S 0112 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINQ BUILIIING-RLECTRICAI- PERMIT NO,
BUILDING DIVISION, APPLICATION/PERMIT PLUMBING-MECHANICAL. �+ O .1 .c /�
BUILDING PROJECT IDENTIFICATION J 11 L
BUILDpD Sg: • � SANITARY NO, APPLI/CATI N SUI ITTTAkL DATE
`/ S (/// � W I �j
OWN 'S PHONE: CONTCT RSN M LIC NO: u
NIC SCONTRO{.
' .RC{ITE � GIfJFE LIC NO: DR r 5: y77
14,
CONTACT {/ P E� n\ BUILDING PERMIT INFO
t Y� ❑ Consultant Fees Paid by Applicant(Initial) B_ Lqp F.LE PLUMB MECH
LICENSED ONTRACfOR'S DECLAR
QI�IIZ O QTy ELECTRIC PERMIT FEE "
1 hereby,affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{ Owith Section]000)of Division 3oDh,Business and Profusions CWc,ardmylicenxeia
Fad full Come and cRact. PERMITISSUANCE RESIDENTIAL
�U License Class Lie.a S DWL El KITCHEN REMODEL
Date Contractor. APPLIANCES-RESIDENTIAL ,I]ADDITION
❑PLUMBING RE-PIPE
11....pr,I ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
OY a I understand my plans shall M used ox public records MODIFICATION
UPT0200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
�ZI� Licensed Professional 20T02 AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION Con, ON ❑SWIMMING POOLS
O 1 hereby,(fmm that 1 am exempt from the Cotnractor's License Law for the OVER]"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
3 a following reason(Semon]031.5.Business and aofessi,ns Code:Any city or county SIGNS ELECTRICAL El HER
W which requires a permit to construct,alter,improve,demolish,or repair any structure
L�� prior 1,its issuance,atm aims the licaat for such g /-
m reg Pp mode,Lfileaei signed SPECIAL CIRCUIT/MISC.
} Nal he is licensed punuvnuothe provivi,ns of the Cnnwctors License law(Chapter 9
pC) (commencing with Section of Division Softhe Businessand ProfessionsCode)m TEMP.METER OR POLE INST.
�MG xay that he is exempt therefrom and the basis for the alleged exemption.Any violation of _NEW )I ON ❑DEMOLITION
Section by any applicant for a pewit subjects the applicant to a civil Ivnalyof POWER DEVICES. a ,
t„». t more than five hundred unllars($SIXq. �' ❑FOODSERVICE
CC w NT
f=C (JI,as owner of rhe propenY.mmy employtts with wages es their sole compencotion. SWIMMINGPOOL ELECTRICENT
F will da thewrnk,anJ theswewreis not intended or,Raved for sole(Sec.]064,Business QpgWE/"
3 and Professions Code:The Commcmis License Law Joos not apply man owner of OUTLF'IS-SWITCHES-FIXTURES �/ry
prolrny who builds m improves tMrcrn,and who does sucM1 work himttlf or through VV
his own employers,provided that such imprnvcmemx are not intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.ILhowever,Ne huiltling nrimprovcmem is mld within one year of completion _ SQ.FT.FLOOR AREA &SQ.FT.
rbuilder will have the burden of proving that he did not build or improve Tnr Pur- A
poseafsa]e.),
❑ E,as owner of Ne property,am exclusively contracting with licensed contractors to T �D p ,
corutrat the Mimi(Sm.II)44,Business and Professions Code:)no Connacmri Li- srTF/^��r._
cense Law does not apply to on owner of property who builds or improves thereon,and FET.
P QTY.' PLUMBING PERMIT 0
wha ,for such projects with o economical)licensed pursuContractorsno the Contractors
License
aww
❑ lam.Law,exempt undo Sea ,N&PCfor thio reason PERMIT ISSUANCE i
Owner Data ALTER-DRAIN&VENT-WATER(EA) VALUATRIN
VWORKER'S COMPENSATION DECLARATION BACK FLOW PROTF.CI'.DEVICE C ' O
I hereby E m under penalty of perjury one of the following declarations: —E O
I have and will maintain a Certificam of Consent 1.self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND.
saline.as provided for by Section 37M of the labor Code,for the performance of the STORIES TYPE.CONSTRUCTION
work for which this permit is issues. FlXTURES-PER TRAP
❑ 1 have and will mamtain.Workees Compensation Insurance,as requires by Section
3700 ofthe LahorCede,far the Performance ofthe work for which this pewit is issued. GAS-EA.SYSTEM-)INCA OUTLETS
My Workers Compensation Insurance cancer and Policy number arc: OCC.GROUP CPN
Cartier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
'CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This section need not he completed if the permit in Corona hundred dollars(EI W) BUILDING DIVISION FEES
or leas.) GREASETRAP
' Ittrtify that in the performance nfthe woh forwhich thin PLANCHECK FF.E 3,66 66
Phe tutor its'Comp d- �fl
-at-.Law any Canon inan ma,er an q.mhcon euhjttno the Wnrkers'Cnmpen- SEWER-SANITARY-STORM EA,20(l FT. ENERGY PER a
0 z xmion laws of Calif '. ) - fl
7 O� Applicant t WATER HEATER WNENT/ELEM GRADING FF.
G NOTICE TO APPLICANT:If,after m, Ing this ant xemptiR you should WATER SYSTIiM?kHATINC
a become subject m the Worker's Camp tsation provisions a labor Code,you must SOILS FEE
forthwith comply with such pmvisi, or this pewit she dttmed revoked.
�W Q WATER SERVICE
CONSTRU N LENDING ENCY
DZ NEW RESIDENTIAL PLMB. SQ.FT. PAID
U work
by whoRtw thinthem isaed(See.30lending agency for the Performance of Date ReK a
Us F the work for which this permit is issued(Sec.71W],Civ.CJ '
Lender's Name
U TOTAL:
ps Lender's Atutyt
fy 1 cenil'y that I have reuJ this application and state that the shove information is BUILDI
in ganga.E agree to comply with all cityand county ordimmoca and state lows(elating m QTY •MECHANICAL PERMIT FEE
U building comminution.and hereby authnrize representatives ofthis city sumer upon the SEES
above-meationcd property for inspection purposes.
PERMIT ISSUANCE
(We)agree to cove,indemnify and keep M1awkan the City of Cupcnst s against BILE ,
liaemosesjudgments.the granting expenses thispermit.
may in any way accromg-inan said City ALTER OR ADD TO MECH. O
in ons ANT of the grantingNS this pe wit. PLUMB
FEE
APPLICANT ND.RSTANDS AND W LL COMPLY WITH ALL NON-POINT PIR HANDLING UNIT(TO 10,000CFM)SOURCE RF rUl 'IONS MECHA CAL FEF.
AIR HANDLING UNIT(OVER I0,000CFM1 CONSTR CTION TAX
Signaturea AA pica mmctor nmctnr s EXHAUST HOOD(W/DUCT)
ZARDOUS MA' R _ DISCLOSURE. HOUSING ITIGATION FEE
Will the appsant or future britiin coped'Core or handle hazardous material HEAT]NO UNIT(T0100,01g)BTU)
us,defined by the penin,Municipal C c,Chapter 9.12,and the Health and Safety
Code,Section 85 2 a)? HEATING UNIT(OVER 100,000 BTU)'
❑Yex F-1 No
VENTILATION FAN SINGLE RESIDE PAID
Will the applicant or future Wilding accupam use equipment or devices which Date Receipt a
ithtuardous air contominann as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
strict? TOTAL:
❑Yes ❑No BOILER-COMP(OVER 100.00(i _
I have read the hazsidoua materials istairemenss under Chapter 6,95 of the Cali- AIRCONDITIONER ISSUANCE DATE
fmnia Health&Safety Code,Section,75505.2.5533 end 255M.E underan
sd Nat if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently haver tenant.that it is my responsibility to notify the oceupam
ofthe nquimnn nts which must be,met prim to isa-once of a Certifcam of Occupancy. }�
Ownerorauthnnzed-gent Date `= a
. ISSUED BY:
OFFICE