S 0216 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPF,RTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING D ERTIN AP PLICA'I'IOWPERMIT PLUMBING-MECHANICALVISIOS 0 216
BUILDING PROJF.Cr 1DF_N'I IVICATION
BUILDGD/JJR�LMS
SANITARY APPLICATIONSUBMITTAL DATE
ml
A04(
OWNER -771-W
NIRA T �
SIC CON'fkOhp
ARCHITECUENGINGER: LIC NO: D ..�„ C.lA+�Q e^ ❑
CONTACT r PH � /„ S.� IiU1LDING PERMITINFO
Cf/1 V� ❑ Cambium Fres Paid by Applicant(initial) BLDG a PLUSY MEC
LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT FEE ❑
1 hereby affirm that I am licemed Boder provisions of Chapmr 9 femanicncing _ JOB DESCRIPTION
WOZ with Scminn]OW7pf DivisinnJof the Business and , fessia Cr dmyncense is PERMIT ISSUANCE a RESIDENTIAL,
F-1= in full L,mumel effec�k ❑SFDWI, ❑KITCHEN REMODEL
aU Lsc Ise Ins Lick APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING R&PIPE
F Uatc Cnnannor
M 0. ❑MIJUN-UNIT ❑STRUC'I'ORAL
A CIII'I'CCT'S DCCLAkATION
P. 24 PANti1.S MODIPICA'I'[ON
zq� , IunJerctand my plane shall bu used os public records
oz- UP TO 21x1 AMPS
O Z P- ❑INTERIOR ❑CHIMNEY REPAIR
F•,N-0.61LicemeJ Professional 201-100OAMPS IMPROVEMF:N'f C]SWIMMING IDOLS
OWNER-BUILDER DECLARATION OVER IONAMPS ❑RATHRF,M0 EIJRFE IR ryTy DliNdy11(TION
OC a 1 hereby affirm that 1 all,exempt from he Cmume, rs License law for lie
❑UTHIiR
kOLU following reusai(Sectinn7031.5.Bu.inessand Pmfessinnr Cale:Any city nr cnon,Y SIGNS ELECTRICAL
❑136,Q which require,.permit to emmaracL alter,improve,demolish,nr repair any stomome n •�� A
F'y�J prior to its issuance,else r ail the applicant for such permit o Plc a signed statement TSPECI At.Cl RCOIIIM1SC.
50 thmrrncncimg wit pSectionothe efylvion,of the Cnmmcmr'a Lleerxe Law(Code)at
�� (cpnnncnoing with Secdon]fX0)nf Uivixlon3pfthe Business and Prnldssinns Cnde)m TL'MI'.MIfER OR M)LE INST. I COMMERCIAL'
0.W N that he is exempt therefmm and the basis for the alleged exemption.Any sadmian of ❑NEW BLDG/ADDITION ❑DEMOLI'T'ION
iEyW
yeah na]031.5 by any upplicam lis a permit subject,theapplicant to a civil penaltyofNNEW
DI iVICES 01HNANT El FOOD sERVICE.
I„t Bat marc than Bvc hundred dolhux QS(NB. IMPROVEMENT
6 D 1,as owner of the property,or my employees with wages us their sole compensation, INGPOOLELEC C
will Jo the work,and the st reclum is not intended proffered fnrxale(Sec.7094,Business ❑O'fl ll?H
Winand Professions Cnde:The Contractor's License law does not apply ,,un owner ofrS-SWITCHES-
�' property who builds or improves thereon,and who does such work himself or through
his own nnployees,provided thus such impmvemems are not intended or offeml forSIDENI'IAL SQ
sale.IL however,the building or improvement is sold within one yea of rontplction,the SQ.FL IT.00R ARBA SISQ.19'.
owner-builder will have the burden of proving that he did not build or improve for pur-
Nwo fsnla).
I,as owner of the pracipsoly,ant excluavely Continuing with licensed contractors to
amsume,the project(Sec.704L Business and Professions Cale:)'Hic Connector,Li-
nxeLaw does not apply ll)anowner ofpropenywho builds or hapmves lnerenn.and QTY, PLUMBING PERMIT .E
Li-
ce
farsnch projects with acmmrtmnr(s)licemed'mans I tothe Conwmor's
License Law. PERM I'I'ISSUANCE
1 um exempt under Sec. .B&I'C fnr this reason
ALTER-DRAIN&VGNT-WATBR EA) &VALU71ON
Owner Da1a /oy —_•
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby Call under penalty ofperjmy one of the following declarations:
I have and will maintain a Certificate of Comenuo self-inure for Worker's Camper- DRAINS-FLOOR,ROOF.AREA,COND, - STORIES '1'Y pECONSTRUCION
ro
sation,as pvided for by Section 3](0 of the Labor Cade,for the penfomtance of the
w kfonvenchlhispernit Lsis.mcd FIXTURES-PER TRAP
have and will matin Worker's Compensation Insurance,as rational by Section
3710 of the Lob yy Cute,for the perhvnumce ofthewprkfor hthi permit is issued. GAS-13A.SYSTEM IINC.4 OUTLETS OCC.GROUP APN
My Wos�rs pFyitM1km and Fetid 01
l.-Q-liI7P�ytyn}rytunmce cwrlw
Carrier: /w(L_Policy No.: OAS-BA,SYSTI:M�OV13R 4(BA)
CERTIFlC T13 Oil COMPENSATION INSURANCE
FROM WORKERS GRP.ASIVINDIISTRL WASTE IN ERCEIvInIt
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This stion need not be completed if the patternis for one hundred dollars($1001 GRGASI3TRAP
nr less.) V1,ANCIIliCK 103E
I certify that in the performance lithe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.2(0 IT.
not employ any person in any manner.ut as m heaven.subject n the Warkcn'Compen- ENERGY FEE
OZ satipn Low,of C.1ifomA'T'
ia.Dole WATER HEAVER W/VENT/ELECI'R GRADING FEE Applicant
NOTICE TO APPLICANT If,alter milking this Cephicme of Exertplain,you should WATER SYSTEM/TREATING
(~ [' become subject to the Workers Compensation provisions of the Lalun Code,you must SOILS FEE
Wmy fnnhwith emnply with sucb provisions nr this pennitshull hedecmed revoked. WA113R S13RVICH
4 Q
CONSTRUCTION LENDINGAGCNCY NEW k1iSIDIiNTIAI.PLMB. SV.I'I'. PAID
`r7 Z Dula Receipt p
L7p l farebyaffithimanhemisammstmaipnlendingagency bar theperfnmmncc of
tr Lhe Cra work far which this pemtit in lsxded(See.309],Civ.Cd
� (~ IsnJer,Name TOTAL:
ULenders Address TOTAL
>' 4 I verle ify that I have mail thin application and stathat the aM,ve automation is NIIILDING ITE
rFah correct.l agree to comply with all city and county ordinances and state lows relating n' QTY. MECHANICAL PERMIT FEE
C) 7 building Construction,and hereby authorize representatives of this city to enter um the SEISMIC FEE
above-mentioned property for inspation p I've'. PERMIT ISSUANCE ,
(We)agree to save,indemnify and keep harmlesmin
harmless he City of Cupo ngainIt ELECTRIC FEE
liabilities,judgments,costs and expanses which may in any way overlie against said City AC1'131t OR ALI)11)MECH.
in .sequence of ma granting ol'thi.s perntiL PLUMBING.PUP
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'(TO 10,000 CFM)
SOURCE REGULATIONS. MI3CIIANICN,PEE, f
AIR HANDLING ON,(OVER 10.000 CIM) CONS]RUCTION TAX
Signatum of Applican/Contmmor Data EXHAUST II(OD OVMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building aceupunt sroreor handle balance.,material HEAPING UNIT(To 100.000 BTU) s
as defined by the Cupertino Municipal Cole,Chapter 9.12.and the Health and Safety
Cole,Section 25532(x)^ IHINTING UNIT(OVER 110.000 B OU
C)Yes No VENTH.AI'ION FAN(SINGLE RESID) PAID
Dom Receipt#
Will the.,heart or future building nwapant use etulpntcid mdesi.,which BOILER-COMI'(3111'ORIOI1,W11 IT,
emit hamoluus air camaminants as defined by the Bay Arca Air Quality Management TOI'A1,
District? Yes BOILER (OVER 100.( 0 BTU)
❑ 11No
(have the haunted,mtmtials u under Chapter(095 of me Cali IE Alit CONDITIONER , ISSUANCE,DATE
myuire
fomiu Health afety Cak,Sections 23505.853J and 255J4.1 umlaa d that if the NEW RI'SIUEN'1'IAL MECH. SQ.FF.
building c lyhavea enanLthaitismyres,onshiloyti ,,yther cupam
of 9i•^ o b' s Ipmar issuame ofa Ce u
cane ramh iud agent giant (YFAL: s ISSUED BY
OFFICE