30716 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PERMIT NO. 3 O I( w
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANICAL 1v
BUILDING PROJECT IDRNfTF'ICA'DON
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATL
AME: PHONE: CONTRACTOR'S NAME: LIC NO:,� V/ V
/ „r NIC CO TIROL#
IRCHITECrIENGINEER: LIC NO: ADDRESS: ❑
O IJA
CONTACT. PHONE: - BUILDING PERMIT INFO
Aqoo� _ ' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
fdqLJ 1:1t ElLIC: M?D CONTRA R'S GEC1. RADON QTY ELECTRIC PERMIT FEF.
1 hereby affirm that 1 am licensed under pmvisi.ns of CTapter9(commencing JOB DESCRIPTION
Q=Z with Section 7000).f Division 3ofthe Businesa.rd prafesslons CMc,amd my license is PERMIT ISSUANCE RESIDENTIAL:
in full�fofrce Iend�reyyy�t����gyg,s�
�OF ❑SFU WI. El KITCHEN REMODEL
UZU Licen l.,a Lie.b
�QR Date '- Commcto APPLIANCES-RESIDENTIAL CADDITION El PLUMBING RE-PIPE
1„py ARC({ITEM'S DUCLARAI'[ON CMULD-UNIT CSTRUCfURAI.
y1 PANELS
I CZ JZ 1understandm y plans shell he used as public records MODIFICATION
:Jl2W AMPS O UP 0 ❑INTERIOR ❑CHIMNEY REPAIR
egc44jpj Coenuri Rvfessional 201-10n)AMPS IMPROVEMENT
��A� Oat I am exempt
from
m Ce Contractor's
OVER 1000AMPS C BATH REMODEUREPAIR ❑D�MOLITION
y 6 1 hereby a(finn that 1 em exempt from Ne Commcmr'e Littnse Lew for the
pe 3 d U following reason.(Section 7(31.5,Business and Pndeasionx Curie:Any city m ommy SIGNS ELECTRICAL ❑OTHER'
LSNl which requires a permit to cmrstmn,.her,improve,demolish,m repair any swcwrc
prior as its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed pum.am m the provisions of the Contractors License Law(Chapter 9
(commencing with Sodom 7W0)of Bit,Wen 3 of the Business and Professions Cde)or TEMP.MIT ER OR POLE INST. COMMERCIAL:
L y M eC that he is exempt thercfmm and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION El DEMOLITION
Section 7031.5 by any applicant for it pemtit subjects the applicant to a civil penalty of POWER DEVICES TgNpNT ❑FOODSERVICE
R} not mom than five hundred dollars($500). i R .HENT
a Cl.as owner of the property.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC 0TH
C will do the wmk.mrd the structure isms intended.,offemA forsale(St 7(94,Business
and Professions Code:The Conoodors License law docs not apply to on owner at OUTI.E S-SWITCHES-FIXTURES
Property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are nut intended or off,rW far NEW RESIDENTIAL ELECfR SQ FT.
eel..IL however the building or improvement is sold within ane year ofcompletion,the Q.FT.FLOOR AREA $/SQ.FT.
owner-hullder will have the burden of forcing that he did not build or improve for pur-
pose of sale.).
C 1,aser of the property.am exclusively contracting with licensed contractors to TOTAL:
onxtmm theproject(Sec.719q Bminwse and Profession,Code:)The Comracnv'e Li
nae Law does not apply to an ownerof property whobuilds or improvesthemun,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a contmaor(s)licensed pntsunm to the Conovcmra
License law' PERMIT ISSUANCE
1 am exempt under Sec. ,13,a1'C for this reason
ALTER-DRAIN A,VEM'-WATER( )
Owner pate EAVALUATION I
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO=.DEVJCE
I hereby affnn tinder penalty of perjury now of the following declarations:
❑(hove and willmaimaineCenificateof Conumto self-insum for WoMers C.mpcn- DR STORIES
STORIES TYPE CONSTRUCTION
salion,its provided for by Section 3700of the tabor Cwle,for the performance m the
work which this Famous is issued, FIXTURES-PERTRAP
]&1 hove and will maintain Worker's Compensutinn Insurance,as required by Section
3710 oftl�hre�e sgLa,aC�ttemmrJCCpuuoppde,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS
M arab. ajjl I sumnce carrier and Pnlic m1 J OCC GROUP APN
Policy Nm `I. • 2ea GAS-CA.SYSTCMOVF.R 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE.INTERCEPTOR BUILDING DIVISION FP.I'S
(Thissection need mot h.completed if the permit is roans,manhood dollars($100)
m less.) GREASE TRAP
PLANCHECK PEE
(ossify that int ho anyancrero astoFrm subject
to themitisissmd.lpen. SEWER-SANITARY-STORM HA.200 Fa.
not employ any perste in any manner so as to become subject to the Workerx'Compete ENERGY PEE '
ration laws of California.Data O z WATER HEATER WNI:NTB:LECIR 0
Applicata GRADING PEE
.~N-t NO'IICH 1'0 APPLICANT:If,after making his Certificate of Brampton,you should WATER SYSTEMITREATING -
h become mbject to the Workers Com{cnsmion provisions of the Labor Code,you mull SOILS FEB
forthwith comply with such provisions or this permit e1a11 be deemed revoked WATER SERVICE
Z CONSTRUCTION(.ENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT PAID
U0 I hereby alErin that there is a construction lending agency for the performance of Da¢ ceiptM
Fthe work far which this pemdt is issued(See.3197,Civ.C.)
O U Lenders Name TOTAL:
Lender's Address TOTAL:
g11 1 certify that I have read this appl icution unit state the the above information is BUILDING FEE
a
14 comes.1 agree to comply%an all city arta county dinu s ane sure laws dating to QTY. MECIIANICAL PERMIT FEE
U7- building constmction,end hereby anWorizc representatives ofthkeity et racialism the SEISMIC FEE
ateve-m,ntioned property for inspection purleus. PERMIT ISSUANCE
(We)agree Ia save,indemnify and keep harMess the City of Cupeninn against ELECTRIC FEE
liabilities,judgments,cors and expenses which may in any way acme against said City ALTER OR ADD TD MECH.
in .sequence of the grunting of this permit. PLUMBING FEE
APPLICANAT UNDERSTANUI AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOURCE GU S MECHANICAL FEE
AIR HANDLING UNII'(OVER 10,110)CFM( CONSTRUCTIONTAX
$ .t..f - -v-9_
ppican Caruana, Datc EXHAUST HOOD(WMUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building scuFamt store or handle hazardous material DEALING UNIT(TO I W,WO BTU)
as defmW by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Cale,Satin 25532(a)? HEATING UNIT(OVER I W,II(I(1 BTU)
❑Yes CNo VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt M
mait haz.Nous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP QHP OR I W.CM ATV)
v District? TOTAL:
Fl r7 No BOILER-COMP(OVER W,OWI3TU)
(have r Suet Met
Setionslls,equ5533 is under Chapterfi95oftht the
AIR CONDITIONER �I�g'ANCE D�1TEe"1
fatale Health&Safety Coda Sections 25505,25537 aqd 5534.1 undemlatd the if the NEW RESIDENTIAL MECH. SQ,IT. ^4L" Oa
bm1dingdTa ry+�eo 1 1 e nl,lha' o reiptmsibility to notify the occupant
of the r<quie�cn th a ismanre ora Ceni'fwnse ofpOcc fancy. O
—xRJrL/6J.a
O ,seen r are TOTAL: ISSUED BY:
OFFICE