S 0259 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO BUILDING-ELE-C'I RICAL PERNU lNo.
BUILDING DIVISION APPLICATION/PERMIT rl.uhixlNc-h1ECUS 0259
fiUII.DING PROJECT IDENTIFICATION
BUILDING ADI � IL, � ;SANITA]RYNO. AVPLICATION SUI1n11T1'AL DATE
NE 'S NAME: I- t J,IIONE: CON"RA 'S N Mli: LIC No:61p7 CON'I'ROI,4
v1C ITE(T/i?NC N EER:IF C i"No: ADD 'SS:
r /41J�
c NTACT: I TON, BUILDING PERMIT INFO
�- / 1 ❑
NConsultant Fees Paid by Applicant(Initial) BI.DO EL¢Cr Pu E MEC"
x
LIC,yFSSSEED`•CONTRACTOR'S DF.CLARm'ION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby alRrm Ill.,1 am licensed Me,provkinm of Chapter 9(commeaing
�TLZ with Scene.7(XXBof Division 3 of he Bleinccs and Preresslnnn Cede,and my license is RESIDENTIAL:
PERMIT ISSUANCE.
��� in full force and erred ❑SPDW1, C1 KITCHEN RIiNOUEL
W License Cluss Lice APPLIANCES-RESIDEN PIAL [:1 ADDITION [:J PLUMBING RI 1'11'1:
r9jsGa Du'c�TSDECL ❑MULTI-UNIT ❑MODIFI'IJRAO
ARCHITECTS DECLARATION PANELS
O Z Z 1 understand my plim—leill be,modns public records AlOD117CA1'ION
O UP TO 21X1 AMPS
OWNER-BUILDER DECLARATION ❑IN'FER16R ❑CHIMNIiNG REPAIR
OZ-n Licensed Pndes,ioal 201-IOtX)AMPS Ih1PROVF.MENT ❑SW'hMAfING POOLS
N
yrX J OVER than AMPS QQpp����Qp'+}I R �@0E El DEMOLITION
C W Q I hereby affrm thin I am exempt from the Contractors License Law for the 69T
RV V
0.U full 8 (Section 70315,limitm,,rand Professions Care:A Y city or county SIGNS ELECTRICAL
WF 3u'LLQ wnih4me tt I' ,,,prove,demolish. repair any ar,
O
rll Ur �/1CMIINVmotion,..uame.aknrerlure.lhc apph If M1prmitl rl 'ged,facnent SPECIAL CIRCUIT MISC.
y•.1 that he is licensed punuanunIse provisions of the Connector,License Law ICM1apmrY COMMERCIAL'
�prp0 (commencing with Section]00(BofDivisdan 3 ofthe Business and Professions Code)or TEMR METER OR POLE INS T.
.a c C that he is exempt'hcmfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X^NSection 101LS by any opplicant 0n a permil a1j,c,,the applicant a civil penalryof POWER DEVICES I' ANT E]FOOD$liRVlGli
n mom than Ove hundred doll...($51)(0. PROV EMENT
y5C QI,mnvise—I the property,army cmploycc,with w.gcs au lheirsolt,rualnsntion, SWIMMING POOL ELECTRIC
will do the work,and the stmclum is not intended m offered file sale(Sec.]000,Ba,incs ❑Ul lik
H
ul3 m and Profes>ions Cole:The Connnetnr.c License Law docs not apply to an owner of Oil'1'LETS-SWITCHES-FIXTURES
properly who build,or improves thereon,and who Jots such work himself or though NEW RESIDENTIAL ELECT FT.
his own employee,,provided that such impmvemen's art nal intended or offered far SQ.FT FLOOR AREA $"ISQ.IT.
owner-however,thebuildinguren 4 prmenl is midwithinone ldor icompletion,ut- aX�.
owner-builder will have the burden of proving that M1c did not mild or improve for Cur- �/� � m � `�•_a$
po,e of mlcJ. TOTAL: yr 'VAYV �aJ
01.as owner of the properly unl.,lc,ively'crom1 dng with IicdasW eomrucmry to
,n,tmO he pnq,k,(See.71W4,Business and Pa fnsdon,Cnde:)'nle Comorene,1-i-
cen,a Law docs not apply to an owner of properly who builds or improve,thereon.anti QTY. PLUMBING PERMIT F
who co muclsfor such projects with a contractors)licensed pursuant o the Conlracmr's
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. .it&P C for this reason
ALTER-DRAIN&V ENI'-WATER IIIA)
' V
ALUATION
Owner Dam ACK FLOW PROTECT DVICWORKERSCOMPINSATIONDECLANA) VttO
I hereby al'frin under penally of perjury one of the following deducclons
[J I haveand will nain'ain a Cenifcme of Cnaem to selbinsm,for Workers Co.,.- DRAINS-FLOOR.ROOEAREA.COND. STO ?,S TYPE CONSTRUCTION
.tion,as provided for by Section 3703 of the Labor Code.hn the pedomunce of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker',Compenvaion Insumnce,as minced by Section G EA.SYSTEM I INC.a OUTLETS
3]tk9 ofine Lutx,r Crdc.fnr'M1c perlbcmance of lM1e worA Larwbichlhrs
it,, ed,
OCC.GROUP AI'N
My Wark� nmcc eu rand Po"Y '� n- -A.SYSTF,M-OVERJ(VA)
Ca:11T .mc PnlicyN
CERTIFICATE OF EXEMVI'ION FROM WORKERS' GREASI]INOIJSTRLW'ASTli1N'I'l1RCEPi'OR
COMPENSATION INSURANCE IT I VISI N FEES
(Mukkectionneednotbecomplacd iflhepenniti,f)ronchumimddollan($)IXO GREASE TRAP PLANCHECK
or le..l
I cenify that inthe performance of1 sobskfor which this to,he Wmiter,' dlahal SEWIiR-SANITARY-53'ORM FIN,200 ET. IiN1iRGY FEE
.of employ,any Canna in any manneno a,a nccome sunjec'to,he WurkerL Gsmpcn-
Z .tion Lows of Cnlilnrnia,Dae WATIiR IIIiATIik WNIiNTQiLIICI'N GRADING FEE
ZApplicant
tM NOTICE TO APPLICANT.If.alter making d,Crifileme of Excmptmn.You should WATE SYSTEM/TREATING SUIIX 19ili
1-'
become.bjcc o the Worker's CmiTen.'ion Pmvisimw of the Luton Calc,you mus'
forthwith comply wall such provision orhis pemait shall be deemed rm'oked. WATER SERVICE
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR SQ.FT. PAID
D Z Date Reca X
UO work],it
thisthat
Eclnereis.co(Sce.30[ending agency for the performance of
LL F" 'M1e work tar which this Carroll i4,,,.ed ISee.309].Civ,C.) 'rDTnL:
OU Lender's Name TO"1'AL:
r U Lender,Add.,, - RUILI) �A
G I[miry but I have mad Ve this upplicalimi and late that I into n is
F h correct.lagrceto nnnply with all ally eel county nrdin and stain la Ivting ua QTY MECHANICAL PIiRMIT FEE Sli.- IC F
U building construction,and hereby a.Ihorim arm, ovesofthis cit enter 1;.lee
above-mentioned pvoCcny for ins{eeion sc PERMIT ISSUANCE ELECT 1 F.
(We)agree to,ave,terbiumd keep females , dry of Caperton a alas'
Iiabiiities.judgnsn's,a,.a,an Ccnecn wM1ich may' ny way ace e.gai it City AI TER OR ADD TO MECfi. I'LUMI 'C PEE
nseyucncc of'hc r mgnfthi.apennit, m
APPLICANT II STANDS AND PLY ALL.NO -jlOi AIR HANDLING UNIT(TO IU,IXX)CIM) MIiCIIANIC LPHE T
SOURCE - LATION$' l//V� X/L-1
LADLING UNIT(OVI3R Io.tNp CFM) CONSTRUCT( l'A%
ch/Crum. or Dam EXHAUST HOOD HVMUCO HOUSING MENG TION FEE
o HAZARDOUS MATERIALS DISCLOSURE
Willmen,dieme or lattice builJingrxwpum,mrcar handle huaadoLLsmacdal HEATI NO UNIT(TO I WJXX)1{'1'U)
s defined by Inc Cupertino Mmlwipnl Crall,Cnaplcr 9,12,and @c IIcahn and Suray HFA'I INC 0NI'I(OVER Ihn of)RIG)
Calc.Section 2553201
❑ T
Yes ❑No VENT LATION FAN(SINGLE RESID) ('AID
Doc Rarip'M
1
r Will Inc applicant jafichommds a building by rtermthin B y A .Air Qu or Marla ement BOILER-COMP CHP OR JORT IO HTO)
rim hnardous an,cnmamina'a us dc0ncd by me Bay Arca Air Quality Management
U(.Irictu BOILER-COMP(OVER HX).( ))BTU)
Yes ❑No
I have mail'he Reardous macrials myuiremcros and,,Chapter 6.95 of In,Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code.Sections 25505.25533 and 25531.I understand but fide NEW RESIDENTIAL MECH. SQ.FI'.
hilding Mes nM mrren0y nave a tarsal.Ina'it is my respmeibility In naify the occupam
nrme reyndreanem,wm[n moa x ma prim to is.aan«acct cmifeam araapancy.
Owner m uwhor s J ugem
Date TOLAL: ISSUED BY:
OFFICE