S 0541 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PERMIT No
BUILDINGOF
DIVISION APPI,ICATION4aFRMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENDFICATION
ILDING ADDRESS: SANITARY NO. AI`I'LICATION SDIiMI'I-I'AL IIATI
.31P20 $9 f Vi*c% kiei" M<rino �\
O PM'S NAtN 1: CONTRACTORS NAME: LIC NO',
ji.
ondDkUlp»�o B: 4I� ���0 NIC Q)N]'ROLp
ARCHITECT/F.NGINEER: IJGNO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) Ii1,13G E:LE.C'T PLUMB MMH
❑ ❑ X ❑
LICENSED CONT'RACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
Ol�Zwith Se<tian](1W1of Divivinn lofthe Rosiness and Prnfasions Code,and mylicenu is RESIDENTIAL:
w O PERMIT ISSUANCE
k-s infullfnrceandeRect. ❑SFUWL. ❑KITCHEN REMODEL
�UU Licensc Class Lick APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RF.-('IPE
IY Ilam Contmer o
to a ❑MUI.TI-UNfE ❑STRUCTURAL
ANdmil be a DECLARATION
p.,p h PANELS MODIFICATION
Z p—7J. 1 smdemwnd my plana shall he asst us public me 61 UP TO 2W AMPS
OZ�Q ❑INTERIOR ❑CHIh1N1iY REPAIR
rot: l Licensed Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
-� OWNER-BUILDER DECLARATION OVER IW0AM1'S ❑BATA REMODFUREPAIR El DEMOLITION
I hereby affirm u
that 1 am empt front the Cmmr
mc 's License Law for the
K:6U following sea on.(Section]031.5.Huxiness and Profesvinns Cale:Any city er cnumy SIGNS ELECTRICAL ❑Ol'HfiR
3 U which maluircs o iwrmit m consrun,alter,intprnve,demolish,nr repair any uruaurc
C�SnO prior fail,issuance,.N.requires flm,pplwam forsuch,unnll 1.Bleusigncdsmtemcm SPECIAL CIRCUIT/MISC.
y)Y that he is Beamed puts...I ,,he provisions of the Cmbomxmrs License Law(Chapter')
W o (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.MI.W..R OR POLE INST. COMMERCIAL:
dye that he is exempt Iliumbmn ani the Torii.for the alleged exemption.Any viulution of ❑NEW BLDG/AUDITION []DEMOLITION
uX1 Section 0131.5 by any applicant for a permit subjects no applicant to a civil penalty of POWER DEVICES ❑TFNANT ❑FWD SERVICE
h of more than Eve hundred dollars(SSW).
2=0 ❑ hnN owner ofNeprupeny,nr my employees with wages asthcirnnleunnpensatinn, yi,N'f
SWIMMING POOL ELECT RIC ❑OTHER
i_ will do the work,mud the structure is not intended nr offered mrsale(Sec.](U4,Holmes,
Fm
and Professions Calc:The Contractors License Law does not apply m o
on wner of OUTLETS-SWI'1'CHE.S-FIXTURES
roperty who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such impnwemems are not intended or offered for NEW RESIDENT JAL ELECTR SQ IT
.It.If.howeveg Ne building or improvement is sold within one year of completion,the SQ.ET.
F�OR AR SISQ.FI'.
ser-builder will have me hutden of proving that he did not build or improve for pur- p/
ID
petro of vale.).
❑I.m main.f the property,am exclusively contracting with licensed connotation,to
TOTAL: AUG
construct the pro cul(Seo.7044,Business and Professions Cale)The Cmumemr.s Li. W1I�po j D[/1a�
ase Law does notapply m on owner of property who hands or iinpreves thereon,and QTY. PLUMBING PERMIT FEE UG R[(gu
whocontmetsfor.suchprojectswimmcont ctor(s)IlcensedpursuantwThe Contractor'x
Llcen I PERMIT ISSUANCG
m femptum Scc. .B&11Cforthisrertan Y Uh l.UrtMIINO
ALTER-DRAIN&VENT-WATHR(EA) VALUATION
Ow Uaw
W KERS COMPENSAT ECI.ARATION BACK FLOW PROTECT.DEVICE
I hereby alar under penalty of perjury tine of the following declarations:
I have and will maintain a Certificate ofConsenuo sdGinsum for Worker's Cumpcm DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCT ION
sation,as provided for by Section 37ql of the Lhor Cale,for the unfurnumue of the
work for which Ibis permit i.iNsved. FIX TO RISS-PER TRAP
❑ I hove and will maintain Worker's Compensation Insurance,as required by Section
3]WofthehbrCm ,forfhepdomanceofthework for which this permit isixwcd, Gq5-EA.SYSTEM-1 INC.40NtL-f5 OCCGROUP AIN
My Worker's Compensation Insurance carrier and Policy monism am:
Currier: Policy No.: GAS-EA.SYSI'Eld OV ER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASMNIASTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissection need not becompleted it thelermif is hnonchundreddollms(SIM) GREAS17TRA(
or less.) I'LANCNF.CK FRT:
I certify that in the Performance nOhe work for which this permit is issued,i shall SEWER-SANITARY-STORM EA,2W Pf.
not employ any person In any manner so taw accurate subject m the Workers'Compom ENERGY FEE.
Z tuition lows of Califamia.Date WATER HEATER WNENT/ELECTR
O ApplicantI GRADING FEE
NOTICE TO APPLICANT:1L Co ranking this provisions
n s of of Exemption.dyou should WATER SYSTIiM/fRGArING SOILS 10i1i
tx , become subject m the Workers Compensation provisions of the Labor Codc,you must
[>a forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
7 z CONSTRUCTION LENDING ngagerAGENCY NEW RESIDENTIAL PLM . SQ.Er. PAID Receipt M
L)Q (hereby e(litm that isacnnswc0on lending agency for the peRnmtawe nl
the work for which this permit is issued(Sec.30KO.Civ.CJ
O U Lender's Name TOTAL:
U Lenders Address
a 1 certify that 1 have read Nie application and smm thus Nstove ve information is HUILDING E
to correct. agme nr comply with all city and county ordinances and stove laws reladog n' QTY. MECHANICAL PERMIT FEE
building construction,and hereby audomm mpresemalmas of Nis city to enter upon the SEISMIC FEE
above-mentioned pmpeay,for inspection purposes. PERMIT ISSUANCE.
(Wel agree as save tr
indemnify and keep lumless the City of Cupertino against ELECTRIC FEF
liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECN.
PLUMBING
in conserSucnce of the granting ofthis Permit.
APPLICANT UVERSTANDSAND WILL CMP
LY WITH ALL
)CFM)L NON POIN AIR HANDLING UNIT(TO 10,00MECHANICAL ITE
0StP I .G ATIO ax(Vf��- 11`1\`
AIR HANDLING UNIT(OVER 10,000CF14) CONSTRUCTION TAX
ignature of AppcanlCommelor. Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION E
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicant or future building oompsom me or handle hvardous matmal HEATING UNIT(TO 101.000 BTU)
as definul by the Cupealno Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 255120)? HEATING UNIT(OVER 100.003 BTU)
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID
Dem Nca pt M
Will the applicant or future building occupant use equipment or devices which
emit hanardnus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR I010,0110 BTU) TOTAL
Baer? BOILER-COMI(OVER 100.00013TU)
❑Yes F]No
I have read the hazardous materielsas,imments under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Ilealth&Safdy Codc,Sections 25505,25533 and 25534.'understand that b Pse NEW RPSIDENTIAL MECH. SQ.FT.
building does not currently have a tenon.that it is my responsibility to notify the occupant
of the"Socmems which must be met poor to issuance of o Certificate of Occupancy.
Owner err authorized agent Data TOTAL: ISSUED BV:
OFFICE