B 0604APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY c
BUD. HNG -E LECTRICAL PERMIT
CITY OF CUPF.RTINO PLUMBING-.+IECHnmcAl.
NUILDING DIVISION APPLICATION/PERMIT ,,,�r_nunux-r Hxrzxrrnv...... S�Q�� �6Q
GINEE LIC NO ADDRESS,
T❑J
.sos� o
❑
BUILDING
fir. CnshLFcaidby �lY (.il17
BLDG - ELC:Cr
p'1'Y. ELECTRIC PERMIT I FEE
1 hcrehy affirm that 1 in liacloed under ouskin., of Chapter 9lcommcncing
MWZ with St 700(pnf Di,si Sol the Im,mr.vs and Professions Codeand my lice.,. is
CW OF- in full force and effect. 04 1
NV Licenu CI... Llc. a
Q W ).to Cut
melnf
ARCHrrc('1 s DECLARATION
F -N Z I unde,xnnd my pLm'.J 11 be used a, pohllc record,
CZ -a
1 '4 F' W Licensed 11rolessiowl
OWNER -BUILDER DECLARATION
C W 6 I homily affirm that 1 am exempt from the Comr.tou rs LicenLaw for the
�L L U following rcaxnn. (Section 70}1.5, Rusin.., and Professions Code: Any city or cony
11!'314 F' which ,.lobes It permit to construct, other, improve, demolish. or repair any soca..
prior. its imuence. also requires the applicant l oreach pvordto file a,igncdsmmn.m
that he is licensed pursuant to the provision of the Contractor, License Law (Chapter 9
N0p minimal with Section l(XXH of Division 3 ofthe Business and Professions Code)or
a , c that he is exempt tomorrow and the basis for the alleged exemption. Any violation of
7C ^ Section ](111.5 by any applicant for a Permit subjects the applicant o a civil penalty of
�.y.m not mom than live hundred dollar, ($500).
SG p Lax^wn.rol''he prop.ny,,enty cmpoyces with wage, as mei, snlc lonclusatilm
GGGG2'"' will Jo the work, anJmeamcmrc musemadedofoRered fur sole Sr,. 70,CL Booms,
W m and Professinnx Code: The Contractor', License Law docs not apply to an owner of
a 3 proper who build, or improves thereon, and who does such work himulf or through
hisemployees, provided that such improvements are not intended or oRered for
salenlf, however, the building or improvement is sold within one year of cnmplminn, the
owncr-huildcr will have the burden of proving than he did not build or improve for for-
❑ Las owner of the proper. am exclusively contralim, with lutowd contiatots to
construct the project (See. BIW. Bu,mexs and professions Cm1e:) The C^mmetm', Li-
no, Law does not apply to an owner m propcny what builds or improves thereon, and QTY,
who contracts for such projects with a contractors) licensed pursuant o the Contractor,
License Law.
❑ I ton exempt 1mJcr Seo. . B & P C for this reason
PERMIT ISSUANCE
APPLIANCIiS - RESIDENTIAL
PANELS
IJP TO 21X) AMPS
SIGNS ELECTRICAL (/
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST,
POWER DEVICES
SWIMMINGPOOLELECI'RIC t
OU'TLE'TS-SWI'rCHC.S-FLXrURS
NEW RESIDENTIAL ELECIit SV PE
Owner Da1p
WORKERS COMPENSATION DECLARATION
�. 1 hereby arhrm under penalty of perjury one of the following declarations.
1 have and will mainmin a Certificate of Consent u1 «If -insure for Wo,ker's Comp..
/ saninn, nx prnvidcd Inr by SCClinn 3700 ono. LOM. Cola for he purfonnanca or 'he
w'orA Inr which phis perm. Is issn
I hove nnA will nmimain WorkrAcr, Cnmpensulinn Insurance, as rcqulreA by Scctinn
37W.fmcl,is Cde.E the rrmmance of the work for which this per�ymit is iuueJ.
Cumcerke t n rnnce carne Policy Nu.Y��I_/
CER TIFICATEOE SAI [O PION Nxt^M'n,��:NrX`�t/
C( I.. 1'E....otdift INS CCYYII((J% 77
('ILie tont.. .lied not be umtpluN ifth^Iw' tis fur uncbunJrcJ Aollnn ($lisp
or less.)
toy any that in the performancen as t bee for which this permiti,iamed.lshall
not employ any person in any mvnner m az m become subject to the Workers' Compel
Z cation I..., of California. Dae
O O Applicant
IZ ✓�N-I NOrICI: TO APPLICANT: IL aIle,..king illi, Ccn'IEoam of Exuntption, you should
F" lice..... xabjca a1 the W ..lor's Conlpinc.nom pnrvixina of the LuMa Code, you (mixt
forthwith comply with such provisions or this pemtil shall be deemed revoked.
Q
CONSTRUCTION LENDING AGENCY
U 0 I hcrehy ichnn thauherc i., sued (See 3ylending agency for the peRonnunce of
W the for which that pmmit i, issued (Ss.}tXR. Civ. C,)
O U Lcndcr,Name
r 1lndcr x Anfil,
IA I ,agree that 1 have with
thirty and county
and elven that the %Mrve information i,
UZ building I ogle ,comply with all city all county ordinances and some laws relating he QTY,
U Z building c^n,nmai..n. and hcmM1y amhnnm repmsenmtives of this city ulcmer upon the
above eationed property for'mspenion purposes.
(We) agree to s'.ve, indeu only and keep hamO.ss the City of Copeman ogainw
hiduhics.judglncnP, "INs and expenses which nnty in any way tu'cow o,am,l,aid City
in cnnwyuet.e of the gmanag of mix permit.
Aum lr ANT 1151 DER STAN US AND WILL COMPLY WI'T']I ALI, NON -POINT
I IAZA It XAJS MAI'F.RIA IS DISCLOSURE:
Will the applicant or Icame building misspent store or handle heeardaus material
as def Bed by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 8532UC
El Y., ❑No
W111 1111 opplicant or Lome huihrng occupant me equipment nndcvitx, which
mit hamrdoa., air ennlantimnnx as dcGncd by he Itny Arca Air Quality Menagc.u'.t
DlunfB
C] Yes ON.
I have read the hoverdon, mntandc no sircmenrs under Chapter 6,95 of the Cali
folia Ilenhh & Safety Code, Sections 25505.25533 and 25534.1 t dermaid thio if the
baildi ng does and cmxnI ly have a orient, that II is Illy resporobuily to molly the oecapam
+fol. myulrcme M1nmst beth no, oI...... ce d a CenlOcmc of Oceuparey.
.0
PLUMBING PERMIT
PERMITISSUANCE
AL'rl:R - DRAIN & V BN'1'- WATER (I:A)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOK. AREA, COND.
PIXTU RES - PER TRAP
GAS - IiA. SYSrI:M-1 INC. 4 OUTLET'S
GAS- EA. SYSTEM -OVER 4 (EA)
GREASUINDUSTRL WASTE INTERCEPTOR
GREASE'1'14\P
SEWER -SANITARY - S'R)RM EA. 2110 FI'.
WATER ((EATER WIVENGIE .ECTR
WATER SYS'reM,TREXHNG
WATER SERVICE
NEW RESIDENTIAL ('LMB. SV. IT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ACI'ER OR ADD TO MEC( I.
AIR HANDLING UNIT(TO 1u(XX)CFM)
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD (WIDUCI )
I ENI ING UNIT GO I OIL(X10 II'I'U)
HEATING UNIT(OVER HXLIXU BTU)
VENI'ILA'RON FAN (SINGLE RISID)
BOILER -COMP (}HP OR 100,000 B'I'U)
BOILER - COMP(OVER I(X),IXX)BTU)
AIR CONDITIONER
NEW RESIDENTIAL-MECH. SQ IT.
FEE
FEE
,- L -S —
3S 3
'ERMIT INFO
c
JOB DESCRIPOUN
RESIDENTIAL:
L;SPDWL
❑ KITCHEN REMODIiI,
❑ADDITION
❑PLUMBING RI: -PIPE
[I MULTI -UNIT
❑STRUCTURAL
MODIFICATION
❑ IN] ERROR
❑ Cl IIMNEY REPAIR
IMPROVEMENT
E]SWIMMING POOLS
❑ BATH R17MODEUREPAIR 0DEMOLITION
SO. IT, FLOOR ARIA $15q Fr.
BUILDING DIVISION FEES
FEL
laic
PLUMBING
CONS I'RUCI'ION TAX
I IOUSING MI"I'IGATION FIA:
PAID
Oath Reed. a
�)T�I• J v ISSULD
OFFICE