S 0327 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'F.RTINO BUILDING.ELECTRICAL PERMIT NO.
IiUH,DINC UI VISION APPLICATION/PERMIT
PLUMBINGltojE F:CHANIFIC Q 0 3
IIUILDING YIt(3JEC1'IDI:NTIF'ICA'HON �J lJ
BUILDINGADDRESS: SANITARY N0. API'IACATION SUBMITTAL.DAI'li
t 9 OW ERSN E: Sx PHONE. CONTRACBURIS NAME; LIC NO: 2
NIC GQNTRGi.p
AR E /ENGINEER: hIC NO'. ADD FSS:
CONTACT: PHONE: BLl[LDING PERMIT INFO
L / 9q6 47 D ❑ Consultant Fees Paid by Applicant(ONE:
BU)G ELEC PLUMB MECH
(/I4 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTy. EI.ECTRICPERMIT , FEE,
1 hereby Oran that I am licensed under provisions al Chapter 9 Rommencimg JOB DESCRIPTION
npZp with Sanion]fl(111)nfUivisionloDha Business and Professions Cade,and my license is RESIDENTIAL:
P[RMO'ISSUANCE.
�F, infill forceavdeffat. ❑SFDWL ❑KITCHEN REMODEL
License Class Lic.IT APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RE-PIPE;
�+a4 Doc Contractor 0MULTI-UNIT ❑STRUCTURAL
ARCHITECT'S DECLARATION
PANELS MODIFICATION
Zp4Z ]understand my plana shellMuud as public records UP 10200 AMPS OZ�p ❑INTERIOR ❑CHIMNIiY REPAIR
Licensed Professional 2Ol7111NtAMPS IMPROVEMENT OSWIMM[NGPOOLS
4 J OWNER BUILDER Up OVIiR I(Nl11AMl'S ❑BATH RF,1ODFIJREPAII UEMOI.rr[ON
�J Q I hereby affirm Thal I om exempt from the Contractor's License Law for the
Il p a U following reason.(Section 7011.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTIER
al W O t- which requires a Permit to contract.alter,improve,demolish,or repair any structure i_
fn prior to its issuance,also requires the applicant for such permit to rile a signed alinement SPECIAL CIRCUIT/MISC.
y dhathoklicamedpur...atto the pmvididool the Comrecmr's License Law(Chaptec9
(ssnnmencing with Section](NNOoI'Division lof(he Bmirwomd Professiane Code)or TEMP.MITER OR POLE[NST. COMMERCIAL'
a S 0c C that he is exempt therefrom and the basis far the alleged exemption.Any vinflation of NEW FILDGIADDITION ❑DEMOL.I'I]ON
�m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
y y- nmoquedam five hundred dollars WINDY IMPROVEMENT
L dp I,us owner of the propeny,nr my employees with wages sea thou sole annponeadom, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended or offered for sale(Sao]1144.Business El ITT HER
W so and Professions Crib:The Contractor's License Law does not apply to an owner of DO I'LITS-SWI3'CRISS-FIXTURL'S
a 3..
property who builds or improves thereon,and who doss such work himself or through
his own employees,provided that such improvements are not headed or offered for NEW RESIDENTIAL ELECTR SQ IT.
sole.LE',however.the building or improvanem is sold withinine yearofcodollimm,the SQ.IT.FLOOR ARBA $/SQ.FT.
mer builder will have the burden of proving(hot he did not build.r improve for our-
Ease of aide).
❑ 1,as owner of the property.am aaefinively,oducc ing with licensed connmenms t.
construct the project(Sec.7044,Business and Professions Codep The Contractors Lt. p
empo Lawdoas run apply loan ownerofpropeny whobaildsor improves thereon,and QTY. PLUMBING PERMIT Fri?: /0
wan contracts for.such project,with a contmcmf(s)licensed pursuant to the Contractor's
License low. PE
m
-RMI ISSUANCE
Iaexemptunder Sec. ,B&PCnath[sreoson
ALTER-DRAIN A,VENT-WA .R ) 01
Owner WORKER'S COMPENSATION DECLARATION BACK PLOW PRO ECT.DEVICE
I hereby affirm under penalty of perjury one of the following delara(ions: V `- n
•�Ihave andwill muimainaCcnificats of Cotham to selGinsurcfor Workers Cnmpen- DRAINS-FLOOR,ROOF.AREA,GOND. STORIES V TYPE.CONSTRUCTION
sudon,as provided for by Section 3]00 of the Labor Code,lin the performance of the
work for which IN,permit is Issued. FIXTURES-PER'I'RAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code.for the performance of the work for which this permit is issued. GAS-EA.SYSI1RM-I INC.4 OUTLETS ICC.GROUP MIN
My Warkeh Qn nc tion fns EPmeeca Brand Polley nu Mr GAS-IiA.SYSTEM OVER 4(PAT
Cortise I'nlity No.: A
Cf:RI'IP ATEOFEXEMVUON FROM WORK,RS' GRI.ASI%INDUSTRI,WAS'I'Ii INB'ERCEPIDIR
COMPENSATION INSURANCE BUILDING DIVISION FITHS
(This section need not he completed if the permit is Tonne hundred dollars 100) GREASETRAP
or less.)(This PLANCHECK FEE
lceriryth:n inthe performance ofthe work for which this permit isiswed,lshall SEW17R-SANITARY-STORM I!A.200 FT.
not employ any person in any Inunner sone us become subject In the Workers'Compere- ENERGY PER.
�Z sand Lows of C.fmnd..Dude WATER HEATER W/VENT/ELECfR GRADING FEE
Z Q Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WA'D.R SYSTEMITREATING
(-' y hecame subject to the Worked Connpenardion provisions of the Labor Cale,you must 50114 FEE
forhwilh comply with such provisions or this per rit shall ha deemed revoked MAI lilt SERVICE.
Q
CONSTRUCTION LENDING AGENCY NEW R[SIDF,NTIAI.PCMB. SQ.1T. PAID
L) 0 Ihereby o0irm that them is aconswminn lending agency for the performance of Das pt
ReceiM
p+ the work for which this grand is issued(Sec.3097,Civ.C.)
Leader's Nome 'TOTAL,:
0 U Lended Address TOTAL"
d I cenify that I have read this application and state that the above information ii BUILDING PERtFih correct.l agree to comply with nil city and county ordinances and state laws relmingm QTY. MECHANICAL P13RNIIT FF,F,
U � bndtingcoreductioo,and hemby:mthmire representatives of(hiscity manner uponthe SEISMIC KE
inane-meri.nnl property for inspection pmpnms. P17RMI'IISSUANCE
(We)agrsave,indemnify and kap haddra,w the City of Coperino against ELEC
ee m TRIC PEI.
liabili(ies,judgmems.crashed expenses which may in any way actors,againn.so ly ALTER OR ADD TO MECH. PLUMBING FEE a
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILT.COMPLY W H ALL Is' -P 1 IR HANDLING 11Nl'1'(TO IB,INIB CPM) MECHANICAL FEE
SOURCE REGULATIONS,
oo AIR HANDLING UNIT LOVER III,II(NI CFhf) CONSTRUCTION TAX
Sig re ofA picanVContmcmr U. IIAUSTHOOD(W/DUCT) HOUSING'MFI'IGATIONFEE
HAZARDOUS MATERIALS SC )SURF.
Will the applicant or future budding.ccupnm sat nrlmndlehmurr us material HEAUNGUNI'I'fIO100,00(IB'i'U)
as definod by the Cupertino Municipal Code,Chapter 9.12,unit the lleol n urea Safety
Code,Section 25532(x)? 1 HEATING UNIT(OVER 100.0014)BTU)
C-]yes ON. VEN'I'I LATION FA N(S INGLE RES I D) PAI[)
Dade - RwapIM
Will the applicant or future building occupant use equipment or devices which ❑OILP,R-COMP(711PORIW,INN)BTU)
emit hazardous air comaminonds as defined by the Bay Area Air Quality Management 'TOTAL:
d Dilmell Yes ❑No BOILER-COMP(OVER 100,000 BTO)
1 Ihave rendthehound...ndeielsregmiremems under Chapter fi95nrthe Cali.. AIR CONDITIONER ISSUANCE DATE
Emit Heahh&Safety Code.Sections 25505,25533 and 25514.1 undamand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant.that it is my responsibility in notify the occupied
of the requirements which must he me(prior m issuance of a Ccrificam.f(kcupancy.
Owneroratuhademal Ogen( Date TOTAL: ISSUEDB
OFFICE