S 1194 (2) APPLICANTT.TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF&PFIrrINO BUILDING-ELECTRICAL - Pli IT NO
BUILDING DIVISION APPLICATIONAPERMITPLUMBING.MECHANICAL 1194
BUILDING PROJELT IDENTIFICATION
BUILDING ADDRESS t SANITARY NO. GJAPPLICSUBMTITAL HATE
�%V606- NAP
AME: PHONE: CONTRACTORS NAME: LIC NO:
7A-, 2 . 3 N/C CONTROL p
•ARCHITE.CTILNGINFER: LIC NO: ADDRIESS. ❑
CONTACT: PHONE: BUILDING PER INTO
❑ Consultant Fees Paid by Applicant(Initial) BLDG F.1.ECI' PLUMB MECH
❑ ❑
LICENSE D CONTRACTOR'S DLCLARA'1'ION QTY ELECTRIC PERMIT FEF.
1 hffim
hereby at that 1 em licensed under Provisions of Chapter 9(commencing JOB DFSCRIPTION
won Dan with Section]B()(BofDivision 3ofthe It mrssand l'mfeedmPERMIT ISSUANCE ns Codemat my license is RESIDENTIAL
F W� in full force and dTea. ❑SIl)W I. ❑KITCIIIEN RIiMODEL
U License Class 1.10.M APPLIANCES—RESIDENTIAL ❑ADDITION C)PLUMBING RE-PIPE(—n W Date Conaranor
m61y ❑MULTI-UNIT' [j S1
ARCHITECTS DECLARATION F-O y PANELS MODIFICATION
n O n I understand my plans shell he used as public records
On 0 DP TG 21N1AMPS ❑INTERIOR [I CHIMNEY REPAIR
tel I"W Licensed Profexsional 2111-10110AMPS IMPROVEMENT C]SWIMMING POOLS
OOGGC raj OWNER-BUILDER DECLARRI'ION OVER IM)AMPS
C BATH REMODEUREPAIR [I DEMOLITION
y 1 hereby affirm that I am exempt from Contractor's Coor's License Law for the
x 3 d F fNlowing reason.(Section 7(1]1.5,Business and Professions Code:Any city or countySIGNS[LECTRICAI. ❑OTII
Rl ti whidt requires o permit to construct,olmr,improve,demolish,or repair any swemrc
O prinnnirs issuancq also reyuircs We applicam l'or such permint fleusigneJ sm¢ment SPECIAL CIRCUIT/MISC.
j. (cornnsanci gwit pumuant 70th)provisions of the Comraaors License law lChodmr9
(eft he
xempth Section700B)of basisonlof the Business and
on.Any
Code)or '1'fEMP.METER OR POLE INST.
a y o a that he is exempt theafmm and the basis for the alleged exemption.Any violation of ❑TEN NLDG/ADDITION ❑FOOD SERVICE LLX7 k,
Section]UI LS by any applicant fora Permit subjects the upplicanuoncivil penalty of POWER DEVICES ❑TENANT [I FOOD SERVICE
no m than five hundred dalton(S500).
F owner of the rt.or eat emloeex with wages as theirsole com nsation, SWIMMING POOL ELECT RIC OTHERVF;MIiNT
C property. Y P Y b' . ❑OTHER
JI do the work,and the structure C.a is nm,lacem or Law
do tarsale(Sec.7104.ivnB.se,at
¢]�'� ad property
wh b Coati:The Oamraemr's Liceme Luo does not apply s if owner of OIITLH'TS-SWI'fCHliS-P
C� his own who builds or improves thereon,and who does such work himself or through
his own mnployces,provided that such improvements arc not amended(it offered for NEW RESIPBN'I'IAL IELECTR SQ FI'.
side.IL howevio- he building or improvement is sold within oneyear ofconspletiamahe SQ.IT.FLOOR AREA $/$Q.IT.
crbuilder will have the huMcn of provbaring that he did not build or improve r pur-
pose of sale). P A 0 D
Ei I.as owner of the property,am exclusively contracting with licensed contractors In
construct the pragect(Sec,70H4,Business and Professions Code:)The Contractors Li-
cense lawduesoat apply tomowtterof pmprrly who builds or improves thereon,and QTY PLUMBING PERMIT FEE nSILIa FEBocontincts forsuchprujects with acmnractogs)licensedpusuannothe Contractor's I11i�" 2m
Licence Law. PERMIT ISSUANCE A
I um exempt under See .H&P C fear this reason
` ALTER—DRAIN&VENT—WATIER(EA) @nthU
wn [)are
WOR KF SCOMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I h y affirm un r penally of perjury one of the following declarations:
I have and will maintain aCerificatcofConsom mself-ileare for Worker's Compete DRAINS—FLOOR,ROOF AREA,COND' STORMS '1'YPIi CONSTHUCf1ON
sation,as provided for by Section 37W of the Labor Cole,for the performance of the
work fill which this permit is issued. FIXTURES—PER TRAP -
❑I have and will maintain Worker's Compensation Insurance,as required by Section
17M of the[..bar Code,Nunn,pc,liumuccol the work for which this permit is icsmed. GAS—EA,SYS7TEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance eerier and Policy number am:
Carrier: Polley No.: GAS—EA.SYSTEMOVER4 HDO
CERTIFICATEOP M- IMPDON FROM WORKERS' GREASFJINDDST'R1.WASTE 1Nl'IikClifT(lR
COMPENSATION INSURANCE BUILDING DIVISION hEES
obis section need oat he completed ifthe presit is for one hundred dollars diI On GREASE,TRAP
ear leas.) PLANCHECK PEE
I cenify Nat imhe perfomwnce of the work for whichthis wormit is issued,lshall SEWER—SANITARY—STORM EA.21X1 Ff..
not employ any person in any manner so as m become suhject m the Workers'Camper. ENERGY FEE
O Z sation Laws of Od;famia.Date WATER HEATER WNIENT/IELECI'R GRADING PEE
Z O Appucam
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSI EMORHATING tPAI'D
FEE
a become subject ,,,he Worker's Compensation provisions mf the Labor Dole,gnu must
{il ra forthwith comply with such provisions or this permit shall he domed revoked. WATER SERVICE
Q
as CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL 1'LMH. SQ.FC
Ll O Iherchy off manor there isucnnswction lending agency for the perfonnanceof Dme eiptp
ur r+ Ne work for which this permit is issued(See301 Civ,C.) Tf1TA1.:
I--t IsMer'x Nome
0U lxnders Address TOTAL BUILDING Is
As 1 certify that I have read this application and late that the above information is
rFn W correct.l agree to comply with all city and county ordinances and Stam laws relating to QTY. MECHANICAL PERMIT FEE
61 .� building construction,and hereby amhorbe representatives ofthis city m enecrupon the 51?ISMIC PEI;
`w above-mentiond property for inspection purposes. PHRMI'IISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cuperino against ELIECTRIC FIEF
lixtublies,judgmems,costs and expenses which may in anywayaermeagainst said City ALTER OR ADDTO MECH.
PLUMBING FEEin consequence ofthe granting alibis tis permi
APPLICANT UNDE ANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT(TO 10,070 CFM)
MECHANICAL ?8
SOU ER 'UL ' O _ f
AIR HANDLING UNIT(OVER B4O111CFM) GDN$'I'RDGTI TAX
ig re
MATERIALS DISCLOSURE
of as Date EXHAUST HOOD IW/DUCT) HOUSING MiRGNFIO
NAPAR US
A. e applicant or umre building mcearat store mhamlle hvordaus material HEAPING UNIT(TO 10B00I BTIB
as defined by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,00011 rU)
p Yes E]No PAID
VIENTIIATIfIN PAN(SINGI.1?RESID) —Date Receipt
Will the applicant or future building occupant use equipment or devices which
emit hazardous air cmmamimmes as defined by the Bay Arca Air Quality Munagemem BOILER—COMP(3HPOR 100,01110 BTU) ,I,OTAL.
District? BOILER—COMPIOVER100,0)10BTU)
E)Vies Fl No
I have mad the hazardous materials requirements matter Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE.IJA///T���Ii
Simon Health&Safely Code,Sections 255115,25531 and 25574.1 understood that if the NEW RESIDENTIAL MECH. SQ.FT. 6 /
building does no,currently have a actual,that it is my responsibility to notify the occupant
of the the requirements which must be met prior to issuance of u Condr.of Derogatory.
Owner ear authorized agent Date TOTAL: ISSUED BY:
OFFICE
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