S 0855 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITU OF CU;
BUILDING-EI,ECFRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMI'1' vLuniBwC.-MEcxANICAL S 0855
BUILDING PROJECI'IDE.NTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLIC TIONSUB ITTALpATE
61
OWNER'S NAMIi: ]JJE: CONTRAC•Ri 7%! N:/2
Z NIC CONIROLN
ARCHITF.0 IENGINECR:LolLIC NO ADiyiyb'S;• /��^M, w •� ❑
CONTACT: `.�n� ./Q`I NC X13 1 `c w BUILDING PERM ITINFO
/w+��b ❑ Consultant Fees Paid by Applicant(Initial) BLDG IiLEcf PI,LFu2_pm,�n M a
❑ +`
Lm ENSEDCON'nsed under
DECLARATION QTy ELECTRIC PERMIT FEE JOB DESCRIPTION
I h.aihy affirm that I am licensed under provisions of Chapter 9(commencing -
mf�Z with Section'lINN)1 nl nrasion 3oftIt Boniness and Prof as'nn%Cone, dmylicerscls RESIDENTIAL
�y /fj�` � PERMIT ISSUANCE
FOO in full force and cR'yi„xOq • ❑SFDWL ❑KITCHEN REMODEL
�UU License—C sec �'/-�(G�`o Lich - APPLIANCES-RFSIDF.NUAL [-]ADDITION [I PLUMBING RI PIPIT
FZµ( Uate '. iii B CatnDECL
rn<a ❑MULTI-UNIT' ❑STRUCfURAI.
A CHITECI"S DECLARAT 1
F.❑n PANEIS MODIFICATION
Z O- I om)rntand my Plans shall h used m public records UP TO 2M AMPS
OZ-0 ❑INTERIOR El CHIMNEY REPAIR
�U Licensed Professional 201-100RAMPS IMPROVEMENT C]SWIMMING FOOTS
4 OWNER-BUILDER DECLARATION OVI?R 11x111 AMPS [IBATH RF.MODI:IJRI:PAIR C1 DEMOLITION
yjy I herchy uRlrm that 1 an,exempt from the Continuous License Law for the perO,I, H
X O L U following reason,(Section 7031.5,Business and Professions Cade:Any city.1.,Italy SIGNS ELECTRICAL
which requires a perm m
mit construct.Art,improve,demolish,art repair any structure
H�OJ prior to its issuance,also requites the applicant for such mitan file asignWmoeme.t SFEiCIAL CIRCUDUMESC. �Q
F,yy that he is licensed pursuant to the provisions of the Contracts LittMelaw(ChaPer9 .'
�a�p0 (commencing with Section 7000)oflivislon3ofthe Business unit Professions CvxdI '1EMI'.METER OR POLE INST. COMMERCIAL:
L y e y' that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�Y11 li Sectian 70315 by any applicant for a Permit subjects the applicant to a civil penalty of POWERDEVICES ❑TENANT ❑FOOD SERVICE
� Qoe nm more than five hundred dollars 1$50(1),
Les owner nDhe n,nrm em to ceswith xu sus thcirsole roes nswion, SWIMMING POOL EL17CTRIC IMPkOVIiMENq'
0 ❑ PrtsPe Y Y P Y g M' [I OTHER
F. ill do thew,rk,.rd the stmcture is not oterradmoliered for sale(SeaJ014,Emitters
a 3$ and Professions Cone:The Contractors License Inca does not apply m an.caner of OVI'LIi TS-SWITCHPS-PI%TURES
progeny who wilds or improves thereon.and who does such work himself or through
his awn employees,provided Ilia,such improvertual ae not intended or offered for NEW RESIDENTIAL.ELFCTR Sq/1.
sale.IL however,the building or improvement is sold within one yearofcomplcnan,the SQ.PI'.FLOOR AREA $/SQ.Pr.
awater-hudder will have the burden of proving that he dW urn build or improve for pur.
{rose of sale.).
I,as ownend the property,aisel wisely contracting with licensed contractors to I"
canswa the projeat(Sec.9(W4,faciness and Professions Cade:)The Contractor's Li.
cense law does not apply to an owner of Progeny who builds or improves therean.and QTY, PLUMBINGPERMIT FEE
who contracts for such projects with u contractors)licensed pursuant the Contraemrs
License Law. PERMITISSUANCE
❑ lam exempt under Sec. ,B&P C for this reason
A Ul1;R-DRAIN&VENT'-WATER(lin) VALUATION
Owner Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE —/
I hardly M.under penalty of Perjury one of Ne following declarations:
❑(have andwill nmimainaCmificoe of Cnn¢nuoulGinmm far Worker's Carman. DRAINS-FLOOR,HOOEAREA OND STORIES TYPECONSTHUCfION
salon,as Provided for by Satin.3](X1 of the Inbar Cone,for the performance of the
w rk for which this Pearn is issued. FIX'TURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
00ofthe LabarCode,fort epalimmr ce of the work for which lhispeimit is issued. GAS-ITA.SYSTEM-I INC.4OUTLETS OCC.GROUP APN
My Work C x 'tion a i�it FF - rier and Policy nYp�{f�N� n
Carrie, Policy No.: f�a�•'DGAS-EA..SYSTEM.OVER 4(EA)
ICATE
CERTIFOF FXEMITION FROM WORKERS' GREASIVINDUSTRL WASTE.INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissectionoeed not be completed ifthe pe.it is fonnehundrW delta.Is 100) GRI?ASE TRAP
or less.) PLANCHECK FEE?
I cattily licit in the parboulano,orthe walk or Inch this permit is i.ssued,l%hall SliWliR-SANITARY-STORM EA.2W FI'.
not employ any person in any manner so as to become subject to the Workers'Conipan, ENERGY FEE
,Z sari,.Incas of Califomie.Data WATER HEATER WNEMLIELE. R
O Applicant GRADINCrPIai
y NOTICE TO APPLICANT:If,utter making Nis Ce.ificata of Exemption,you should WATER SYSTEAUTREATING G
F 7 become subject ,I the Workers Cmnpemution provisions of the Labor Code.you mon S O ficil
Wfonhwith comply with such provisions or this permit hall the deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NIiW RESIDENTIAL Iq,MII. SQ FF. PAID
L) 0 l hereby ofirm that there is a construction lending agency f(it per4aniancu of IIY LT- k Bq isuu
U. For
the work for which this Permit is issued(Sec.3097,Civ.C.)
0 T(yl'AI.:
0 V Lenders Name
W LendelAddress
I TOTAL'
LL cerlfy the,1 have read this application and xmm that the above information is BUILDING M.
fn cotrecl.I agree m comply wish ellcity raid county oNinancs and alae lows rclnting m QTY. MECHANICAL PERMIT FEE
L1 hulliingennonteli I,and hereby fir...iae upmsenmtiva'of t hi%city to enter opm theSP.ISMIC FEE
above-mentioned property for inspection purposes. PERMIT'
IA
above-mentioned
561-50-
(We)agreesave,indemnify and keep harmless the City of Cupcni ul almicl fiLECTRIC ITS
1.
liabilities,judgmems,costs and expenses which may in any way seem,against said City ALTER OR ADD TO MECIL PLUMBING FEC —
in consequence of the painting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIH HANDLING UNIT(1010,"CFM) MECHANICAL WiE Lf%
SOURCE REGULATIONS,
NR HANDLING UNIT fOVI?k 111,0011 CPM) CONSTRUCTION TAX
Signature of ApplicantaContrector Date EXHAUST HOOD OVIDUCT) HOUSINGMITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicaat or future building occuPamstente"r handle bvmdous mmeriil HEATING UNIT(TO 1e0,000 BTU)
as defined by ilia Cupertino Muni'i onc.Chap¢r 9.12.and the Health mad Safety
Cade,Satin.2.55920)? [IRA]ING UNIT(OVER[Bourn BTU)
0 Ye's VCN9'II.A I'ION FANS I NGLE RESID) EAI( parte R.cciptN
Will the applicant or fume building occupant use equipment or devices which 7zi HOILER-COMP(7IIP OR 1(10,0410 BTI)
mat locations air coatnmiar a W by the Bay Area Air Quality Management TOTAh;
District? BOILER-COMP(OVER 1 W,RnI BTU)
❑Ys a
I hove mol the hatrardausmaterials ramircmena under Chapter 6,95 of the Cali- I AIR CONDITIONER (/ ISSUANCE DATE
f ratio Health Satcty Code,Salines 25505,25533 and 25574,1 understand that it the NEW RESIDENTIAL.MECIL SQ.FF. -7-
th
�/
hullding doe ten ly havcutemm�,lhm it is my rsMmsihility mmtif the anupam [ — L //
of Ne ms c s he r t ort,issuance,(a CmiEr cup _
Ou eros onaed.,an, u m e TO-FAL,' ISSUED BY:16 /
OFFICE