30102 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILD I 30102
NG-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PF.RMIT PLUMB;NG-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
°uzi O PtL.ivE.¢Z Rvr;- 6
OW ft;M PHONE: CONTRACTOR'S NAME: LIC NO:
NIC CONTROL#
ROUT ZCf/ENGIp�ER: LIC NO: ADDRESS: El
CONTACT: �7,'f`7�•/. Q �Pyp 3 BUILDING PERMIT INFO
G2� 1SWA."%W �����+ ❑ Consultant Fees Paid byApplicant(Initlal) B_L�DyT EL)EC PLUMB #FAH
LICENSED CONTRACTOR'S DECLARATION QTY. ELIiCTRIC PERMIT FEE
I hereby affirm dhat I am licensed under provisions n(Chaprcr 9lttrmmersing JOB DESCRIPTION
CZp with Section?000)of Division 3 ofthe Businessand Profeasiom Cade.and my license is PERMIT ISSUANCE RESIDENTIAL•
me
n fallfene Class it affect. ❑SFDWL ❑KITCHEN REMODEL
�U License Class Lic.p
FF.. Dare Contractor APPLIANCES-RCSIDF,N'reAL ❑ADDITION ❑PLUMBING RE-PIPE
Iy,7y ARCHI'fECFS DECLARATION ❑MULT6UNIT ❑STRUCTURAI.
I understand m plans shall be used as Public rccmds PANELS
G Z Z y P P UPTO 2MODIFICATION
_ 110 AMPS ❑INTERIOR [I CHIMNEY REPAIR
�+.m{.�' Licensed Pmfosainnpl 201-1000AMPS IMPROVEMENT
OWNER-BUILDER exemp from
DeCe Comm ON OVER 1000AMPS ❑BATH REMODEL/RF.PAIR ❑DEMOLITION
y 1 hereby.(Sect that I am exempt from rhe Contrnctuts License Law for the
X 36 F following reason.(Section]onstru Bu sines and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
LL] Y, which requires a permit re construct,peter,improve,demolish,or repair any swemm
' �> Chit l inhe
lend purs ant to he reamer,lhovisio soothe suchContremrifmicense aw(smtemmn SPECIAL CIRCUIT/MISC.
} that he is licensed pursuant to provisions of Ne Contractor's License Lew(Chapter 9
m_po (commencing with Section 7")ofDivision 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. '
C.{y o r that he is exempt therefrom end the basis for the alleged exemption. ,vinlvtion of JCNFW BLDG/ADDITION [I DEMOLITION
ire Io Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
} not more than live hundred dollars($500). ❑TENANT ❑1'OOD SERVICE
£ � ❑1,as ownmofthe propeny,ormy employees with wagesis their sole compensation, SWIMMING POOL ELECTRIC IMPROVEME
will do the work,and the sanctum is not intenddloroffeml hostile(Sce.]O4q Business []OTHER 'sir
add Professions Code The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pmpeny who milds or improves Hires.,and who does such work himadf m through a^
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ IT
sale.If,howeverthe building or improvement is sold within one year of completion,he SQ.FT FLOOR AREA $/SQ.FT.
pum if one.).
will have the burden of proving that he did not holed or improve for par- �i'q O�
pose of sowne
❑ spat owner of the prnpeny,ton exclusively Professions with licensed urnicam'sa to
consumer the project(Sec.]044,Business and Professions CodcO The Cnmrw:eoes Li-
came low does not apply to as owner of pri who builds or imp Teen thereon,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a contracmrtp licensed pursuant the Contravenes
License Law. PI' UANCE
❑1.,if exempt under Sec ,It&P C bar his reason
AI.TIiRt &VENT-WATER(EA)
Owner Date V
nnALUATION
WORKERS COMPENSATION DECLARATION BACKFLOW R `DRVICP. I ��'1/J rriQ Ira ��
I hereby affirm under penalty of perjury ane of the following declarations: LA (�w�
I have and will maintain a Cerldieamof Conacm mself-insure for Worker's Comped- DRAINS-FLOOR, ,A` -GOND. C TYPE CONSTRUCTION
anion,a provided for by Section 37M of the Labor Code,for the performance of the {Jsjl 7 1.
work for which this permit is issued. RXYU - •R TRAP -.�
❑1 have and will maintain Worker's Compensation Insurance,as inquired by Section 11
37M of the Labor Code,for the performance of the work for which this permit is issued ;OAS- 'BM-I INC.4O
My Workers Compensation Insurance tartlet and Policy number art: - IdleOCC.GROUP r yr VUf Cfi il�V AIN
Cartier. Policy No.: QMS-CA.SYS _ ER41EA7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRI? DUSTRI.WA. E CEPTOR BUILDING DIVISION F''S
(This section need not he completed if the permit is for one hundred dollars(S 100) -
orless.) OVOTRA PLANCHECK HE
I certify that in the prof o.....f the work far which this permit is issued,I shall
net employ any person in any manner so as to become subject to me Workers,Co.,.. SEWER- TAR RM EA.2O0 EL
,Z satin Lawsof Colifstrou Dam ENERGY FEE
Z WATIiIATIiR ENT/- TR
Z O Applicant GRADING FEE
.Ni NOTICE TO APPLICANT:If, for making this Ccnifieme of Cxemptin,you alto ild WATER SYSTE BEATING
F` become subjecd do the Worker's Compensation provisions of the Labor CMe,yon muvSOILS FCR.
forthwith comply with such provisions or this permit shall he deemed revoked. WATERSERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT '�O�1D
LJ Q (hereby affirm that them is v construction lending agency for the perfommncr,of g,J Dam R¢ n t O
41. f• the work for which this parotid is issued(Sec.3197,Civ,C.)
0 U ......Name TOTAL
I
l ^ Addrcas )Tp
Q. certify that 1 have read this application and stem that the above information is 1 TNG FEE is,
N cortecn.I agree mcomply with all city and county ordinances end nom laws relining to QTY. MECHANICAL PERMIT FEE n�
GZ building construction.and hemisy authoriurcpmseratives ofthis city mcneeruponthe
SEISMIC FEE �Lr
a ame-fr ntioned pmpeny for inspection purposes.
PERMIT ISSUANCE
(We)egret to sove,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE, �-d
liabilities,judgments,amassed expenses which may in any way accomfigainst said City ALTER OR ADD TO MECH. p
in command.alder,granting nfrhik permit 'LUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLNON-POINT AIR HANDLING UNIT(TO 110,0X0 CFM)
SOURCE REGULATIONS. MECHANICAL FEF. ^Q -
AIRDANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
941 J P,41
Signature dApplicvnVCordracter Date EXHAUST FOOD(WMUCD f HOUSING MITIGATION FEC -�HAZARDOUS MATERIALS DISCLOSURE
Wi 11 the applicant or future mildingoccupandsmre or handle maromislnamdul HEATI NO UNIT TO 1O0,000 WrLD
as defined by de Cupcnino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532fa7'! HEATING UNIT(OVER 100,100 BTU)
El Yes ❑No / (110
VENTILATION PAN SINGLERE.SID7 PAID
Will the applicant ar future building Ilse Receipd p
4, itgbytheu seequipmentofdeviceswhich BOILER-COMP
Lmid hazardous air mntwetinands ns defined by the Bay Area Air Quality Management (3HPQR 1011,00(1 BTU)
UisWn] - TOTAL:
❑Yea EJ No BOILER-COMP(OVER loamm BTif) ' p
I have tend the haeardom materials requirements under Chapter 6,9.5 of the Cali- AIR CONDITIONER ISSUANCE DATE /a
forma Ilulth 8 Safety Cade,Section 25So5,25533 and 255.9.1 underswml mn dam NEW RESIDENTIAL MECH. SQ.FT.
building does not enrtednly have a Icni Nat it is my responsibility do unify beefeater,of Ne requirements which most ho met prior m occur.of n Ceniftcate of Ocvetpancy.
Owner or authonzed.gent Data- TOTAL:
ISSUED BY
OFFICE �I