S 0649 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
I
CITY OF CUPRRTINO UILDING-ELECTRICAL 1112KMIT NO.
PLUMBING-MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT IIUILDIN:1ROECTIDRNTI4ILATION C 0649 64Q
SANITARY NO. APPLICATION SUPMITTN.DA'1 i1
H_UILDING ADDRESS.
11WNER'S AME a 'IIONIi: C NET ACTORS pMH: x LICNO: N/C ONIROLP
s 6 eo.'x ���►3 ❑
ARCHITECDENGINHER: LIC NO: ADD F.SS: rL
CONTACT; PHONE: 11 BUILDING PERMIT INFO
❑ Crnsultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MUCH
LICENSE ❑ ❑ ❑
renweI hereby iffirin fhad[DCONTRACTORlice v,I under provisions rel'Cliapter 9(cmmnencing QTY
PF.RMI'I'ISSU ELECTRIC PERMIT FEE JOB FEESCRIPTION
S DECLARAI
CIaOZO with Section 7BB(1)ofDnvwon 3 of the Business and Professions Code,andmy lmenwiw RESIDENTIAL.
F ANCE
Ilfsrmim H t ❑SFDWL ❑KITCHEN REMODEL
aUF Class Lep APPLIANCHS-RESIDENTIAL ❑ADD]TION ❑PLUMBING RI:1'll'1:
Dam Contractor
.,y ARCHITECTS DECLARATIONppNELS ❑MULTI-UNIT ❑STRUCTURAL
oz—a I understand my plansshall be used as public mcnMODIFICATION
rds UP T020)AMIlS
[I INTERIOR 11 CHIMNEY REPAIR
W Licensed Pndessional 201-I000AMPS IMPROVEMENT SWIMMING POOLS
f4j 'y OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATHREMODEL/ItEl IR ElDEMOLITION
1 herehy ulllnn thin I am exempt from the Can..stun,License Law In the
igy�(SOyU felluwingaaso.(Section'7031.5,Busine.,sand Profession,Code:A.,citynrr dy SIGNS ELBC'1'RICAh ❑OTHh:RUP U
413 V.F' which re4mit urnxt
uines a pert nmcl,alley,improve,denelish,in repair day structure Me a7
��3 privrtoi"i....cv:.Nom,mers lheapplicant forsush permit In file a signed lecaraeal SPECIAL CIRCUITIMISC.
fssp�t2 that he is licensed punuam to the provisions of the Contractor's License Law(Chapter J
WE5 (commencing with Section 7000)of Division 3 of the Business and Professions Code)nr TEMP.MITER OR POLE INST. COMMERCIAL:
Q.%o yv that he is exempt thcrefraln and the basis for Inc alleged exemption.Any violation of ❑NEW BLDG/ADDITION [D DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not mom than five hundred dollars($5110). IMPROVEMENT
SG ❑I,usnwner of the property,or lay employeeswithwngexmtheirsnle cnmpenxminn, SWIMMING POOL ELECT RIC
will do the work,and the structure is not intended or altered or sale(Sec.70/4,liusinces ❑OTHER'
and Professions Coda:The Contractor's Liernse Law does nal apply In an owner of OUTLF.Tfi—SWI'I'CflBS—PIXB'UItES
a' pnperty who builds or improves thereon,and who ones such work himself or through
his own employees,provided that such impmventents me nm intended or tukered far NEW RESIDEN'I']AL ELECTR SQ PI'.
sale.If.however,the building or improvement is sold within nue year of completion.The SQ.IT,FLOOR AREA $/SQ.IT.
owner-builder will have the barren of proving that he did not build or improve far par. TOTAL: SEP 26 �["
of sale). RE.
"I as owner of The properly,am exclusively contracting with licensed contractors ,,
Conten the project(Sec 7044,Business and Prefcasinm Codi The Conuaonrs Li-
c se Law does not apply to air owner ofpmpenywho haddsorimproves thdent,:rad QTY. PLUMBING PERM I FEE CITY Ur 1,urEKINC
elm enmrads for such pr jcds with a cmnhnmm(0 Ilcensnl purnuam To The Cnnmwmtrx
License Law. MFLOOR.
UANCE
❑ I um caempt track,Scc. ,B&P C for this reason
AIN&V I3 IEA) VALUATION
Owner Dae
• WORnderPCOMPENSATION D[Cl
as BACK IBOi .DEVICE
I hereby affirm under Penalty of perjury one of the followasd a1,ee1 ns:
ion,us dad will l for by eCeni 377 of Comemto Code.for
Workahce afthe L(IOR.ROOF,AREA, ON STORIES TYPE CONSTRUCT ION
smirk,as hick hi for by Salina 3]W ofNe Labor Code,for the pedormunce ofthe E;rwork for which Mix permit is issued. -1'13N'I'NAPI have and will nwiahma Worker's Compensation hwomne.,as ruquired by Sect7710 ortbe Labor Cale.fon is perfrmance.fthc work for which This permit is issued. YS'I'13M-1 NC.40U'FI.pI' OCC.GROUP AFN
My Worker's Compensation Insurance carrier and Policy number arc: -
Canicc Policy Nn: SYS'I'EM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASUINUUSTRi.WASTE INTF:RCIHHY]R
COMPENSATION INSURANCE BUILDING DIVISION FEES
This section need not hecompleted ifthe permit is fortune hundred dollars($IfxB GREASETRAP
or Iesa) PhANCIIECK FEE
I certify that in the pafonndare.f1he wturk for which this permit is issued,Inhall SEWER-SA N If ARY-STORM EA.21X1 IT,
not "'my
sin any munner w atm becalm suhjeo m the Workers'Co ii,cn- ENERGY FEE
O z e. n Law.,o' a?ort in.Dole WATER BTIMHk WNENT/ELECTR GRADING FEE
Applicant
NOTICE TO APPLICAN'.IL a ter making this Cem ificme of Exemption,you should WAT13R SYS'I'13MIJ'REA'TING SOUS FEE
a ; become subject to the W risers Compensation provisions of the labor Code,you must
forthwith comply with such provisions or this permit shall ha deemed revoked. WATER SERVICE
C1. a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,14. PAID
U 0 Iherebyaffirrn thatthe.is.c...towion lending agency Emilie pedormance of Date Beret
the work for which this permit is issued Xce.3097,Civ.C.7
W.
I<nder's Name TOTAL:
W Lender's Address 'ICTAL:
I conify that I have read lhix applicodon and mate thud the above inif all ai Is BUILDih'FIA
cadma.l agree mcarply with city a ad county mrdmanaxaad wile laws rclmin, o QTY. ' MECHANICAL PERMIT PER
U G bulldingamsured,mand berehyamharis reprosenteives nEthiscity mne
ear upsn the 51315MIC FF.E
Z
above-mentioned ImEctr y far inspection purynas. PERMIT ISSUANCE
(We)agree to save,indemnify and kan
p hanle.ss the City of Cupeninn against IiLCCTRIC FEE
Iiahilities,judgmenu,cosisand expenses which may many any deems against said City (—
Cad.,
ALTER OR ADD TO MECH. PLUMBING
in consequence of the granting of This permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITf ALL NO INTAIR HANDLING UNIT(TO 10,000CFM) MECHANIC LPEC
SOURC REGULATIONS.
AIR HANDLING UNIT(OVER IB(IINI CPM) C'ONS'IRU TION TAX
Signature of Applie Co wmnr I to EXHAUST HOOD(WIUUCT7 HOUSING MI ATION FI3U
HAZARDOUS MATERIALS DISCLOSI E
Will th applicardorfuture building occupant store or handle hazardous materialHFATING UNI'I'1'T0 IIXI,Ig1(1 BTU)
as defined by The Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Scam 2553260? HEATING UNU(OVER 101.001 BTIJ)
❑Yes ❑No VENTILATION FAN(SINGLE RESEW) PAID
Dae Rccend
Will the applicant er future building occupant use equipment or devices which
emir hamormci o r cnmaminams as defined by the Buy Arca Air Quality Masagement BOILER (3HP OR 101,W0 BTU) TOTAI,
District? BOILER-COMP(OVER 10T00 BTU)
E]Yes 7N
I have read the hamNtuus mammals requircmems under Chapter 6,95 of The Cali- AIR CON ISS1JVqCE DATE
fordo Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if The NEN'RESIDENT[At.MECIL SQ.PT
building does not currently have a tenant,that it is lay responsibility to notify the rccupmt
of the requirement.,which mu.a M met prier to iavace of a Certificate of Occupancy.
Owner or authmimJ agent Dom 'PO TAL. ISSUED BY:
OFFICE