30385 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINOLDBUILDING-ELECTRICAL PHRMITNO. �O L5
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICNFION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
OW C'S AME rl 2-1 RI Q PHONE: CO AC'1'OIR�'.S✓A is �I .IC N�
/ N/C CONTROLX
ARCHITECT/1?NGINF.F,R: LIC NO: ADORES$: � i ❑
fill
CONTACT: PHONE: BUILDING PERMIT INFO
` ^ /' f�/—/000
�a,�s y� ❑ Consultant Fces Paid by Applicant(Initial) BLDG ELECT PLUMB ME IT
GAS cokli4✓Ir r (J00 ❑ yi ❑ ❑
LICENSED CONTRACTORS DECLARA'MON QTY. ELECTRIC PERMIT FEF:
1 hereby aRirro that 1 am licensed codec provisions of Chapter 9(commencing JOB DESCRIPTION
C 00 will)Section 7000)of Division 3ofthe Business mut Poollaseiom Code,and mylicenm is
fc,�0 in 1'1!ItMI'T ISSUANCE' RESIDENTIAL:
full force nnJ a t.
�UE License c r'�� Lic.a 7gZ3 / ❑SPDWL ❑KITCHC•N REMODEL
((J� hale &a.'_Cr APPLIANCES-RES IDENTIAL
FZflc ❑ADDITION ❑PLUMBING RF.-PIPE
�rnn GG�y ANCHI'l1iCf:S DECLAHATI N ❑MULTFUNIT ❑STRUCTURAL
F PANELS
ZOI-Z IunJcrs[ant my plans shall be used ns public rccoNs' MODIFICATION
OZ-0 UP TO 200 AMPS []INTERIOR C1 CHIMNEY REPAIR
[=',3 F'n� Licensed Profexxionel 201d(100AMPS IMPROVEMENT
¢a J OWNER-BUILDF.RDECLARATION OVER 10WAMPS
Ni6 1 hereby affirm that 1 um exempt from the Contruclor's License Law for the Ts❑[,B,ATyyHFF RF.Mq/D/E,'VRRPAIR DEM LITTON
x LL O F following rensun.(Section LIJLS,Business and Professions L'(Me:Any city or caumY SIGNS ELECTRICAL K60;t n 49
u1which its issuance.
a n permit to quires t ct,alter.improve,demolish,or repair any statement
i ✓n -�0
r/�� prior to its iesuunce.also requires the applicant for such permit Eleusigned smtemem SPISCIAL CIRCUITIMISC.
M [bill be is licensed pursumn to the provisions of the One sent''s].',cause Law Chapter
W�(CO (commencing with Section(NEO)of llivision3ol'tl¢Business and PntfessionsCWe)or THMP.METER OR POLE INST. COMMERCIAL:
Q.ax n C [hot he is exempt therefrom and the heads for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W ySerum.70315 by myapplicunt fora permitsubjects the applicant m a civil Penalty of POWER DEVICES
n momthan five hundreddollac(E50)a ❑TENANT ❑FOOD SERVICE
QI,as owner of theorm lois with woes as theirsole cont nsation, SWIMMING POOL ELECT RIC IMPROVEMENT
sti0 O property au Yrrttp Y g pe
II dothework,nodthe is Coeisnotintendedo Lawdd(ansate(Sec.o(ld,Business ❑OTHER
3 m
and Professions il&Code:The C improve,them/s hicenac Law saes nm apply to un owner of OUTLETS-SWITCHES-FI%TURES
propeny who oy ers.ortidednththereon,and who Jacs such work himself or th d I
his own employees,provided that eueb improvnnemx are not intended nr offered for NEW HESIUI?N'1']AL❑Lf?GTR SQ FI'.
sale.If,however,the building or improvement is sold within ane yearofco..pletiren,the SQ.IT.FLOOR AREA $/$Q.FT.
owner-builder will havethe burden urinating that he did not build or improve for par ar••e Pie/( n
lntsa of sale.).
p 1,os marmot in,Import ,em exclusively cnntrneting with licensed eontracmrs
sero the p..jem(Set.70kPI.Businessland!Professions CWe:)The Cnmractnr's Li� �p
cense Law does not apply to on ownerofpropary who builds or improves therceat.and QTY, PLUMBING PERMIT FEE
whocontratsfor such prayers with a commcmr(s)licensed purscam tothe Contractor's / �yno
License Law. P-It MIT ISSUANCE - `�! !s, 1996
❑I am exempt under Sec. ,B&P C for ihl.s reamn -! L U
ALTER-DRAIN&VENT-WATER(FA)
Owner Data
- _-VALUATION
• WORKER'S COMPENSATION DECLARA'P10N BACK FLOW PROTECT EV
JA
I hereby affirm under penalty of perjury one of the following declarations:
I have=n will maintain a Cenifatcof Consentto selfimme for Worker's Camper- DRAINS-FLOOR,RO AR ,COND' STONIFS J'YPB CONSTRUCTION
amino,ea provided for by Section 37M of the Labor Coale,for the performance of the
kt farwhich this permit is issued. FIXI DRES-PERT
1 have and will maintain Worker's Cnmpemalion Insurance,as terminal by Section
3] offoe LabarCWC.flat the penhnmance of the work fore 'c]t this permit is issued. GAS-EA.SYSTEM-1R40 .ETS OCC GROUP qYN
M R1eof ."eLnan an .
aaarl1 � yy
GAS-EA.SYSTEM : ( )
CERTIFICATE OF I!XE!MPTION FROM WORKERS'
COMPENSATION INSURANCE GRIiASFJ]NDUSTRL WAS'IEI UR
CDtis action need not brrompiciM if the permit is foranc hundreddnllms(51 W) BUILDING DIVISION FEES
nr leas.) GREASETRAP PLANCHECK FEE
I cedify that in(hit orformance ofthe work lbrwhich this permit is issued,l that SEWER-SANITARY-S"f(]RM 8A.2ql FT.
nal employ any person many manner eo.a m several,subject to the Work,.Compere - ENERGY FEE
Oz smion laws of Celifomia.Dam WATER HEATER WNENT/ELECIR
Applicant GRADING FEE
h NOTICH'10 APPLICAN'E If,offer tanking his CenlOatm of Exemption,you should WATER SYSTENUTREATING
a ; became suhject to the Worker's Compensation pmvisiom of the Labor Code,you must SOILS FEL!
Wforthwith comply with such provisions or[his permit shall be teemed mvaked.
Q WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
U l hereby affirm that hem is u connotation lending agency for the perl'ormence of Dam R eipl
W (, the weak far which this permit is issued(Sec.3W2,Ci,C.)
0 U Lender's Name TpTgl..
Lender's Address TOTAL:
Ifa il'y that l have find this application and.state[hal thenbove information is BUIIDIN 1',
Vi correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEF,
C.)Z building construction,and hereby authorize representatives ofthis city to enmruponthe SEISMIC FEL!
.hove-mentioned propeny for inspection purposes. PERMIT ISSUANCE
(We agree to snug Indemnify and keep taintless the City
a sertinn against ELECTRIC F13
liabilities.judgments,cess end expemcs which mayin any way be aim[said City ALTER OR ADD TO MECtI.
to coneeyurnce.fine granting of this permit. PLUMBIN EEE
APPLICANT OF DS AND W}}}f COMPLY WIT IL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURC NS, //� MF,CHANIC FEE
/a{ AIN HANDLING UNIT(OVER 10,00h CFM) CONSTRUCT] TAX
Signawre of pla"a"Contracmr Line EXHAUST FOOD(W)DULT) HOUSING MITI TION FF.F,
HAZANDOUS ��tt .S DISCLOSURE
Will the applicant or future bili ing+ccupant store or handle hemrdou.s national HEATING UNIT LTD IWAXI BTU)
e,defined by the Cupenmo Municipal CWe,Chapter 9.12,and the Health and Safety
CWe.Section 25532(0)1 HEATING UNIT(OVER Ilk,"BTU)
El Yet, C]No PAID
V ENTILATION PAN(SINGLE LIPS]D) am Recent
Will the it contaminants
or future building by the tryse Area
Air
mlity or Managemces ent BOILER-COMP CHIP OR IWADO BTU)
mil hazardous air ronmminaors as Defined by the Bey Area Air Quality Management TOTAL.
Distract? - BOILER-COMP(OVER BB,DdBBTU)
❑YesO
' ❑Na '
I have mad the Mr Noss materials psrr AIR CONDITIONER ISSUANCE DATE
mluimmenB unser Cha 6.95 of the Cali
famin Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that tithe NEW RESIDENTIAL MEED. SQ.FT.
building does not currently have o from,that it is my responsibility t<I notify the occupant
of the requirements which must be met prior to issuan¢of a Certificate of Occupancy.
Owner or mumnized agent Date TOTAL: ISSUED BY:
OFFICE