UNIT(OVER 100,001 BTU)
❑Yex 71 No VENTILATION PAN(SINGLE RESID) PAID pate Receipt
Will the applicant or future building occupant use equipment or devices which
emit hazardous air romumimants as defined by the Bay Area Air Quality Management BOILER'-COMP QHP OR 10(1,(00 BTU) 'TOTAL:
District? BOILER-COME(OVER 100.000 BTU)
❑Yea [J No
I novo read the hamtdoue materials requirement,orale,Chapter 6.95 of the Coli- AIR CONDITIONER ISSUANCE DATE
(.or.Health&Safely Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building docs nm cu mall,have a tectum.Nat in is my rcaPmsiMlhy to notify the occupant
of the requirements which nmxt be tact pdor,,is....sent a Cenlficam of Occupancy.
Ownerormaknrieed agent Date TOTAL; ISSUED BY:
OFFICE