S 1587 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPC'RTINO BUILDING-ELECTRICAL PEtHI NO. 1587
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. l`�
IIUILDING PR03EC1'IDENTIPIUATION
BUILDING ADDRESS: SANI'T'ARY NO. APPLICATION SUBMITTAL DA'Z'E
OWNER'S NAME}'#, • PHONE: CONTRACTOR'S NAME: LIC NO
NIC CONTROLM
3.3f6/ ❑
�gRCHfI'IiCT/F.NGINEER: LIC NO: AUI,RESS: �O �� n•
Z a J a
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�❑ 77C ❑
LICENSEDCON'TRACTOR'Sande,'SDECen,of CON Q ELECTRIC P17RMIT FEE
1 hereby uRimt that 1 um licenxd under provisions of Chapter 9(commencing JOB DFSC TION
WDO with Section]INNI).fllivision3ef the Busine"c and Pndessinns Code,and my llcencc ixMI'1'ISSUANCE RESIDENTIAL;
FWF in full ferce and r�eKL G7/ 6w ❑SFDWL [I KITCHEN REMODEL.
�UU License Class ,,SS JC Lic# AI'PL CES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
F Z W Dam Contractor
RtG4 [I MULTI-UNIT El STRUCTURAL
ARCHITECTS IIECLARATI
p.,❑m PANELS MODIFICATION
Z O-i Z 1 understand my plans Shull be used as public records
OZ—O UP TO 200 AM [:1 INTERIOR [I CHIMNEY REPAIR
F oI E'W Licensed Pct fe,onal 2111-IIXNIAMPS IMPROVEMENT SWIMMING POOLS
thatI.t-BUILDERmhe CosmicRAI OVER 1000AMP5 - BA'ffl REMODEIIREPAIR 0 DEMOLITION
C tY 6 1 hereby affimt that I am exempt from the Cesion,C s License Law for the I-i a
g O y U which requires a.(Section]Iy1L5,Business and P,.&saloon Gude:Any city or c.amY SIGNS ELECTRICAL LLL OTHER
LL O Ft� which rots iA.a permit to c resthe,..lo improve,demolish,or repair any structure NQ A (C! DY14
6 prionoirs issuance.also reyuires the applicam for such permino Fileusigned sratemem SPECIAL CIRCUIT/MISC.
SSp�j:i4 that he is licensed pursuantin the provirsnnsot the Contractor's Limn.a Luw lChuprer9
y CLEC (cnmmearms with Smile.7nM)of Division 3 Mahe Business vnd Pmfcssbns Codurir TEMP.MLTIiB OR IYl1.E 1N5'f. OMM R IAL
4iha he is exempt therefrom and the basin for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION [3 DEMOLITION
m
aXl_al Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TIiNANT ❑FOOD SERVICE
� 6t marc than Five hundred dollars(S500).
Lax ownendthe norm to ees with wv es as their sole coin tion. SWIMMING I'(IOL F.LECI'HIC IMPROVEMENT
C ❑ Pn'Pe Y Yet^P Y g Pen.va
E. wdldothewark.a lhestmctureisnotimend oroRert forsale(Sm.]04q Boniness ❑OTT{IiR
mand Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FU TURES
p' property who builds or improves thereon,and who doers such work himself or through
his own employees,provided that such improvements are non intended or offered for NEW RESIDENTIAL HLEC!'R SQ FT.
sale.IC however,the building or improvement is sold within one year ofoompletion,the SQ.IT.FLOOR AREA S/SQ.PI'.
ser-builder will have the burden of proving that he did not build or improve for par-
pose of"ale.). .1.
❑1,as owner of me property,am exclusively contracting with licensed contractors to n rs B 1)
anstruct the p jeer(Sm.]M4,Business and Professions Code ins,Cuntmctors V- IIS p
se Law docs not apply to an owner ofpmperty who builds or impresses thereon,and QTY, PLUMBING PERMIT
who contracts for such p jer
es with a conwcums)licensed puratem m the Contractors
License L. PERMIT ISSUANCE. MAY 5 ANMI
C]I amnxempr under Sec. .B&PC for this reason IP
ALTER-DRAIN&VENT-WATER IEA) VALUATION
Owner Dvte Uf' ('IL-�j5�1,
WORKER'S COMPENSATION UECLAITATIo, BACK PLOW PROi'EC I'.DEVICE d%%UU(UJ
1 herehy affirm under pewlty of perjury one arm,following declarations:
l hrvemd will maintain u Cenificnaeof Con.sem to self-insure for Worker's Canten- DRAINS-FLOOR.ROOF,AREA,CONE). STORIES TYPE.CONSTRUCTION
cation,vs provided for by Section 3]1X1 of the Labor Cede.for the Per earearm of the
work for which this permit is issued FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as rcyuired by Section
37M ofthe Labor Code,for the performance ofrhe work for which this permit is issued. GAS-FA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Workers Compensation Insurance curia and Policy number arc:
Carrier: Policy Nn.: GAS-IiA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
or
BUILDING DIVISION FEES
(This Seth..need not he campleedif the pane,is forme hundred dollars IS 100) GREASETRAP -- --
or IcsxJ PLANCHECK FEE
Icenify that in the Performance efthe work!nr which this permit is ismed.l shall SEWER-SANITARY-S'TORM HA.200 I4.
Z
not
enlpaoy any pvown in my \e�oytcvytNee".the WorkeK Compel, ENERGY FEE
zO Applaant T// s / �/ h d WAI HR HEATER WNENTMLECfR GRAVING FIT,
(..t rn NOTICE TO APPI A Certificate of Exemption.you should WATER SYSTEM/TREATING
> become subject m the Wo is Compensation provisions of the Labor Coda yon must 501IS FEE
WfoMwith comply with such pmvisions.,,his permit shallbo deemed rcvnkcd. WATER SERVICE
GQ CONSTRUCTION[.ENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PI', PAID Dare eipo#
7 Z Ihereby affirm that is a construction lending agency for the performance of
WO the work for which this permit is lssuml(Sec.3097,Civ.CJ
Q U Isndcrs Name TOTAL:
Lender's Address TO'T'AL:
I cenify that 1 have read this.,heram.and some that he above information is BUILDING PF.E
not ,t correct.l agree to comply with all city and county ordinances and stare laws relating m QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U Z building constrection.and hereby amhmize rcprescntutims of this city m enter upon the
abawc mentioned property fox inspection purposes. PERMIT ISSUANCE ELECTRIC PEE
(We)agree m save,indemnify and keep harmless the City of CrKmino again
t,
liabilities,judgments.costs and expenses which may in any way uccme against sold City ALTER OR ADD'TO MEC H. PLUMBING PEE
ase,rence of rhe granting of this permit.
APPLICANT UND17RSTANDS AND WILL COMPLY WITH ALL NON-POTNT I AI IANDLING UNIT(TO 10,(NNICFM) MECHANICAL ME
SOURCE REGULATIONS.
AIR HAANQLING UNIT(OVER 10,003 CFM) CONSTRUCTION TAX
Signamreof ApplicodaC7mmcmr Date EXHAUSTH DW/DUCT) HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future build,.,weapon store nr handle haendoes material HEXI'ING UNIT( 101,001)BTU)
as defined by she Cupertino Municipal Cal,Chapter 9.12,and the Health and Safety
Gale,Section 2559$W't HEATING UNIT(OV U.lN10BTU)
C]yes ❑Nn VENTILATION PAN(SINGE ISTD) PAID
Date Receipt#
Will the applicml or future building occupant use eyuipmam or devices which BOILER-COMP(3liP fIR I(NI,INNI TU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
District? BOILER-COMP(OVER Ig1,(I(NIBTU)
]Yes ❑N.
(have read rhe hazardous materials rents under Chuprer fi.'JS of rhe dli- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cod.. came"
IA 25533 and 25534.1 i nderstwd that if rhe NEW RESIDENTIAL MECH. SQ.FT.
buildingdaxs��{{''ndo {Iy4�evocnv Jho it is my resgmsibiliry mnmify the occupant
of rbc renviGv(n fh musYbe rP nor to issuance nl'a Cent! f O e
Owner o��rLL//uUo red ag490 Fig ent Dore TOTAL: ISSUED BY:
OFFICE