S 0115 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CU
,' i RUB.BLNO-ELECTRICAL, rranuTNo.
IIUIIAING DIVISION APPLICATION/PERMIT I'LUMItI W:-MECHANICAL. 0115
BUILDING PROJFI6T IDENTIFICATION
BUILDING ADDRESS: 3SANITARY NO). rAPPLICATION .DATEOW . 'S NAME: �HONE: CO TRACTOR # LIC NO:
E. Jf T Owl COV 'IJ
CHITF;Cf/ENCINEER: - LIC NO: A ESS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG ELELT PLUMB MIiCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
�d#Z with Section Tf100)osion3ofthe Husinesx anJ Rvfession'Co_de,, Jmylicenu is RESIDENTIAL
W O q PERMIT ISSUANCE
P l in full Crime and e l ❑SFDWL ❑KITCHEN REMODEL
aUW License Clms Conn APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE.PIPE
of Dam Crim ECL
y 1 ❑MULTI-UNIT' [I STRUCTURAL
F+Dy A CHITECTS DECLARATION PANELS
it Z .I understand my plans shall he used as public records MODIFICATION
Sz UPT020DAMPS [I INTERIOR El CHIMNEY REPAIR
Licen...
dpodessiomaI 2101-BN9AMPS IMPROV EMI3NT SWIMMING 13001-S
•] OWNER-BUILDER DECLARATION OVER IINNIAMPS El BATH REMODEL/REPAIR Cl DEMOLITION
1 hereby affirm that I am eumpt from the Control License Law far the �y{�OTHER
(�6 U following recon.(Section 9031.5,Business aril Pmfersiom Code:Any city mentally SIGNS ELECTRICAL
413 a t' which requires a permit m mmtruct,vlmq improve.Demolish,or repair any stmetute
FLLp prism its issmnce,akoacmiresthenpplicantforsacbpermit mfileasigned statement SPECIALCIRC ITIMISC. low 2%
Wgggg Qf that he is licensed pursuant to the provisinm of the Central License Law(Chapter 9 COMMERCIAL
�OC (commencing with Section 7")of Division 3 mthe Business and Pmfessionv G+Jel ar TEMH . OR MOLE INST.
Q.d s that he is exempt therefrom and the holism far the alleged exemptirso Any Is in
of ❑NEW BLIOG/ADDITION ❑DEMOLITION
�m Section 7031.5 by any applicant for apcnnit subjects the applicant to a civil penalty of POWE )EV ❑TENANT ❑FWD SERVICE
= mtmone Nan five hundred do11ara(S5W). IMPROVEMENT
� O ❑I,us nwncr of the Property,ornry empinyces with wages as theirmle comprnmtima, SWIM ING . .rll
will do the work,vnd theahucturo Is urn intcndcA err nlfbred for sale(Sec.9(lid.11nnincxs []OTHER
L 3 and Professions Cade:The Curia lis Licen.ae Law does net apply to an owner of OVI'LF.TS-SWI'TCIIGS-FI%T
popery who builds or improves thereon,and who does such work himself or through
his nava employees,pmvidW that.such improvements ase not intended or offered for NEW RESIDENTIAL ELEGOr SQ PI'.
sale.If.hnwevee the building or improvement is sold within one yemofi,on,il nn.the SQ. LARilp� LSQ.IT.
owner builder will have the Wool of proving that he did not build err improve for Aur- #Y Y
pons of sale J.
I,az owner of the property,an eadunivdy enmtaning with licensed contractors m TOTAL`
conmoct the project(Sec.7041.Business and Professions Calc:)The Contractnr'z Li- SEP B pb
cense Law does not apply o an owner f progeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE Oil q((�I!/
who contracts for such projects with a comillar(sl licensed Formula to the Contrail ,I �f/. W
License Low. I PERMIT ISSUANCE m L'urEy�-jN
I uexempt under Sec &
. ,BPC for this al
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dam
WORKF.R:S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Ceniticate of Conwntto self-insure for Worker's Compeer- DRAINS-FLOOR,ROOF,AREA,COND. ,TORIES [TYPEECONSTRUC�IONcation,az pmvided for by Section 377 of the Labor Code,for the perfannnce of thew ik furwhicbthispennit is issued. FIXTURES-PER TRAP 9
1 have and will mainin Worker's Compensmiom Insuatnm,as moi and by Smion
)0 of lh labor Code.frtheperfnmunceaftheworkfor wIf hill, t" tied. GAS-EA.SYSTEM-I INCAOUT1.ETS OCC.GROUT'
My Work s + motion yt cuao and Delay � GAS-EA.SYSTEM OVF.R4(EA7
Carrier: h TTY ser GurtMTINO
CERTIFICATE OkjHXIUv1PTION FROM WORKERSGREASE INDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissection need not becampleted ifthepermitisfomnehundrcddollac(SIN)I GRP.ASE TRAP
err lcsz.l PLANCHECK F17%
I cenify that in Ne performance of the work far which this permit is issued,i shall SEWER-SANITARY-STORM EA.200 IT
not employ any perin any maer m nnus m become mbliecuo the W..Aar.'Compco- ENERGY Pini
son
ZZ scion Laws of California.Dam WATER HEATER WNEN'IMLECTR GRADING FEE
O Applicant
i NOTICE TO APPLICANT.If,attar making this Centrale of Exemption,You should WATER SYSTEM/IRFATING SOILS FEE
fiscal subject to Ne Weasel Compensation provisions of the labor Code.You must
W forthwith comply with each Provisions err Nis per mit shall he deemed revel WATER SERVICE
0
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID Date Receipt#
VQ thereby affirm that is uennnmetion lending agency for the performance of
Lk. the work for which this permit Is issued(Sec.3197,Civ.C.) TOTAL:
1-'' Lender's Name
WLcrakes Address TUl'AL:
fy I certify that 1 have real this application and state that the above Iafnmtatimt is BUILDINGEFEE
rq correct.I agree m comply with rill city and county obliterates and stale laws mining to QTY MECHANICAL PERMIT FEE SEISMICU Z building conswction,and hereby authorize mpmeematives ofihis city to enter upon the
aMwe-memioned property for inspection putryxes. PERMIT ISSUANCE ELECTR(We)agtu m saw,indemnify and keep hareahl the City of Criteron against
Ia "Ita"jud menti.costs and expenses whichmay in anyway acerae egrinslavidCity ALTERORAUU TO MECH. PLUMBIqua f Ne&mating of this it.P A UNDERSTANDS WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Uf"CFMI MECHA
S01 CF GULATIONS. f,�F`f
AIR HANDLING UNIT(OVER 10,000 Cl CONSTRUCTION TAX
Signamm of ApplicaddCenuacmr Date EXHAUST HOOD(WIDUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theopplicem to,manichullJing woupamsmemliadle bnnallousmdenul HEATING ON]'1'('TO 100009 BTU)
as defiered by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532nd? HEATING UNIT(OVER Iflyl BTU)
C]Vol C1 No VENTILATION PAN(SINGLE RESID) PAID Dam Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP OHP OR 1010.0X9 BTU)
emit hmardo s,air comaminams as defined by the Bay Arra Air Quality Management TOTAL:
Dourct4 BOILER-COMP(OVER 100.000 BTU)
❑Yes FNo
I haveread thehanandous matorivls requirements under Chapter(.95 ofthe Cali- AIR CONDITIONER ISSUANCE DATE
fmmia Ilealth&Safety Cade.Sections 25505,25533 and 25534.1 umdmid,n i that if the NEW RESIDENTIAL MECH. SQ.lel..
building does not currently have it tenl that it is my respra bibly to ratify the ocntpaat
of the requiremena which must he met nor to issuance of a Cerificam of Mittel
Owner or amhrdzed agent Dam TDTAL: ISSUED BY:
OFFICE