S 4467 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPERTINO BUILDING-ELECTRICAL PES[TNO. 4467
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS'. SANITARY NO. APPLICATION SUBMITTAL DATE
I l 2 r�2o vs77.4,3 — ?
OWNS 'S NAME. PHONE: CONTRACTOR'S NAME: LIC NO'.
r �L -e NIC CONTROLp
'ARCHITEC TNGINEER: P LIC NO: ADDRESS: ❑
CONTACT: PHONIi: BUILDING PERMIT'INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
Cdr 3 Z 1:1 � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under prowbwns of chapter 9(commencing JOB DESCRIPTION
'000 will Seelio iMXnuf Divi,eon 3onhe Businee,and Profe,ssiom Gale.and my lieemse is PERMITISSUANCE, .� RESIDENTIAL:
F in full force and effect. ❑SFUWL ❑KITCHEN REMODEL
<-U License Claw Lie. APPLIANCES-RESIDENTIAL ❑AUDITION C]PLUMBING RE-PIPE
NQ Wh Dam Contractor
F>y ARCHITECT'S DECLARM[ON PANEI,S [_1 MULTI-UNIT ❑STRULTURAI.
Z p y Z 1 understand my plans shall be used as public records Baa MODIFICATION
OZ4Q UPT0200AMPS G O [I INTERIOR [I CHIMNEY REPAIR
e,1 Licensed Professional 201-16g1AMP$ IMPROVEMENT ❑SWIMMING POOLS
Ny E,'4j OWNER NU[LUEH UGCLANA'fION OVER Iq,AMPS ❑BATH REMODEUREPAIR DEMOLITION
C C¢ 1 hereby affect that 1 am exempt from the Contmaah License Law for the
xo. 6O following reason.(Section 7031.5,Business and Profession.Gde:Any city or county SIGNS ELLCIRICAL ❑OTHER
m13 W m which requires a permit to remxnuet,alter,improve,demolish,or repair any svuelarc
Q prim to it issuance,ul.vo require,the applicant for such Permian flea signed sm¢mrnl SPECIAL CIRCUI I'IMISC on+n R In
that he is licensed pursuant m the provisions of the Contractors License Law(Chapter 9
�tYO� (commencing with Section 700X))of Division J ofthe Business and Professions Cmfe)m TEMP.METER OR POLE[NST J
G d e C that Ire is exempt therefrom and the base,fm the alleged exenmtion.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Wim Section 7031.5 by any applicant for a permitsubjecs the applicant to a civil Penalty of LOWER DEVICES ENANT FOOD SERVICE
= of mom than five hundred dollars($500). PROVEMENT
2Z0 F-1 Las ownarofine prnpcnY,mnty employer,with wages.,thelremc,onn ,nsadbn, SWIMMING POOL ELECT RIC
F" will do thework,muddle u..come is not imended moll erred for saw(See.7614.Business
W3 w and Professions Code:The Commerce,License Law docs not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property whir build,or improves thereon,and who does such work himself or through
her own employee,Provided that soh ingtmvemens are our intended nr offered fur NEW RESIDENTIAL ELECI'R SQ IT.
sale.If.how the building or ouprm'ement issold within one year of completion.the SQ.Fr.FLOOR AREA VSQ.FL
ner-huilder rill have the burden of proving That he did not build m improve for pur-
e. < 7r of the pmpeny,tun exclusively contracting with licensed nmtracmrs m T 'AL:
conswa the project(Sec.70,14,Businew end Professions Code:)The Contractor's Li-
OnseLaw does not apply manowner ofproperty whu builds or improves Chereon.and QTY. PLUMBING PERMIT FEE
who conroll,forsachProjcm,with.cnn0nctogn)licensed pursuant othc Contractor's
Liecnsa Law. /'� PERMIT ISSUANCE
dptundx, _` �l. .B&PC for thA on
ALTER-DRAIN All VENT-WATER(FA) VALUATION
OwwY"
�� —�ONKER:S CON DECLARATION RACK PLOW NHOTECI'.Il1iVICE
1 hereby affirm under penalty of perjury one of the following declarations:
D [have and will tnainminn Ccnifican,of Consent o self insure far Worker's Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE.CONSTRUCTION
nation,as provided I...by Section 37000 the Labor Code.I'or the perfnme nce of the
work for which min Permit is issued. FIXTURES-PER TRAP
r 1 have and will maintain Worker's Compensation Insurance,as required by Section
37mgofthe L.bur Code.laths perfnmanc,of the work for whi,h,hi, mtil is issued. GAS-1?A.SYSTEM-I INC.4 OUT I C.GROUP APN
My Workers Compensation Insurance eaten and Policy anoher are:
Carrier: Policy Noa GAS-F.A.SYSTEM-OVER 4(EA)
CERTIFICATE OI'EXEMPTION FROM WORKERS' GRfiASIJINDUSTRL WASTL INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
This section need not becompleted iflhe Permit is for one handle dollon($100) GREASETRAP
or less) PIANCHECK ftiE
I verify that in the performanceof the work for which this Permit is issued,l shall SEWER-SANITARY-S'I ORM EA,200 FT
not employ any person in any manner so a,to Femme subject In the Workers Curtner- ENERGY FEE
Z ,.fall Low,of California.Date WATER HEATER WATlx T/ELECTR
0 GRADING FEE
Applicant
= NUTICE'10 APPLICANT.If.atIllnaking this Ccnificate of Exemmion,you should WATER SYSTEMTREA'I'ING
(X > becmw
oe beja to the Wallace,Cumon p
pensmirovi.lfmn of the Labor Code.you must SOILS FEE
lk1 htrhwilh comply with such provisions or this pvamm,hall be deemed invoked. WATER SERVICE
CONST RUC IIONLENDING AGENCY NEW RESIDENI'(A].PLMB. SQ.FT PAID Ume Receipt
U 0 I hereby aDinn deal is a conslmction lending agency for the performance of
4. F the work for which this permit is issued(Sec.3097.Civ.C.)
C) U lend,,',Name TOTAL
lender's Address DAL
} U.1 1 sanity that 1 have mad this application and slate that the above information is r �, BUILDING PEE
a
y cones,1 agme monnPly with all cityand moody oNinanees and nam laws relminR m QTY. HANICAL PERMIT FEE
U
U Z htilding umrwctlnn.and hereby imthorinc npre.scm.tives nfthi,city to enter upon lM1eA
SEISMIC FEE
above-mentioned proper,for inspection purpaus. PERMIT IS CE ax 17
(We)agree tet save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEB
*. I.
lr.mss and ex a swhiehnmyin any way-,me agnimtraid City ALTER OR O oMECH.
PLUMBING TEF.
c granting t 's pen it.)ERSTAN)S L COMPLY WITH ALL NON-POINT AIR HAND 1 UNITOO10.000CFM) MECHANICAL PEE
TIONS. CONSTRUCTION TAX
AIN IIAND N6 NI CPM)icaMComrea - Date EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FEE
PIAlV RDOUS MATERIALS DISCLOSURE
Will the a,,Ii...t or fwum buildingxcupall nmm nr handle hraardou,mmerial HEATING ON[T(TO 100,XX)BTU)
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety
Cale,Section 25532ffil HEATING ON]((OVER 1110.000 B'rU)
Yes No U VLN'1'l1.ATI0N IAN(SINGLE.RESIU) PAID Doe RettlptN �
Will the applicam or future building occup in use equipment or devices which BOILER-COMP(JHP OR 10d"BTU)
emit hnna le.,air.aro miums as defined by the Bay Area Air Quality Management pL:
Uisniefl BOILER-COMP OVER 100,000 13'1'U)
❑Yes ❑No
I have read the hamrduus materials evil is under CTanr 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
qulrnncn p
fomes Icallh&S' y Ct S t ms 25515,25533 and 2SS34.1 unit d that if the NEN'RtISIDEN'1'IAL MECIL SQ.17 y
uildin Jasnol ntly lav .t nes .I t' "5 my rtsponsibility rn notify the ocapanl
o t my 'remen hicM1 m < I i seance of a Cefi f of cup' ^
ler M: IhnriecJ agent Date I OI'AL: ISSUED BY:
�N
OFFICE