S 1019 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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PERMIT NO.
IVISION APPLICATION/PERMIT S 1019
BUILSANITARY NO. APPLICATION SUBMITTAL UATIESS'. PHONIi: CON'IRACTORSNNIC CONTROI,p
L — DO1INEER: LIC NO: ADIIRESS: ❑
CONTACT: PHONE - BUILDING PERMIT INFO
' ` V , 1I � �OO ❑�Itant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECx
too W ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DIiCLARAI'ION QTY ELECTRIC PERMIT FEE
I hereby M.that 1 am licensed under provision,of chapter 9(commencing JOB DESCRIPTION
awaz with Secana 71)( ul'oivisina 3onhe Businas,and Prorcssions Code.undmy license is F F TI 1JL'
W p PERMIT ISSUANCIi
Cul- I ifullrem a Class
s eRccl. FDWL ❑KI TCIIEN REMODEL
Q U hrccosc Clercs Lich APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING BE PIPE
F z ul Dam Comracun
vIQL ARCHIT'ECT'S DECLARATION ❑MUI,TI.UNI'T El STRUCTURAL
PANELS MODIFICATION
zoyz l understand my Piaui be used m public records 'TO AMT'S
p z V, UI ❑INTERIOR �CHMNEY REPAIR
(Fa-,fn Loomed Pode,,ional 2111-1IXXIAMPS IMPROVEMENT I]SWIMMING POOLS
CYE. OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODFUIREPAIR [I DEMOLITION
C w Q I hereby affirm that I am cram the crathe Cmaranor's Licence Law fur the
X O W U following reason.ISeetion 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
,ii:6.y which requires a permh to construct,cher,improve,den ol ish,or relish any marenne I I
2:0< prior to its issuance.atwrmarec the applicant for such permit to a signed,mmment SPECIAL CIRCUITIMISC. I
that he is licensed pursuantto the pe-kinosufthe Centrahni,,LkarwLaw(Chapter')
� QQ (commencing with Sotion Y(XKB(if Division 3ofthc Hu,lnennmd Prefe-am,Code)er TEMP.MET ER OR POLE INti P. COMMERCIAL
A. W that he is exempt therefrom and the basis for the alleged cxcmgioa Any violation of NEW'BLDG/ADDITION ❑DEMOLITION
Xma Section 9011.5byany upplicunl foruperntit et,hjc,,,the applicant u civil penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE.
I- nomn
t nradefive hundred dollars IS500) z IMPROVEMENT
W F
Q1,asa%nerofthc property,oriny employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
.O will dothaw-ork,andthesamendeisnonimendedoroffered tersule(See.JDWc
.Businu OTHER
W 3 and Profession,Gale:The Counselors License Law does nal apply to an caner of OUTLETS-SWITCHES-FI%TURES
propery who build,or improves Ihemon,and who does such work hfinell it through
his own employee,,provided that.such impmvememe me net intended or offered for NEW RESIDENTIAL ELECfR SQ PC
sale.Ifhowever.the building lir improvement is sold within one ycmof completion.the SQ.FT.FLOOR AREA SISQ.IT.
owina-builder will have the burden of proving that he did not huild or impnrva for par.
Vlrc of sale.).
h use oworr of the property,ten cul mively connecting with licensed comrmwrs to 'IDTAL:
nnstrucl the project(Sec BW,Business and Professions Gxlc:J The CommearI cenew QTY. PLUMBING PERMIT FEE
who amnmeta fur such pargcels with a nmlmetor(n)licrnal pursuant to the Cmmnec or's
License law. i PIIRMI'T ISSUANCE
I um trancho Be,. .BAt PC 1.1 this realm
ALTER-DRAIN&VENT'-WATER(EA) VALUATION
Owner [)aid
,. WON F 'S CONTIHNSATION DECLARATION BACK PLOW PROTECT.DEVIC12
I hereby affirm at penalty of perjury one of me foLlohing declamnons,
❑Ihuvemtd ivulmaiumin a Certificate of Consent to self-iawre for Worker's Compete DRAINS-FLOOR.ROOF,AREA,COND.
onion,as provided for by Section 37M of the Labor Code,for the performance of the STORIES TVI'F,CONSTRIJCTIO:
work lin which his parotink osiad. I FIXTURES-PER TRAP
1 have and will maintain Worker's Comperoaaa n Insurance,as required by Section
TlOaofine Leben CWa.Rinhe peafmaninccofnhe work Enwhwlado,permit is issued. GAS-EA.SYSTEM-1 INC.[OUTLFIS OCG GROUP MIN
My Worker's Compenmtion Insurance carrier and Policy number art:
Carrier. Policy No.: t GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE I GREASFANDUSTRI,WASTE INI ERCHMOR
BUILDING DIVISION FEES
(Thio section need nut becompleed if the permit is Ensure hundred dollars 151q)1 GREASE TRAP
or IessJ PLANCI{F.CK FEF,
Toy anythatinthe perfinnumcc any
the work for whichthis the'W isissued,Campo - SEWER-SANITARY-
notemploy any person in any manner m alio become subject In the Worked Camper- S'1'ORM EA,200 FL ENERGY FliE
O Z alion Law—IC California.Date WATER HEATER W/VENTIELECTR GRADING IEE
Z O Applicant
NOTICE 1'0 APPLICANT:If,after making this CenlEcae of Exainption,you should WATER SYSTEMOREA'TING
? became subject to she Wake-Compensation provisions A the Labor Code,you mum .SOILS FEE
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0
= Z CONSTRUCTION LENDING ng agency
NEW RIiSIDENIlAl.1'LMN, SQ.IrI'. PAID
U I frwhichnnlhalmere ieace (Seri.3007,
agency fur the performance of Uma Receipt It
t-c me work for which this permit h inxur+l fSec.31M)1,Civ.C.)
Leader's Name TO'CA L:
Lvndar's AAJres. T( 1.:
Pm I certify that I have read this application and ,are than thC above information is BUILIIING I'EE
F'IZ) currect.l agree to comply with all city and county ordinances and.head,laws relatingtn QTY MECHANICAL PERMIT FEE
U Z buildingconswdlon,and hereby mahorize aTrcwmmivrb ofmis City In Cmerupun the SEISMIC FEE
above mentioned property fur inspection purposes I PERMIT ISSUANCE
(Wel agree t.ssva,indemnify and keep harmless rhe v-,oft Cri
upamo slim ra ELECTRIC FEE
liabilities.judgments.costs and expenws which may in any way accrue against said City ALTER OR ADD'1'0 METH.
in consequence of the granting of this permit. AIR HANDLING UNIT(TO 10.(100 CEN) PLUMBING PE-E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER IgWo CF,M7
CONS'DRUM ION'FAX
Signature of ApplicanVComracmr Dare EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant er future building occupant wore or handle hazardous material IIEAT]NO UNIT('TO IIq.gX)BTU)
as,debated by the Cupertino Municipal Code.Chapter 9.12,sal the Hcahh and Safety
Coale,Semian 25532Uau I I[EATING UNIT(OVIR I W.000 BI U)
[I Yea [-I No
VEN'TILAT[ON PAN[SINGLE RESIIp PAID
Will he applicant lir future building occupant ti,c equipment or devices which Orae Rei,eyl p
'Dot havnrdous air contaminant,as defined by the Bay Area Air Quality Management (TOILER-COMP CrHP OR 100.0X)BTU)
uld ^ IOTA I:
❑Yc. 0N BOILF.H-COMPIOVER IW,IXXI BTU[
I have mad the ht/ardeus materials reunite car,under chapter 6.95 ofthe Cal i- AIR CONDITIONER
1 P ISSUANCE DATE
fuiliil Ileal s&Scurry Cale.Sections Shat i 8toy and 25531.1 understand d the if Aha NEWRESIDENTIAL MUCH. SU.FI'.
of ffict nounwhich haveu¢n.mL mm in is my rc,pmcibi nifir nnlilYthrrccupant f/ O ^/Q
of the requt s ons which mu. Mm t ri t '.c cora Cerifcmc oflhcu ancy
r—
Owrnnnat izedn•
Data TOTAL: TSSUId6RY —_
OFFICE