S 0497APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN
BUILDING DIVISION APPLICATIONIPERMPf
Z.Clar��1G ❑
OFFICE
'
❑ Consultant Fees Paid by Applicant (Initial)
BLOC. ELECT I'I.UMB MECII
❑ ❑ ❑ Le
PCZ
F1_
F1_
i -Z W
.1C..
Fly
Z p�Z
OZ' -•0
❑rJ/pF�
6' w 6
k 3 L OF
ul U.
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 um licensed under pmvisions of Chapter 9 (commencing
with Section71MW1ofDivisinn3ofthe Businessland Professions Cmle.endnry license is
m full force and eIT _
Uccn Liag
nate r- S DEC
ARCHITECT'S DEC A ION
I understand my plans shall be used as public records
QTY ELECTRIC PERMIT FEE
JOE DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KITCHEN
❑ADDITION PLUMBING RY I'IPIi
❑MULTI -UNIT ❑ MODIFICATI .
MODIFICATION
El INTERIOR C3 CHIMNEY REPAIR
IMPROVEMENT ElSWIMMING POOIS
[I BATH RIiMODEIJREPAIR DUEMOLITION
El OTHER
-
I'CRMIT ISSUANCE
APPLIANCES — RESIDENTIAL
PANELS
UPT0200AMPS
Licermel Professional
OWNER -BUILDER DECLARATIONOVER
I hcrehy affirm that 1 am exempt from the Customers License Law for the
following mason. (Section 7011.5, Business and Professions Codi Any city or county
which requires a permit In conswm, otter, improve, dermisb, or repair any fracture
prior (to its issuance, also requires the applicant lar such Permian file u signed.mmment
201-1000AMPS
I(NMIAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUUUMISC.
�y
DT�C
.52
� �
U�y
FZi
�=O(]has
aand
muanttotheprovisionsoftheConactor'sLicenLaw(Chapmra
thatheislicensedpuContractor's e,
(commencing with Section 700(1) o(Division 3 ofthe Business and Profession Cadepn
that lie is exempt therefrom and the basis for the alleged exemption. Any viomtion of
Suction 7031.5 by any applicant for u cannot subjects We applicant to u c ivil penalty or
oat mom than live hundred dollars (5500).
owner nfthe propeny, or myempiny¢s with wages as theirxule compensation,
will do the work, and the stranure is not intended oroBeredi for sale (Sm. 744. Business❑
Professions Code: The Contractor's License Law does not apply In an owner of
I I!MP. METER OR POLE INST.
COMMERCIAL•
El NEW BLDG/ADDITION [D DEMOLITION
[]TENANT ❑FOODSERVIGI:
IMPROVE F.
OTHER
POWER DEVICES
SWIMMING POOL ELECT RIC
OUTLETS-SWITCHBS-FIXTURI!.
property who builds or improves thereon, and who dues such work himself or through
his own employees. pmvideal that such improvements are not intended or offered for
sale. IL however, the building or improvement is sold within one yearofenmpleiortoe
ownenbuilder will have the burden of proving thin he did not hulld or Improve for put.
NEW RESIDENTIAL ELECTR SQ FT
n
sop. ler. FLOOR AREA
$/SQ. FT.
O
Pace or ale.).
❑ 1, a owner of the property, am exclusively contracting with licensed contract rs nr
mntioct the project (See. 704,, Bus nes. end Professions Cde:) The Commcmrs Li-
cemseLaw does not apply toanowner ofpropenywhobuilds orimproves themes, and
QTY. PLUMBING PERMIT ••F.
who contracu Ra such projects with a cnmmnor(s) licensed pursuant to the Common s
PERMIT ISSUANCE
License Law.
❑ 1 am exempt under Sec. , R & P C for this mason
Owner Ilam
ALI'17R- DRAIN &VEN'P- WATER (HAL
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTE(7f.. DEVICE
�❑
I hereby affirm under penalty of perjuryone of the following declarations:
I have and will maintain aCenificale of Consent hsself-insure fat Wmker's Campers-
smmn, us provided for by Section 3700 ol'the Labor Caste, rnr the perflsnname of the
DRAINS- FLOOR, ROOF, AREA, COND.
STORIES
TYPH CONSTRUCTION
work for which this pemtit is issued.
FIXTURES - PER TRAP
have and will maintain Wmmrs Compensation Insurance, as required by Section
3 t@e Labe, Code , fon he perfon...cordite work for which this perook is issued
lo
GAS - EA. SYS TEM- I INC.4 OUTLETS
OCC. GROUT'
AI'N
My Wer er's �pmmppeneulimt Ins gg,�ymler and Polic r�
Cmrov,:�F4ilI!Il �t9- P.liey No. r9..lkll^50
GAS- EA. SYSTEM OVER 4(EA)
CERTIFICATE OF RXHMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRHASFANDUSTRL WASTC IN LERCIiPTOR
BUILDING DIVISION FEE$
(Thowsaion madam heeompleled ifihepc... mil tritium hundred dollars(8100)
or leas.)
GREASETRAP
I'LANCHECK FEE
I verify that in the performance ofthe work for which this pamnit is issued, I shall
not employ any person in any manner so as to become subject to the Workers' Course.
SEWER -SANITARY -SIORM EA. 200 FT.
ENERGY ITT!
O Z
h
Q
UO
{U
yrs
V)
L)�
saloon Laws of Cal fame. Dam
WATER HEATIiR WNEN'1'IPLECTR
IT -13
GRADING I
1,101ICE TO APPLICANT: If, after making this Cenificam of Exemption. you should
become subject m the Workers Compensation provisions of the Labor Code, you nun
forthwith comply with smelt prmisiimsnr this permit shall W deemed revMed.
CONSONLENDING AGENCY
I hereby uffuthat ere is isacmwocdon lending agency for the performance of
m
the walk for which this permit is issued (Sec. 3097, Civ. CJ
Lender's Name
WATER SYSTEM/TREATING
WAUIR SERVICE
SOIIS FEC
PAID
Date ace IN
NEW RESIDENTIAL PLMIf. SQ 17.
I "TOTAL:
TOTAL:
Lender'.Addreas
BUILDING FP
.
1 cenify Lou I have read This application and sem altar the abase infntmminn is
correct. I agree to comply with all city nndcoumy oNinances and slate lavo relating to
building construction, and hcrehy actlurim representatives oftlanivity to emcrupun the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC -'
Orme-mentional property for modgemim purposes.
(We) agate or save, indemnify and keep hurmless the City if Cupertino against
PLUMBING P
Iiabil ities, judcaurro,costs and expenses which may i n any way seems, against said City
in asequence (if the granting of this pernnil.
ALTER OR ADDTO MSCI I.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICALWE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOU C EGULATIONS.
-
AIR HANDLING UNIT(OVI!R 10,000CFM)
CONSTRUCTION TAX
Si not rcofApplican ontmcmr D, a
HAZARDOUS MATERIALS DISCLOSURE
FiXHAUST HOOD(W/DIICfI
HOUSING MITIGATION FEE
HEATING UNIT CFO IW.000 BTU)
Will theapplicaut or future building occupant fore0r handle masNoua material
a. defined by 0a Copenino Municipal Code. Chapter 9.12, and the Hra11hani I Safely
Coke, Section 25532mq)
HEATING UNIT (OVER I00J0010 WILL
❑Yes r-1 No
Will the applicant or future building recurull ase equipl0eal of devicca which
emit hazardous air contaminants as dennd by the Flay Area Air Quality Management
OivWRI
E) Yea ❑No
PAID
Dine Receipt 0
TOTAL:
VENTILATION FAN (SINGLE RESIID
BOILER - COMP GHP OR IOO,INI(1 BTU)
BOILER -COMP (OVER 100.(X)0 BTU)
CONDITIONER
I love rcuA the mortalsmortalsmaterialsmaterialsuls requirements under Chapter 6.95 (if the
r the Cali-
fomia Health & Safety Code. Sections 25505, 25533 and 25500. l erdemaml that if the
building does nor c mentlylmve a meal that it is my responsibility to notify the occupant
ISSUANCE DATE
/ Zx _ f% 97
( (/
NEW RESIDENTIAL MECH. SQ. FT.
of the requirements which must he met prior to issuance of a Cenificom of Occupancy.
ISSUED BY: tis / /
'/
TOTAL: 14 1D
Owner or authorized! agent hate
OFFICE