S 2201 (2) APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPERTINO nuaDING-ELECTRICAL reRy`prr No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECItANICAI, kJ 2201
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
1CiClApr led
-2� 9
OWN,R'S I`IAME: k NE: CONTRACTORS NAM � . LIC NO:O� NIC CONTROL#
Cd A)
•'ARCHITECTENGINEER: L O: -US S�: 4 ❑
CONTACT: PHONE: /VVI (� G�'�� 1LDING P NO
INFO 77
I r /I pJ �� ❑ Consultant Fees Paid Applicant(Initial) BL ELEC PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION/ QTY ELECTRIC PERMIT FEE
I hereby affirm mal l ant licensed under provisions ofChapter 9¢ommendng JOB DESCRIPTION
OaZ wiNSecdon981Nforoivision3nf the Hu,iness and Professions Code,and my Eecaw is 7Z- / RESIDENTIAL:
u10 PERMIT ISSUANCE c7D
F W in full force and elTed. ❑SFDWL ❑KITCHEN REMODEL
�UV License Class Lir.# APPLIANCES-RESIDENTIAL ❑ADDITION Ll PLUMBING RE-PIPE
FZIy Date Contractor
m66 El MULTI El STRUCTURAL
ARCHITECT'S DECLARATION MODIFICATION
p.,�y PANI:I.G
Z O h a 1 understand my plane shall be used as public records
OyFq1 UP To 20 AMPS [I INTERIOR [I CHIMNEY REPAIR
Licensed Pmfax,m d 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 100AMPS El BATH RF,MODEIJREPAIR ❑DEMOLITION
W i hereby vffimt Net 1 am exempt firm the Canonerov's License Law far the
O lY U following memr.(Section 71131.5,Business and Pm@selons Code:Any city or emn(y SIGNS ELECTRICAL ❑OTHER
which ne9aines a permit to conamet,alter,improve,demolish,or repair any eI...am n
prlono its lvauunad,also numberthe applicant fimomh pamm m file ani,laricatemenl SPECIAL CIRCUITIMISC. s
ray that he is licensed pursuant In the previsions of the Contractor's License Law(Chapter 9
pO (countercoup with Section9000)nfDivieton 3of he Businessand P..fav,fmsCmkb., TEMP.METER OR POLE INST. COMMERCIAL'
W
a{y m C (hat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Wtiy Section 91131.5 by any applicum for a permit suhjees the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
F, hot more than five hundred dollars S501p. IMPROVEMENT
dQ Q1,av owner of Bar Property,or my employ,,,with wages an th,h,olecompcnrsation- SWIMMING POOL ELECTRIC
p. will dm the work,and the structure is not intended or offered for sale(Sec.9044,Ifimm.vs COTTER
and Professions Cade:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves theram,and who does such work himselfor through
his own employees,provided that such improvements am not intended or oftener]for W ESIDENTIAL ELECTR SQ PT.
sale ow
If,hever,the building or improvement issold within one year ofromple(imn.the SQ.FR FLOOR AREA $ISQ.FT.
mer-builds will have the burden of proving that he did not builds improve for pur-
poscatcall.). 7„
TOTAL:
E] Las owner of the properly,am exclusively contracting with licensed contractors to l(/
construct the pmjed(Sec.7M4,Brani and Pumaxaons Code:)The Contrucmh Li-
seLaw does not apply manowner ofpropcry who builds or improves thereon,and QTY, IN ERMIT FEE
who contracts for such p jeeu with a contmcmr(s)licensed pursuant to the Contractors
License Law.
1 am exempt under Sec. .B&P C for this reason PERMIT ISSUANCE
-
ALTeR-DRAIN&VENT-WATER EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm mai under Certify to Perjury one nltheself following W rker s Co
❑ (have and will mainuinn Certificate ofConsent in self-insure for Worker's Cnmpen- DRAINS-FLOOR.ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
station,ac provided Ter by Section 390 of the Labor Code,far
I,,,the performance of the
woo ,
(Ak for which This pam:lt is issued. FIXTURES-PER TRAP
�I have and will maintain Workers Compensation Insurance,as require.)by Section
-
3 l of We Lahr Code,bor the Performance of the work for which this permit is issued GAS-F.A.SYSTEM-I I NC.4 OUTLETS OCC.GROUP APN
MyWorker' oro ,'lion rwamnce earlenand Policy(r�'m[�� /f 1 �/y� GAS-EA.SYST Flt
Car rier Policy No.:xs--i n I Tam
CE IFICATE OF EXEMPTION FROM WORKERS GREASFJINUUST STE IZIANVIt
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thi.v section need no(be completed if the permit is fo�mehundreddrliurs($10) GRBASETRAP
or lase.) PLANCHECK PEE /
I county that in the performance,flhe work for which this Permit is issued,I shall SEWER-SANIT -s .2�
act employ any pcnsmn in any manner so m to blame subject to the Workers Cnmpen- ENERGY FEE
o ,Z senior Laws of California.Data WATER HEATS /VENUELECTR
APPliwnt GRADING FEE
NOTICE TO APPLICAN'C If,after making this CerlMam of Exemption,you should WATER SYSTB. TINO
become subject to Ne Workers Compensation provisions of(he Lahr Cada you must SOILS FEE
[Y.l ti (nrthwith comply with such provisions or(M1is pemti(shall be deemed revoked. WATER SERVICE
Yl Ca
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.F'f. PAID
U �" lfar lboh thi that is ss issued
30 leading agency for Neperfnmtance of Dole eaipt#
U � the work for which this permit is issued(Sec.3099,Cie CJ
Q ULender's Name TOTAL:
Lenders Address TOTAL:
-
[.,. I certify Nat 1 hove revdtliis application and stn(,Ihn(the above information is BUILDING FEE
ti
formal.I agree banal with ml city and oounty ordinuncos and,rote laws reluting m QTY. MECHANICAL PERMIT FEB
U Z building construction,and barony authorize representatives mnn'Is any to enter m
erre sE1sMle Fen
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC TEP,
(We)agreem save,indemnify Ind keep harnlav,the City of Coleman drains(
Iiahllities,judgments,ensu and expenses which may in any way uceruengainst said Cityin ALTER DR ADD TO MECH.
PLUMRING PEE
consequence ce UNDERSTANDS
S(hisD WILL
SOURCE
ANTI WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB,IXNICFM) /
MECHANICAL EEE
SOURCE REGULATION,.
' AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of ApplicanVContmctor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazordoms material HEATING UNIT(TO 100,00 R'1 U)
as defined by the Cupertino Municipal Code,Chapter 9.12,sad the Health and Safety
Code,Seetlon 25532(,)'7 HEATING UNIT(OVER l0l BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Dale Receipt#
Will the applicant or future building occupant use equlpmmut or device,which
emit hazardous air conmmimants an defined by the Bay Area Air Quality Managemmrt BOILER-COMP(3HP OR IfgI,IXID BTUj TOTAL
DulrclP BOILER-COMP(OVER 10.00 BIG)
❑Yes ❑No
I have re ad Ilia hour]...materials bemenaac wider Chapter 6,95 of the Cali- AIR CONDITIONER 114ISSUANCE DATE
fmmiu Health&Safety Code,Seniors 25505,25533 and 25534.1 understand(be(if the NEW RESIDENTIAL MECH. SQ.FT. i-��
huilding does not currently have a tenant.that h isrny responsibility(o notify the occupant
ofthe re encwhlc rnuv( met prime o'brane mfr Ce ,a of0 a navy. �,�yJ�•'�� ^�
Owner or authorize anent Dam TOTAL: ISSUED BY:
OFFICE