S 3972 (2) APPLICANSTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYO CCUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMB TNO-MECHANICAL S 3972
BUILDING PROJECT IDENTIFICATION:
BUILDING ADDR[SS: SANITARY NO. APPLICATION SUBMITTAL DATE
21BS Rucker DR, CA 9500,
OWNER'S NAME: N � CONTRACTORS NAME LIC NO:
NIC CONTROL.
CHAARCIHTECTIENOINEIIR: LIC NiO. ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO ,
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB NIECE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERNIIT FEE
1 hereby s1Erm mal 1 am Oceasedwader Prowistow of Clea 9(commencing JOB DESCRIFFION
DaZ wim Sectioo7aX))af UivisionJofthe Busineac and Rofcnsium Q-0a and my license is
RESIDENT
0 0 PERMIT ISSUANCE AL;
CIF in full force and effect. ❑SPDWL ❑KITCHEN REMODEL
QUU License Class ontr APPLIANCES—RESIDENTIAL
H<i Dam Contractor ❑ADDITION El PLUMBING RF.-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
Z,FOy� Iundendrod my Pleas shell teased aapwblemcmds MODIFICATION cc
UPT0200AMP5
O10i1 Licensed ParmasinnA ❑INTERIOR El CHIMNEY REPAIR
201-Ia10AMPS IMPROVEMENT I]SWIMMING El POOLS'
OWNER-BUILDER DECLARATION OVER IWAMPS BATH REMODEUREPAIR DEMOLITION itP
ac I hereby affirm that 1 em exempt from the Contractors License Law for the •+:�
Liyy O t4 U following reason.(Section 7031.5,Bust....and Pro(..inn.Cade:Any city or county SIGNS ELECTRICAL - ❑OTHER L /✓ V
which requires aer
pms mwe
cirml,a]mr.impostor, au,
ve,sehate,or mrytir any swum
cre
do,to its ismarma.also requires IM1e applicant for such Permian file a signed statement SPECIAL CIRCUITRUSC. I{
E } motheia licensed pnrsnanoft
nnthe provisions Cammnnrs License Law(Chepmr9 QQ2(;iL•N �•��
W 00 (commencing with Section 7aN))of Division 3(tribe Business and Professions Code)cr THMPME'I'HRORPOLHINSi COMMERCIAL:
uX
d y m p� that he Is exempt therefrom and the basis lot the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION r t1 l {i Siouan703L5 by any applicantnr o wamitauhjects lire appdicam to a civil farm POWER DEVICES a
m []TENANT ❑FOOD SHRVICFi
t more man five hundred dollars(S500). +
^ZM E]1.as owner ofihe pspeny,or my employees wim wages as their sole coarmwmion, SWIMMING POOL ELECTRIC IMPROVEMENT ;
' b=, will ce he work and the structure,is int inuended m icleyed battle(Sec.7144,Business ❑0"THER 5
LC m and Professions Com,41 he Contractor's License Law cars not apply man owner of OUTLETS—SWITCHES—FIXTURES -
6 property who huilds or improves thereon:and who rices such work himself or mmugh
his own employees.Provided then such i nprosemerts am nm intended or.tiered for NEW RESIDENTIAL ELECTR SQ FE
sale.If.however. he building or improveraNP"sodd within one yew ofeumpletion,the SQ.FE FLOOR AREA $/SQ.FE
.view-haildin,willI' fini himiroofp g(Ocia he didneab Id or improvefar fam. '
ac
n of the properstrianstombi,kely mi wractia,with f end rismasome,to TOTAL:
consumer the Project(See 7044Basin., ad Pr fie Cod )The Comori Lt. - - - - - �'�
rens d t apply1 fp p ty h hill. improve,me 1 QTY. i. PLUMBI t 'TEG
who contracts for such projects with w cwnr I ns)Immedpro: nttotheContractor'sFRIN
License Law "I t PERMIT ISSUANAS
b r. ^y tl
❑ Iam exempt under ,B&PC for this miss,sn
ACI'ER—DRAIN&V, f ER ) VALUATION
Date
WORKER'. COMPfpwrjuyo DfthefRATION BACK FLOW PROTECT.DLV
1 hereby al ll mai under Penalty oe ofjury one of the insum fag declarations 201
�thave anouledaiaty maintain Certificate Compen-the DRAINS—BOOR,ROLE,AREA,COND. I; ION
work.es provided lar by$eelml 3]00 of the Lubar Codc,lar the performance of the
work lav which this permit is issued. FIXTURES—PER TRAP
37 1 have and will ode.fon Workers Cance of the
rkfor hi h requited by Section
7700 of lire Labor Cale,forme performance of the work for which this permit is issued. GAS—Has.SYSTEM-1 INCA OUTLETS OCC GROUPa.� APE/ r
My Workers Compensation Insurance carrier and Policy number am: O
Cwricm Policy No.: I GAS—EA.SYSTEM OVHK 4(HA)
CERTIFICATE Olt EXEMPTION FROM WORKERS' Z
COMPENSATION INSURANCE GREASFANDU$TRL WASTE INTERCEPTOR
(This section need nal becomplluol ifine pwmil is furore hundred dollarsSINE BUILDING DIVISION PEES ,
nr lrss,) GRP.ASH'I RAI' PLANCHECK FEE
I reentry that in lheperfciumneeofthcwmk fevehlehthispe...m k o,ed,],hill SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so as to become subject m me Workers Compen- ENERGY FEE
Z satins.laws of C.limm..Date OWATER HEATER WNEM/ELECfR O Appllcum GRADING FEE
NOTICE TO APPLICANT:If,all"making this Cceiftcmc of Exem o1.you shoo Id WATER SYS'i uvtrnt 'PING
a ; become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
foehwith comply with such provisions or this permit shall be deemed divided.
WATER SERVICE
Q
CONSereisa'[ON LENDING lending
AGENCY NEW RESIDENTIAL PLMB. SQ.FII PAID
OO Ihereby off rot pewitoissmnaec.30 len ding agency for perfolmanrn of RmeiplM
Lt work for which this pemlit is issued(Sec.3097,Civ.C.)
O U Leedces Name TOTAL:
4L7 Lenticrs AJdress TOTAL,
I ccm y that I have Iced this application and state min the above Inimewe n is .. BUILDR G •E
Val comes[.I agree to comply with all city and county underwriters and state laws relating u+ QTY, • -MECHANICAL PERMIT FEE Q
U Z buildingemsteralmr,and hereby authorize meresentativcsof this city mcmteruPon the SEISMICE
abovcmrntloned property for inspection purfarsa' PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupmiaa against F.LI3CT iii
Iiabilines.jud,amors,coslsmad expenses which may in any way seems against said City ALTER OR ADD TO MECH.
in comequarceof the goodagof this petmit. PLUMBING NF
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,fq(1 CFM)
SOURCG REGII MECHANICAL WE
AIN HANDLING UNIT(OVER IO,IN01 CPM)
f f CONSTRUCTION TAX
,Signature of Applican ontmcter Date EXIIAUST.HOOD mmuc i HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willthaeppllemn mfumre wi]dia,wromea,lorenr handle hanarlmts material HEATING ON I1'70100,010 BTU)
as dcf tied by the Cupertino Municipal Code,Chapter 9.12,road the Health and Safety
1 CNe,Section 25512(a)? HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑Na PAID
VENTILATION PAN(SINGLE RESID) Data Reccipt K
will the air contaminants
or Pumas definedding by the B Em ea Air Qu or devices Management
BOILER—COMP DEEP OR 100,000 BTU)
emit hazwdows air conmminants as defined by the Bay Area Air Quality Mnnugemcnl
Domma^ TOTAL.
(:IYws FIN. BOILER—COMP(OVER 100,100 BTU)
I
I have read the hwardous nwmred,requirements under Chapter 6.95 of the CnlF A111 CONDITIONER AAw ISSUANCE,DATE
farm.Health&Safety Cade,Sections 25505.25533 and 25534.1 understand mat if the NEW RESIDENTIAL MECI1. SQ.FT.
building does not currently have a temem,that it is myyyy res,wbilitymnmifythetccupant (/r%,y /� �f�
of the myuiremem. hieh moa mel bnn'seNnce ora Cceifcam(tf(kcupancy. �• /�C�J+�r
rind age yS\\ Date TOTAL: ISSUED BY: , v
OFFICE