B 0122 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CDPE RTINO BUILDING-ELECTRICAL PERM(]'NO.�O 12
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APPLICATION/PERMIT PLUMBING-MF.CHANIICACAI' Vf{//••/,
BUILDING DIVISION BUILDING I'RO1ECf IDENVFI'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
0o L a)# Uu rNa I g g4Z
OW Ii :S NAME: I'IIONE: CONTRACTOR'S NAME: LIC N0:
O � y NIC CON'I'ROLM
rftVsoli /ENG 'IiH: t L .NOO: ADDRESS:
COGNTACf. PHONE BUILDING PERMIT INFO
p /3—700 ❑ Consultant Fees Paid by Applicant(initial) SLUG ELECT PLUMB M�EyC�x
' � Lm�J✓ i'CJ
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRICPERMIT FEE
I herehy ulroni that I am licensed under provisions of Chapler 9(commencing JOB DESCRIPTION
WOZ with SecaionOWO)nf Dlvininn7 of the Nosiness and l'minxsitns GNc.and mylirenx is �I WOO PERMIT ISSUANCE
I- in full force rend effect. ❑S )WI. ❑KITCHEN REMODEL
ce ZUFU License Class Lic.N APPLIANCES-RISIDF:NTIAL UDITION C1 PLUMBING R&PIPE
F- W Dan Cmurecmr
UIQ4 ❑MULTI-UNIT ❑STRUCTURAL.
ARCHITECTS DECLARATION
I,,;E2 to PANELS MODIFICATION
ZOE2Z I understand my plvns shall be used as public..,its UP TO 200 AMPS
pZ—� ❑INTERIOR ❑CHIMNEY REPAIR
1-0= Licensed pane nomal 201-1000AMPS IMPROVEMENT SWIMMING POOLS
A OWNER.BUILDER DECLARATION OVER IIH)fI AMT'S ❑HATH REMODELIREPAIR O DEMOLITION
1 hereby elRnn Oust I nm exempt marine Cnnlnmmr's License Law far the
4 U fallowing rcaxon.(Section"QUI 5,Basin.,end Profession,Gave:Any..,or county SIGNS ELF.C'TRICAI. OTHER �/'J
3 LL which requires a permit m construct,alum,improve,demolish,or repair any structure /`I' 212 /
prior to its issuance,also requires[lie applicant for uch Parmil in rile a signed statement SPECIAL CIRCU IT/MISC.
Shy that he is licensed pursuant a the provisions of the Contractors Licenu lac (--ptar9
pC (cmmnencing with Section 7")of Division 7 ofthe Business and Professions Crude)or TEMP.MFiI'IiR OR POLE INSi COMMERCIAL
4 4 C that he is exempt therefrom end the basis Intent alleged exemption.Any violathm of ❑NEW BLDG/ADDITION ❑Ulitvl0LIT10N
YXl W Section 703 LS lay any applicant for a pmait subjects the applicant In a civil penalty of POWER DE]CPS ❑TENANT ❑FOOD SERVICE
rn
at),more than five hundred dollars S500),
y IMPROVEMENT
r Las ownerufthc pommy. any employees with wages as theirsole wmlr_nsaion, SWIMMING POOL ELECT RIC
❑ m
❑O'fHl?R
wdldo t he work.art t hu structure it not intended oroffcrel lou sale(See.7014,I)nnine"
and Pmfessians Code:The Contractor's License Law does not apply to an owner n OUTLETS SWI'ICI LITS-FIXTURES r 0
property who builds ar improves(hereon,and who docs such work M1imself or through
his own employees,provided that such improvements arc not intended ar offered far NEW RESIDENTIAL IlLECTR SQ IT.
sale.If.however.Ne building or improvement is salt withimone year ofcompletion.the SQ.FT.FLOOR AREA S/SQ.rL
ewnenhuilder will bare the Water of proving that he did not build or improve for pur-
poscef.k.)e TOTA Lly� O
r of the proper)',am exclusively contracting with licensed contreaors ba lJ
mstact the project(Sec.7W4,Business and Professions Cade:)The Contmdor's Li
ase Lawdae.xnol apply manownerofproperty velwbv'dd ,burpnsves thereon,and QTY. PLUMBING PERMIT FEE
who exact for such projects with acsmrrams)licensed pursmnBmthe CanmmmrN
Licros
❑lamcxw bu JerS rt' .B&PCfar this lesson PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER(FA) VALUATION
D r Date /l
'S COMPENSATION DECLARATION BACK I:IAW PROTECT.DEVICE (yL O
I hereb a(fnm Jerpenalty ifpepury ane o(the following declarations: (((
❑(have and will mvinwinn CeniOcam of ConscmmsdGinsure for Workers Compere DRAINS-FLOOR.ROOF AS STORIES TYPE CONSTRUCTION
sublet,as provided for by Section 37W of the[..be,Cede,far the pemearance of the
T work for which this pcmait is issued. FIXTURES AP
L hove and will nwinmin Worker's Compensation Insurance,as required by Section
770of the Labor Cove.for the pctfmarmnceal work for which this -it is Issued. 'OAS-EA.S IIs OU .:TS OCC GROUT' AIN
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: CAS-EA.S
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASFJINI \ ER F R
COMPENSATION INSURANCE: - NU .0 VG])]VISION FEES
(This senior need nob be complcbed ifthc pcmait is fnrone huMmidollars(glfgH GRIiASr I ��
nr less.) I'LANCHEC 11
I certify that in perlimmnceaflhe work an which this permit is issued l shall SEWER 1'
not employ any prs
eon in an,basub tui as to became subject m the Wmkers'Camper- ENERGY F.
O Z. smimn Luws of Cal`fnrnin.none I WATER .R tl 114CAGRAD' P
Z 0 APPlicam
In NOTICE TOAPPLICANT:If,after making this CertiOcnte of Exemption,you should WATERS EMO,RCATING
become subject to the Worker's Compensation provisions of the Labor Cade,you must SOILS -
G forthwith comply with such previsions mchis pe,.If shall lx deemed revoked. WATER SEVICE
CONSTRUCTION LENDING AGENCY NEW RLS( SQ.ET. ('AID
L) O 1herebyalfinn that them iso concoction lendingageney for blue performance of Da Reeeiptp
4. F-' the work for which this permit is issued(Set.30U,Civ.C.)
OU Lender's Name IAL'
W nder's Address T(YIAh:
Le
4 1 certify that l have mind this application and saute that the abase itambeetioo is 11UILDING I L
F.t to cared I agree to comply with all city and county ordinances and state laws relating rt QTY. MECHANICAL PERMIT FEE
V Z huildin6 eonrucbioq and hemby avlhodm representatives of this city to enter upon the Sf:ISMIC EE
aMsvemeamomed prapcny far inspection purposes. / PERMIT ISSUANCE
(We) We nosave,indemnify and keep hsmless Ne City a(Cupertino against ELE C E O
let ilibies,judgmems,costs andexpenxes which may in any way accrue against said City ALTER OR ADD TO MECH,
PI.UMBIN FEE
A se'A ace NDIBmnling Sbhinpe WILL
A L 'A T UNDI?RS' \NDS AND WILL COMPLY WI'1'll ALL NON-1'OINT AIR HANDLING UNIT(TO 10,003 CPM) THOUSING
EEry
S)URC- tEGU.A7)O `
_ AIR HANDLING IINI'f(OVER II1,fN111 CFM) 'fAX
net co pplicen oat.
for
Date EXHAUS'I'1I00DIW/DUCT) ATION FCL:
H ZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant score or handle M1awJous material HEATING ONIT(TO I Off"BTU)
us defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Code.Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
❑Yes No VENTILATION FAN(SINGLE RESID) PAID
Data Receiptp
Will the applieunt or future building..Paul use equipment or devices which
tont hazardous air commme.nts vsdcfredh the Rn Aren Air Quality Manaenard BOILER-GGMP(3Hp OR 100,000 BTU)
Y Y Y 6
DrdndP
ED Yes BOILER-COMP(OVER IWJX10 BTU)
o
I base mad the hmardam;`s materials AIR CONDITIONER ISSUANCE DATE
requirement under Chapter the Cvli
No'llh ,
ffi Safety Cwk.5enions 25505,25577 and 25574.I un erstmW Nm if Ne NEW RESIDENTIAL MECH. SQ.FT. �3 o(/
bcu tyhavFa.unmgtit is my mpnnnihiln t reify lh accupum / -
an hi must be met pronto isamnce of a Ce li Q a 1(fy.
( Date AL: ISSUED BY:
OFFICE