31267 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPERI'INO - BUILDING-ELECTRICAL PERMI'ENO' r
_'BUILDING DIVISION APPLICATION/PERMIT PING R OJECTFIDENTIFIC 31267 1 /6 7
BUILDING PROJECT IDENTIFICATION J1LV 1
LDINGADDRh55: _ { ��� SANITARY NO. •APPLICATION SUeMIT'I'ALDATI
Jun
'S NAMPHONE: CON ACTOR'S 1 NO: `O�e
- h NIC CON//NTRR�...OL#
tC
RCH ECT NGINEER: LIC NO: DDRES40050,
ON'TnCT. / PHONE: BUILDING PERMIT INFO/'�_•�`/
CnilSWtant Fm Paid by ApplicaN(Initial) _ BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARAI[OON N/ QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DZZ with Scam 0000 of.1d,ore 3ofthe Businstlind Professions Code,mdmy license is RESIDENTIAL:
00 PERMIT ISSUANCE
�IyF LicensoR e
ClassJefRn. �$I'DWI. • ❑KITDHEN REMODIif.
onzHU License Class Cmir APPLIANCES—RESIDENTIAL. EIADDITION ❑PLUMBING RE-PIPE
Qg. Date' - 'TSDE rr
F=>y ARCHITECTS DECLARATION PANELS '�MUL'I'I-UNIT El STRUCTURAL
ZOnq ',s I understand my Plans shall he Used us public records;. - ;. .MODIFICATION
UPT0 2W AMPS
OZ—Q ❑INTERIOR ❑CHIMNEY REPAIR
<�H.to I.ia,U,Od Protest innnl 201-1005AMPS - IMPROVEMENT
Se OWNER BUILDER DECLARATION OVER IIXATAMPS [I BATH RF:MODEIJREPAIR ❑DCMOLIT'ION
R•w I hereby o irm that I um exempt from the Contractor's License Low for the
?g5�6U following rear..(Section]031.5.Rustmo, ad Pmfessions Cals.Any city or counly SIGNS ELECTRICAL ❑OTHER
FI'• which requires a Formal to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also q the applicantf h permitl file signed statement SPEC IAL CIRCUIT/MISC.
ythat h .hen ed pursuant the provisions f the Commences L tense La (Chapter 9
CO (con mm�c'ng the Section]00(h fD' si: 3tf the Bui res, Idle fe-'i l Cn)a)or IEM P.M ETEk OR POLEINST. COMMERCIAL:
6
Ho'
o CC that he a exempt therefrom and the basis for the alleged exemption.Any violation of � ❑NEW BLDG/ADDITION ❑DEMOLITION
%,�d I+• Section]031.5 by any applicant far u permit subjects Lha applicant m v civil penalty of POWER DEVICES-
61,U, [I TENANT El FOOD SERVICE
I„>y nal marc than five hundred dollars($500f IMPROVEMENT
d []I,usowaerof the Property.nr my airplay.with wngev as their sole amlper,ation, SWIMMING POOL ELECTRIC
willJmhework,and the structure is not intended or offered for.sule,(See](Wq Business ❑OTHER,
k] m sad Professions CnJa The Contmmors License Law does not apply man owner of OUTLETS—,SWITCHES—FIXTURES
p' properly who builds or improves Ihereu..and who does such work himself.,through
his own employees,provided that such improvements,are not intended or offered for NEW RFSIDF.NTIAL ELECIR
sale:IL however the building or improvement is sold within one yearof completiml, r-
the SQ.FTFLOORAREA S/SQ.TE
b
caner- uilder will have the buNen alproving OUR he did mol build or improve for Fu
poseouildi.
El 1,a, rof the progeny,aexclusively contracting wiffibacnsed contractors to
o..uuci theprogeny, m I Sop.]1144,Bttsinesn linU Pndcaslnna CnlcO The Cnnln¢nlr e.Lb `^
p`°'" 2�1
cense i.nw Joos mol applYman owner of pmpeny who builds mini,niewstherean,snd 1'Y. PLUMBING PERMIT FEE
who contracts fm,nch projecls with a contractors)licensed pursuant m�he Crmmcmrs
License Low. I
' PERMIT ISSUANCE
❑1 or.exempt under Sea. B&P C for this reason
Owner Data ALTER—DRAIN&VENT—WATER HU, VALUATION
WORKER'S COMPENSATION DECLARATION " BACK FLOW FOOD=DEVICE I�I .►�
I hereby afiret under penalty of perjury one of the following declarations:
I have and will maintain a Cenificamof Consenuosdf-insnm for Worker's Croatian- D14AINS—FLOOR,'ROOF,AREA,COND. 5'1'ORIliS TY :C(INSTItUCf10N
sation,as provided for by Seadan 37110 of the Lahor Core,for the performance of the '
work for which this permit is Issued. FIXTURES-1•ER TRAP_
I have and will maintain Workers Compensation Insurance,as required by Section
39011 of the Lalsr Code,for the perfrnnance of the work for which this permitisissued. GAS—PA.SYSTEM-1 INCA OUTLETS01 OCC OROIIIAPN
My Workers Compensation Insumncc commercial Policy number are: 1
Carrier: Policy No.: GAS—EA.SYSTEM OVER 4 mg) ,w I ,
CERTINCATB OP EXEMPTION FROM WORKERS'
" COMPENSATION INSURANCE GREASFIINDUSTRI.WASTE INTERCEPIT)N
(This section need not ha completed ifhepenmit is for one hundred dollars S W) Hill > VISION FEES
ones") !- GREASETRAP PLANCHECKFW
I cenffy them in the performance ofthe work Ter which,hispermil is rowed;l-shall beSEWER—SANITARY—STORM FA.2W FT.
not employ any person in any mannenn as to came object the Worker'Compete `' ENERGY PE
,Z nation Laws of California.Duro Qi, V
7C) Applicant ' - WATER HEA'1'BR W/V 'VELLL'fR GRADING FEE
q NO'fICE'ro APPLICANT:R;eftar making IM1i.,Caniticma of Exemptial,you shnnlJ WATER SYSTI3M/fl<EATING
F•' become subject to the Warkeex Compensation provisions of the Labor Cale,you must SOILS FEE
•wQ forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE -
CCASTRUCTION LENDING AGENCY. , NEW RESIDENTIAL PLMIL .,SQ.FT PAID
VU6. Iherebyieffirm that],,,a lending agency for the performance at Data Re I I
F the work for which this Permit is issued(Sec.3097.Civ.C)
Q V Lender's Name _ 'TOTAL:
L>a Lenders Address I
i cmify Ihul I hove read this upplicmion nnJ store thus the uMve inliamminn is BUILDING FEE
f0./2 coater legreemcomply with ala city and enemy oNiwnces and slate laws relatingm QTY. M17CHANICAL PERMIT FEE
U buildi ng'amstiuction,and hereby vu,bnrize represmuutives ofthis canyon entim,amthe SEISMIC FEE
L Ink
above-mentioned property for inspection purposes. I I `
(We)agree to save,indemnify and keep harmless the Cityor Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liahilines,jadgmena,masand expenses whtchmay in any wayac<meagainsl said City ALTER OR ADD TO MECIi. •
in nsegnence of the grunting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONTOINT AIR HANDLING UNIT(TO 10,11011 CPM)
SOURCE REGULATIONS. MECHANICAL.FEE
AIR HANDLING UNIT(OVER 10.0(IOCFM) CONSTRUCTIONTAX
Signamreof Applicant/Contractor Dere - EXHAUST HOOD(W/DUCT) HOUSING MITIGATION Flil3
HAZARDOUS MATERIALS DISCLOSURE
Will lheappliaant or future bmildingnacupanbmre or hand he hazardous material 'HEATING UNIT(TO 100,010 BTIU
Us defined by He Caperton,Municipal Cade,Chapter 9.12,and tic Health and Safely
Ca1C Scction 35532(v)V , I - HEATING UNIT(OVER 100,000 BTU)
E]Yes C)No PAN
VENTILATION FAN(SINGLE R[SIID , Data Receipt#
Will the applicant or furore building occupant use cyuipmenl or devicas which BOILER—COMP(311P OR 100.1100 BTU)
e �A
mit hazardous our conwminanu as Jefinal by the Puy Area Air Quality Management ;
District? ., TOTAL: �I
❑Yes. E3 No _ BOILER—COMP(OVER 100,0X0 BTU)
1 have read file hazardous m throds requirements under Chapter 695 of the Cali AIR CONDITIONER ISSUANCE DATE-
' forma Health 0e Safety Calc,Sectio 25505,25533 and 25534.1 un aria d them if the, - NEW ItLSIDI?NfIAI.MI3CIi. -SQ.FI'.
building does not urrently have a tenant,that it is my responsibility to minify the occupant
of the requir mends which must ho sect print to issuance of v Ccnlllcatc of Occupancy. -
Owner or authorized agent Datess _ ISSUED BY:
OFFICE