31275 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINtO BUILDING-ELECTRICAL PERMITNO.
,BUILDING DIVISION APPLICATION(PERMIT PLUMBING-MECHANICAL •( 1 2751V
BUILDING PROJECT IDFINTIFICA'I'[ON �I.L
BUILDINGADDRESS: " SANITARY NO, APPLICATIONSSUBMII-J'AL DATH
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OAK11 Lt ,,
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It .46
OWNF* 'S NAME: CONTRACTOR'S NAME. . LIC NO:
L.� J PHONE: ^ U Cr' JNJO G � • ' NIC CON'feOLft
ARC TELT 'GINEF,R: ; - LIC NO: ADDRESS: J
S ❑
J 9 ,Os, AN2A. ct
FforccOd
PHONE: ' BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) - BLDG ELECT '.0 MCCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE '
affirm that I am Iicemed under provi.inns f Chapter 9(commencing JOB DESC IaT10N.
0aZ10B of Divisinn3Ofthcl+nsincss avJ hl dos : l,anJ my li encs,lv RESIDENTIAL' '-
Ij PERMITISSUANCE Ld— d effect /� Q� ❑SFDWI. ❑KITCHEN REMODEL
LLQHGi Commcfor �u0� - APPLIANCES-RGSIDEM'IAL ❑AUDITION �I'LUMBING RE-PIPE
.8n4 MODIFICATION
ARCHITIiCIti DECLARATON, PANIi1.5 ❑MULTI-UNIT ❑STRUCTURAL.
.O vet Z 1 unJcmm�J my plans shall Iw used a.pathic rcnnds MODIFICATION e
)Z—a - ' - U.PIO10OAMPS " ❑INTERIOR ,., OCHIMNEY REPAIR
C—F; Licensed Profe....a.] - 201-IO00AMPS IMPROVEMENT
C
OWNER-BUILDER DEthe nOVER OIO AMIti; ❑BATH REMOUII/REPAIR DEMOLITION
C firs.the License Law frthe
O6Q hereby e
U following reu.on.(Section 7031.5.Bminesa and Professions Crate:Any city Or mum, SIGNS ELECTRICAL -❑OTHER
0LLO y which requires a permit it)t consct. ilnpruve,dcnudw
ish,or repair any sclum
Q, prionoits issmnce,also reyuircs the applicum for loch permnmfile a signed statement SPECIAL CIRCUITMISC.
C } that he is licensed pursuant o are provisions ofthe Contmnuls License Law(Chapter 9
0 00 (commencing with Section RO)()of Division 3 ofthe Business and Profo,mrs,Cale)or TEMP.METER OR POLEINST. COMMERCIAL:
4 c y
that he is exempt th mforn and the basis for de alleged exemption.Any violation of , , ❑NEW BLDG/ADDITION ❑DEMOLITION
�m Semi.n7(Ii LS hY any aPPlicnm liaa permit subjensthe:hpplicam ntxcivil penalty of POWER DEVICES ❑TENANT FOOD SERVICE
r more than live hundred dollar.(85(X1).
[.ZY IMPROVEMENT
_< wi Lo the warofthe pestrac.or mY.imeneeswiN ersd fasedci(See Wsl CBusiness SWIMMING POOLIiLECfRIC
f F se will dothewons and the he Cam is.. Liter ,Law dos nor e(See.o an owner of - ❑ETHER
m and Professions Cade:The Cnntramnr's Liccnu Law does nm apply,et an owner of .OUTLETS-SWITCHES-FlXTURIiS
o,dy who builds ser improve,thereon,and who docasuch work hmmelf Or tmatgh
his own employees,provided that such improvemenu arc not intended or offered for NEW RESIDENTIAL ELECTR SO FI'.
sale.IL however,the building or impmvemcnt is sold within one yew ofecmpletion.the SQ.FT. RARER 8150.FT.
Jenellsmidcr,will have the home.of proving that he did or build Or improve for par- ,
awenf. I ). -
❑ 1,as f theP pent exclusively t i b 'Ib licensedcontractors to TOTAL: )
consumer the project(See710 Bust ness andP f :Cali,)The CiouractmesL-
. builds
/ f� p q -
censeLaw denot apply Of pony h h Id. p re theand QTY PLUMBING PERMIT' FEE Ir Q/ I D
who contracts for such pmjaze;with a aontractogs)licensed pursuant o the C manors 6
License Law. PERMIT ISSUANCE
El I.,it exempt udder Sec .B&P C for an, as .
AU]T:R-DRAIN&VHN'r-WAIER(EA)
Owner Dale
WORK17H S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE CITY Ur
I arch,affirm under pentift,of perjury Otte of the following declarations lrUl'Cn MV V
*C]I havemtd will maintain a Cenificala of Consent to self-insure for Workers Compen- DRAINS-FLOOR.ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 3910)of the Labor Code,for the performance of the
work for such this permit is issued, ,PIX'TURES-1'ER'I'RAP
❑1 have and will maintain Workers Compensation Insurance,as require)by Section
PO of thele r hate.Esr Ne ped'onnawc of the w.rk for which this perrltir is iswN.. GAS-EA.SYSTEM-1 INCAOUTLEfS OCC.GROUP APN
My Worker' p ss• tt career end Policy num�F a
Carzicr: GAS-EA SYSI'BMOVERA(EA7 "
CERTIITC COMPENSATION
ATIO I N FROM WORKERS' - '
COh1PEN5Af10N INSURANCE, � GREiAS1%WUUSIRf.WASTE INTERCEPTOR, BUILDING DIVISION FEES
(Thisseetionamd not be completed ifrhe permit it for ours,hundtcd Jolla.l$100)
GREASETRA;
or icssJ PLANCI{ECK FEE
ready Nat in the perfornanccof the work for which this permit is issued.Ishall SHWER-SANITARY.-STORMEA,20F.
not employ any pe,Ow in any nmoners.as to La co oc Omicm m the Worker,'Comport- ENERGY FEE
.O Z cation Inws of California.Date WATER HEATER WNENT/ELECTR GRADING PEE
Z 0 Applicant
NOTICE TO APPLICANT.If,after making this Ceniftcate of Exemption,you should WA1T.R SYSTEMrtREATING
F ^ become object to the Worker's Compensation f the LsMn Come,you must SOILS 10)3[
1 Accra permit
hal o
fonhwith comply with such pmvisinnx nr this pemtil shall M demned rcvokxd. ', � WA'T[R SERVICE
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SO,FT. PAID Date Receipt N -
L)C) IhertM1y affirm thin them isaconnrocuon lending agency for the performance of ,
the work for which this permit is issued(See3097:Co,C.) -
Lender's Name TDIAL
.
WLender's Addnws .. `.. 1,. ..
. 1 cenify that 1 have read this application morainic that the above information is
BUILDING FEE
L (A cored l agree to comply with all city and county ominant and nate lawxiahning to QTy, MECHANICAL PERMIT FEE
U z building construction,and herebyamhorize reptescmmives ofthis city to enter upon the SEISMIC PEE
abet c-nondioned pntpeny for ho,clion pupas. 1'IiNMII'ISSUANCIi
I Wc)agree to wvc,inJnmtily and keep hannlesx the City,of Cupcnino against T;1.13C'I RIC FEE
liabilities,judgments,costs and expenses which may in anyway acerae against said City ALTERORADDTOMECH.
PLUMBINGFEE
in consequence of the gra U of this it
APPLICANT UNDERSTANDS 4 ' WILL CO WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00(1
.ATIONS. MECHANICAL FEE
SOURCE
AIRHANDLING IINI'I(OVER 0.000 CFM) CONSTRUCTION TAX
Signor of Appli Co - Dam EXHAUST HOOD(W)DUCfy HOUSING MITIGATION PEE
It Z Minot IS TERIALS DISCLOSURE
Will thert,licars nr fmure IN Odin "apanI mmc or handle hazardous material HEATING UNITGO 100,010 BTU) ,
as defined by the Cupcnino Monlcip ;odic,Chapter 4.12,send the H1. end Safety
Code.Section 25532(x)'1 _ HEATING ONI'll(OVER 101X01 BT01
❑Yes No VENI'II.ATION FAN(SINGLE RESID) PAID
Will the applicant or furore In i ng Occupant use equipment or devices which Dam Receipt N
emit hazmdoos an cciamiuml, Bnalby the Buy Area Air OumliD Maitogement BOILER-COMI'1J11P OR 10.1001 BTU) ' Ti)TAL:
Diariafl BOILER-COM P LOVER 10,00 BTU)
❑Ycc � _
read the hazardous materials
AIRCONDITIONER
I have
reyui¢ments under Chapter b.YS of the Cali ISSUANCE DATE
fomie Health k Safety Cal Sections 25505.2553)and 25534.I mtdewtamd Nal if the NEW RESIDENTIAL MECH. SO.Flt
building Jh '1 vemm�ant shat it is my revlwneibility er notify the achyranl, -
ofthe encs wch st be am mnncofa CenifcnI of ncy.
r emhn' Da TOTAL: ISSUED BY: 1
OFFICE /