S 2797 (2) APPUCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE,RTINO BUILDING-ELECTRICAL, PERMIT NO.
BUILDING DIVISION APPLICATION/PERNUT PLUMBING MHCf1ANICAL S 2797
BUILDING PROJECT IDENTIFICATION V
BUILDING ADDRESS: ^ SANITARY NO. P ICA]DON SUBMIMAL DATE
to X671 w n 9
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC Na:
,•••, IL#.� 5ti ♦t/ „n -L NIC CONTROL#
ARCf1IT/f/�1'/EpryGINEER: LIC NO: gY•REr�X u� O c L 'I W/_ ❑
/ I FJsajM6ti I'
CONTACT: PHONE: BUILDING PERMIT INFO'
n v �6 ❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MEECH
/r ZLy-7560 ❑ ❑ ❑ �(
LICENSED CONTRACTOR'S DECLARATION I QTY ELECTRIC PERMIT FEE
1 Hereby alRnn that 1 um licensed under ,pravi,aona of Chapter 9(commencing JOB DESCRIPTION
OCZ with Section 7W0)of Division Softhe Business and Professions Cnde,and lay license i.c RESIDENTIAL:
m O O In PEMIT ISSUANCE
F fyF full lme,mtd est. -L ❑SFDWI. ❑KITCHEN REMODEL
�UU Liccnse Cla Lic# I(. APPLIANCES-RESIDENTIAL El ADDITION L1 PLUMBING RE-PIPE
y 77W Date Contractor
ARCHITECT'S DECLARATI N . ❑MUL'fl-UNIT ❑STRUCTURAL
ZoNZ l understand my plunsshall be used public records PANELS MODIFICATION
OZ4`0 UP TO 200 AMPS El INTERIOR El CHIMNEY REPAIR
F,Snt:.m.�j Ueemed Professional 201-1000AMPS - IMPROVEMENT E)SWIMMING POOLS
�p,
OWNER-BUILDER DECLARATION OVER Into AMPS ❑BATH REMODEL EPAIR ❑DEMOhITION
I hereby nmnn That 1 am exempt foam the Contractor's License Law for the
,s:C❑U0..trU+ following mason.(Section 7031.5,Business Imd Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
m which y ' p I t s" t It P d m f.I p 'ny" care In
F.1",
� prinrt t - 1. require,thapplicantf hp 'tt II 'gndatmm�l SPECIALCIRCUIT/MISC.
�}
That he is licensedp.,chat tthe p l6on,ofth C t t ,License La (Ctrptu9
(�r�Q (commencing with Section AM)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
Q, that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0 NEW BLDGIADDITION ❑DEMOLITION
r�^"•
Section 70315 by any applicant for a permit subject,the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not are than five hundred dollars(S5 W).
F'�} IMPROVEMENT
S6n ❑Losse work,the propeuctur my omeneedmete.red forlle( ec.compensation, SWIMMING POOLELECT RIC
p. coal do the work,and the structure is notimenduf uro0crcd foesnlce(Su.91N4,Business ❑OTHER
and Professions Coaho The Contractor's License Law docs not apply In an owner of OU'fLE'FS-KNIT CITES-FIXTURES —d
property who builds or improves thereon,and who does such work himself or though
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
sale.If.however,the building or improvement is sold within one year ofcontplefiola the SQ.FT.FLOOR AREA $/SQ.FT.
cwru-hmldrr will have me burden of proving that he did not build or inmpmve for poo-
pone of sale.).
E] 1,as owner of the pm ,pert and exclusively contracting with licensed convectors In TOTAL:
construct the project(Sec.7041 Business and Professions Gsle:)Lie Contractors Lt-
cease Law does not apply to an owner of propeny who builds or improves thervion.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a carmicmr(s)licensed pursuant to the Contractor's -
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&PCbmr this rescan
s -
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
O D
/ WORKERAR
'S COMPENSATION�ECLATION BACK FLOW,PJgTLEGT.hJFYICF,
a I hereby admit undcrpecidtyofperm,one of the following dreiaralmrs:
I have and will mainland a Certificate of Calorie to self-insure for Workers Cramped- DRAINS-FL .RO ', A,GOND. ,TORIES TYPE CONSTRUCTION
sntlom,as provided for by Section 37011 of the Labof Cada,for the performance otitic
work lit which this permit is i.esaed. I," 3m FIXTURES-PER TRAP
❑ I have and will maintain Workers Compensation insurance,as required by Section
- 3401 ofthe Labor Cade,for the performance otthe work for which this permit t ldsuhdt F,O�SS E .SY CM• i UTLE'1'S OCC GROUP APN
My slimkr,LcCoryNyp�oppaal In dPolicyn m zA- e9✓ 1 GAS-EA.SYSTEM-OV f A)
Cartier:T\ML CV►`ylranec carts Policy To
CHET IFICATE.IOF EXEMPTION EOM WORKERS'
COMPENSATION INSURANCE GRFASI%INUUS'fRL WASTE l ERCEPfOR :
BUILDING UIVISRIR FEES
(Thiesecdcr.ncednot lx completed if the permit is furnace hundred dollas($9 WL - - -
orless) G PLANCHECK FEB
I certify that in the performance afthc work forwhich this permit is issued.Isliall SEWER-SANITARY-STORM F.A.200 FT.
not employ any person in any manner sits �` c jecuathe Workers'ComPea- ENERGY FEE
zZ satlon Lawsof California.Dam WATER HEATER WIVF,NTELECTR
Applicant ' // �ICC GRADING FEE
ti y NOTICE TO APPLICANT:11;a0cy0lial{ng thinsens, td at Exemption,you should WgpER$YSTF.M/I'RBATING
hecome object m the Workers Compensationisi
provons.1 he Labor Code,you must SOILS PEE
forthwith comply in such Thankians ar this permil shall be d.ormal evoked. WATER SERVICE
aQ
UO CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.hT PAID Date Receipt#
1 hereby al nor that there rasa construction lendingge
ancy for the pedommnw of
u'' (~
the work for which this permit is issued(Sec.3097,Civ.C.)
Lenders Name T AL:
Lender's Address TOTAL. BUILDING FEE
1 entity that 1 have read this application and state that the above information ac
y correct,i agree to comply with all city and circuity ordinances and state hews relating in QTY. MECHANICAL PERMIT 'FEE
U res building construction,and hereby authorize representatives of this city To anter upon the SEISMIC FEB
aMve-mentioned property for inspection purprnes. T1 l
(We)agree mav
one,indemnify and keep hmmless rtrti
e City of Cupeno againq PERMIT ISSUANCE ✓ ELECTRIC FEE
liabilities,judgments,costs and expenses which may litany way accrue against said City ALTER ORADD 10 MECH, PLUMBING FEE
in ansequcnce of the granting of this permit. le
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT V AIR HANDLING UNIT(TO In"CFM) r
SOURCE REGULATIONS. /� / QQQQ MECHANICAL FEE
/ 7// /J/ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
- Signamrcof Contractor Date EXHAUST HOOD(W/DUCT) HOUSING MI'I IGNFION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wi 11 the applieanmr future baildingnnvpant slum or handle hazanlouc material HEATING UNIT(TO 100,IX0 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)4 BEATING UNIT(OVER 100,M)BTU)
❑Yes WN. PAID --
VENTILATION FAN(SINGLE RESID) Date Receipt#
Will the applicant or future building by the B use equipment or Maras which
emit hnzardouv air contaminants ns defined by the Buy Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)s
TOTAL:
District' rya
-]Yes �Na BOILER-COMP(OVP.R IOO,WO HTU)
'I have read the hazardous materials requirements under Chapter 6.95 of me Cali- AIR CONDITIONER
MUAITCF,DATE
fomia Health&Safety Cala Section 255115.25533 and 25534.1 understand that if the NEW RESIDEN'T'IAL MECH. SQ.PT.
building does trot currently M1aveatenant,)hat'n is myrespnn.abil'a,m notify lheaecapaam
of the reyuir is alis metprn ec ofn Certilicate o[Oucupuncy. Z /f
Owner or aulho d em a Date TOT ISSUED BY:,
OFFICE