S 0607 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
,CITY OF CUPRRTINO BUILDING-ELECTRICAL PHRMI'I'NO.
BUILDING DIVISION APPLICATION/PERMIT TING R PROJECT
IDENTIFICATION
S 0607
HUILDIN('.PROJECT IDFIITIFICATION v
BUILDING ADDRESS: SANITARY NO. AI'1'LICA'I'ION SUBMI'TI'AI.DAM.
117
O NCR'S NAM70 PHONE: Z0J-xJ 'S NA XN (,flA1 LIC NO:se Eig e, C`s7�-
J-v
NIC CONTROL4
RCHITF.CT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG BLIiCf 1'LuMB MECH
LICENSED COMRACTDR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under pmvisidns of Chapter 9(sxsmrancing JOB DESCRIPTION
WOO with Section 70CM)ofDivision3afthe Iusinessund Psamosidnx Cade.and my license is RESIDENTIAL:
WOO PERMIT ISSUANCE �y
P-�O i"full farce end eRey. V ❑SFUWL ❑KITCHIiN kBMODEI.
<ZVUcenuQ �� /�Lice tar APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RF.PIPE
F W nater a�s�� —
hGt1 ARCHITF.CI-S DECLARATIO ❑MULTI-UNIT ❑STRUCTURAL.
ZO'n? lindersmnd my,lans,h.11 hediedos public rem Ns PANUS I MODIFICATION
EPAIR
OZ—ad
UPTO 3IXIAMPS ZD El INTERIOR ❑SWIMMINGNFY POOL
W Lianscd Professional 301-IlIIX1AMPg IMPROVIiMFNT SWIMMING POOLS
CYC; OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH RF:MODEIJRfiPAIR ❑DE OLITION
S Q 1 hereby affirm that 1 am exempt from the Comment,'.License Law for the
W3 LL F following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
OI" which requires a permit to consumer,altar,improve,demolish,a repair any structure
prime.its issuance,also requires thevpplicam for such Permit to file aligned statement SPECIAL CIRCUIT/MISC.
that he is licensed pumuaeto the pmvisinns of the C.mmnnln License tutu(Chapter
(commencing with Section 7(X10).(Div ision 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
46 p that he is ex<mpt therefrom anJ the basis finite nllcgeJ exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
WAN Section 7031.5by.ny upplicant for"permitsubjecrs do.pphrourd no civil penaltyof POWER DEVICES ❑TENAM ❑FOODSF.RVICIi
not more than live hundred dollars(5500). IMPROVEMENT'
�=6 I,asowderofthe n.drmenloees with woes asthca solecom sauion, SWIMMING POOL ELECTRIC
❑ property, Y P Y 6 Pe" ❑OTHER
II do the work,and the structure is not intended Inducted for sale(Sec.7044,Business
L 3 and Professions Code:The Contractors License Low does not app1Y to an or,of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thercnn,and who does such work himself or through
his Own employees,pmvidcd that such improvements are not intended or o0'ered Lor NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however.the building or impdwemeol is sold within one'tarofcn"tpletion.the SQ.FT.FLOORAREA S/SQ.axle
er-huilder will have the burden of proving that he did not build or improve for par- -
Pose of sole.).
❑ n
I,as owner oil the property, an exclusively contracting with licensed conuvcmrs m T fAL:
construct the project(Sec.7614,Business and Professions Code)The C"mmerm's J.
cense Low dues not apply loan owner of property who builds or innprrvw them nn,and QTY PLUMBING PERMIT FEE CEIVED
who contracts for such projects with a connowlims)licensed pursuant the Contmcia''s
License Inw. PERMIT ISSUANCE
m
Ioexempludder Sec. ,B X 1'C for Ibis monsoon
ALTER-DRAIN&VENT-WATER(EA) SEP 17 HON
Owner Doc
WOR KERS COMPENSATION DECLARA I'ION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the fallowing declareflor s:
❑I have and will maintain.Cenilic"teof Cdnscnunselbinm ,for Worker's Carmen- DRAINS-FLOOR,ROOF,AREA,CU, .CONS'FRIIM ON
mi
sod,as previch d far by Sec,am That of the L.Mu Cash,0u the perform"nce of the
work for which This permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensmlon Insurance,as required by Section
370D of the Labor Code.for the peuormance"f the wink(or which this permit is issued. GAS-EA.SYS] I INC.40UTLETS OCC.OROUP AI'N
My Workers Complammlon Insurance cormorant Policy number um:
Carrier: Policy Na: GAS-P.A.SYSTEM-OVER 4(FA)
CCECHICATE Op EXEMPTION FROM WORKERS' GRFASETNDUSTRL WASTE INTERCEPTOR
COMPHNSAI'ION INSURANCE BUILDING DIVISION PEES
his section need be completed if the permit is for one hundred dollars IS 101) GREASETRAP
or less.)(TPLANCfILCK PCI;
I cenify that in the performance nfihe work for which this permit is issucd,I shall SEWER-SANITARY-STORM EA.200 FT.
non employ any person in any mann, u h teen 'lac".the Worker'Compc"- ENERGY Pfa?
Z Betio"Lows of ' I omia.Da WATER HEATER WNEM/EL[CIR
O lux s GRADING FISH
Z 0 Applicant
.N.r NOTICE TD APPLIC :IL after n ing this Cenificme of empuon,you should WATER SYSTF.MOAEATING
become subject to the drkees Compensation previsions of t e Labor Cale,you must SOILS FEIi
UJ forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ,IT. PAID Dare
UO thereby affirm that there is a construction lending agency fa the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
DVLenders Name TOTAL: (DIAL.
U lenders Address
I�,o fy I certify that 1 have read this application and sate that the.hove infam itian is BUILDING PER
corral.l agree to comply with all city end aunty aNin""ces and shoe Jews ealvti"gto QTY. MECHANICAL PERMIT FEF.
U Z building construction,and hereby rotation mpresemanves ofthis city to enter upon the SEISMIC F[li
above-mentioned pmpenY fnr'nspection p"9snses. PERMIT ISSUANCE
(We)agree to rove,indemnify and keep harmless the City of Cupertino against F.LECfRIC FEE
Iiabilities,judgmeas,costs add expenses which may ina"y way acmeagainsiond City ALTER ORADDTO MECH.
PLUMBING FF.F.
inconsequencethegranting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT PIR HANDLING UNIT(TO 10.0(1(1 CFM) MECHANICALFEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10,000 CFM( CONSTRUCTIONT
Signature of ApplicanOContractor [)am BXIIAUST HOOD(W/DUCU HOUSINGMITIGA PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building acupa"utore or handle hazardous material HEATING UNIT(TO 100,M)BTU)
us defined by the Coplanar.Mu Icipal Cade,Chapmr 9.12,and the Health and Snfoy
Code,Seddon 25533(.)7 HE UNIT(OVER 100,000 BTU)
❑Yes No VENTILATION FAN(SINGLE RESID) PAID Dam Receipt g
Will the applicant or future huilding occupant use equipment in devices which
.•emit haeuNnus it conundrums IodeOneJ by the 13oy Arco Air Uuallty MnnugeManagementBOILER-COMP(iHP OR IIXI,BEO BTU)
TOTAL:
District'! .U,!'/v. BOILER-COMP(OVER 100.00BTI)
Yes
I have rent(lot huznnldnx mntcrinle retimmn connote,Chapter 6.95d(the Call- AIR CONDITIONER ISSUANCE DATE
(main Health k S.ROy Code,Smtio"s 2IM5,2.5511 nail 25534.1 undcrmund that if the NEW RESIDENTIAL MECIL SQ.FT. r 17 —7 7�7
huilding dates nm curmndy have n tenun616w it is dry responsibility to"reify the owcup"nt
ONE menta whirl est unce mf.Cenificme of Occupancy.
net nr.ut ed age
Date- TO'fAl.: ISSUED ItY:
OFFICE