S0079 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPP:RTINO BUILDING-MECH'N CALICA PERMIT N("—L
RUILOING DIVISION APPLICATION/PERMIT Yl.lG PROJECT[BEST ICICI.
I+UILDINI:PROJECT[BEST
Y SANITARY NO. APPLICATION SUBh11T1'A I.DAPI
.)ING ADDRESS:
W� N t I'lIONE: LIC NO: �NIC COYI'NOI.x
ER: LIC NQ: AD x13.: JJ U' ❑
COM'ACT: PHONE: BUILDING PERMIT INFO
❑ Cansullanl Fees Paid by Applicant(Initial) HLDG ELECT PLUMB NIECH
/
Lf
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that 1 am licenced under previsions of Chapter 9(commencing
CCg 'n full force and cHeI Danr"nn3ofthe Holness anA Prnlessionc CnJq and my liucluel. RESIDENTIAL
Li wi w PERMIT ISSUANC17 ❑SPDW'1, ❑KITCHEN REMODEL
CUF
aUU 1.icensc Class Lic.p APPLIANCES-RESIDEIYr1AL ❑ADDITION [I PLUMBING HE-PIPE
vF'izU Dme Cn doulur ❑MULT1-UNIT ❑STRIICIURAI.
ARCHITECCrS DECLARATION PANELS MODIFICATION
O Z ti Z 1 unJcmaml my plans shall be uud as public recnms UP TO 201 AMPS
[I INTERIOR [I CHIMNEY REPAIR
WLZ Licensed Pmfemional 201-INS)AMPS IMPROVEMENTSWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS El HATH REMODEL/REPAIR El DEMOLITION
Q I hereby affirm that I am exempt from the Contractor's License Law for the C1 OTHER
p(�G U{.. following ower.(Satins 7031.5,Hunav,an I Pmfm..urs Code Any city or county SIGNS ELECTRICAL
W 3 6 N which requires a permit to omen al,altar,improve,demolish,or repair any M umme
j_.O j Lot its issuanee,is^mquires the applicant forsuch 1.11 ofilc usignal amtemem SPECIAL CIRCUIT/MISC.
999999 y that he is licensed pursuan ,,meprnvisions^fthe ContmcmrI License Law(Chace'9 COMMERCIAL
CpO (commencing with Section]WR)(if Division J of the Business and Pose,ions Code)or TEM P.MI CER OR POLE INS'L
a y es C that he is exempt therefrom and the basis for the alleged exemption.Any violation of [1 NEW 6LDGIADDI'fION ❑IJIiMOLITION
W^y Section 7031 S by any appl icamfor a permit subjects the applicant n a civil penalty of POWER DEVICP_S []TENANT ❑FOOD SERVICE
not more than Five hundred dollars Mold,=� ' PROVEMENT
re01,as owner ofthe ppeny.or my employees with wages as their compensation. SWIMMING POOL ELITO RIC THER
E.. will do the work.and the structure is ant intended oroRcred for sale(See7814,Business C
Wwe and Pole...^ns Cudc:Tnc Curr r,tor's Liamsc Law ma,e not apply m am owner of OUTLG fS-SWITCHES-Il%TURLS O
1 Leopeny who builds or improves thereon,ani who does such work himulf or through
his own cmployecs,provided that such impmvaramux am-1 intemled or oBendi for NEW RESIDENTIAL ELEiCTR SQ IT
sulc.IL however.the huilJin tis soW within one fcom lelingthe A VQ� FLOOR AREA &SQ.Fr
Ycnro p �/
own
er-nndder will have me burden of proving that he ire ren stud m impn,ve rm pur-
pose of wle). TQI'AL
1,as owner of the poperty,am exclusively contracting with licensed contractor,no A7{'11�
mmtruel the pmjenl Bee.91114.Buaincss and Pnfiallinnv COneI Tnc CnntoulanI LI- [ �QU p
cerise Law does not apply to an owner Ofpm;any who builds or improves twmm.and QTY. PLUMBING PERMIT FEE J
who contracts for such pmjects with t conuanor(s)licensed pursuantto the Commit r-rtix,iii.
Limnse Low. PERMIT ISSUANCE Ur y
l am exempt under Sec. ,pgpCfor this remain
ALTER-DRAIN.@ VE.VI'-WATER(IIA) VALUATION
Owner Date
AMLI WORK UR:S COMPENSAT]ON DECLARATION BACK FLOW PROT=DEVICE
I hereby affirm under penally of perjury one of the following declarations:
IhuvetndwillmaintainaCenhlwreof Cmnsenuomlf-insumfurworkers COmNn- DRAINS-FLOOR.ROOF.AREA,COND. Sl'URIES TYPE CONST RUCfIO1
cation.:rs provided for by Section 391X1 of the Labor Coda for the performance of the
work for which this Permit is ismed, FIXTURES-[ JITRAP
❑1 have and will maintain Wortarev Compensation Insurance.as required by Section OCC.GROUP AI'N
3700ofthe Labor Code,for the ^ f'he work for which this permit is issued. GAS-IIA SYSTEM-]INC.4 OUTLETS
ncc U
MY WnrkcrsC r valinn los nicr:md Na.:n�
arc Policy lacy GAS-IIA.SYS'I'IiM-OVER4(EA)
CER ICATE OF EXEMPTION FROM W CERS' GREASEVINDUSI'RL WASTE INTERCEPTOR
COMPENSATION INSURANCE NUILUING DIVISION FEES
(T'hisawlion need noted csmplelW it'he permit is factor hundred dollar%($lau GREASIi TRAP PLANCHECK FEE
or lass.)
Toy any altar in parpearrancework for
Na..whicnthis permhiser,C.11all SEWER-SANITARY-STURh1 EA.200 FT' IiNFRGY ITE.
not employ any parson in any Di manner sO us it,Mcome auM1jcd ism hhe WorkoM Compun-
z smion lass of California.Date WATIiN IIEATIiµWNFMIELEC IX GRADING Irlili
Q Applicum 1
NOTICE TO APPLICAN'1:If,a flat making this Certificate of E.cralunn,you should WATER SYS I'EM?REA'1'ING SOILS FEE
F' hecameobject it)the Workers Compcnsmion pmvisions of the Labor Calc,YOOrml
4ak1� forthwith comply with such provisions or this permit shall la,denrcd revoked. WATER SERVICE
Q PAID
L1a
CONSTRUCTION LENDING AGENCY NEW R12SIDEN'I IAL PI.MB, SQ.FIL Ume Receipt x
U O I lamely affirm thatthe.is a nmsuvction lending agency for the Performance of
U F the work for which this Permit is issued(See 3097.Civ.C.) TOTAL:
O U Lender's Nance TOTAL:
} � Lender's Address BUILDING FIiE
6. I certify that 1 have read this application and state Nat the above information is
Vl correct.I agree t^contpl,wdhall city andmunry nrdrances and sum lows relatingw QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U Z building cnnumcinn,and hereby authorize representatives ofmiscity to enter totem the
ahnvc-mentioned property for inspection purposes. PERMIT ISSUANCE r ELECTRIC FEE
(We,agree to save,indemnify and keep harmless the City of Catania.against
liabilihcs.judgmm
es.colas unit expenses whlchmnty in any way alcove nguinsl said City ALTER OR ADD TO MFCH. PLUMBING FEE
in con:poorer of the granting of this permit.
AL'1'LIC 'T UNDERSTANDS AND WILL YhY WITH ALL NON-POINT AIR HANDLING UNIT(TO IILIXXICFM) F1IiCHANICALFEE
SOUItC GULATI ti
AIR HANDLING DNI'T TONER III.IXNI CPM) CONSTRIICCION'1'AX
Sigr firAp ecu ❑mruuor a EXHAUST HOOD(W/DUC) HOUSING MITIGATION FET!
HAZARDOUS MALMALS DISCLOSURE
Will the applicant or fmurc building tccupantsI c or handle ID'arr us mumrial HIi6fING UNI'I'('TO IIXI.gq B'1'll)
as tcfined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I W.IIW B ru)
Code,ScJmn 25532(t)'t
C]Vic, El No VENI'ELATION FAN(SINGLE NESID) PAID
Dale Ruxiplp
Will the applicant or future building occupant use equipment or devices which BOR FR-COMP(3HP OR 1110.0)(h BTU)
emit hazardous air conunnlnantn as defined by the Bay Arca Air Quality Managancnl IDEAL
Uisldct? BOILER-COMP(OVEiR 180.100 BTU)
❑Yes 0 N
A R COKDI'TIUNIiR ISSUANCE CAL I,
1 have road the h ode.S s unlatchn255 5.25533 an under Chapmr com of the Cali-
hsmia Health,(Safety tly have
Sections t can i 25533 am1255}1.l tonerstamh that if the NEW RESIDENTIAL SUCH. SQ.FT.
hnilding does not currently have^tenant can it Is my respmslbility to notify themcupam
of the mtimear ms which must M met prior t^issuance of a Cenilicate nl(kcupuney.
Owner or uuthnrirzJ agent Dam I L: / ISSUED BY.
OFFICE