30987 (4) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICS], PERMITNO,
BUILDING DIVISION APPLICATIONTERMIT PLUMI Z;N MECIIANICAL 30987
IIUII,DINI]PROJF,CI'IDEN'1'IFICA'1'IO.V
BUILDINGADDRESS: SAN]TARY NO. APPLICATION SUBMTITAL DATE
UW ER2/15197
AME: PHONE: N'F Cf 'NAME: CNO:
/ NIC CONTROLs
ETI ,E 4� 4sx- G. c l7s 83 S/
ACHI'IEC(II:NGINf;ER: ^ �� LIC;VO: a���� l)RE,SS: � ❑
CO PACT: v P t4 PHONE: B DING PERMIT INFO
" � ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUME MECH
C Auk-
LICENSED CONTRAClr 'S UECLARAION QTY ELECTRIC PERMIT FEE �L-Jy Lam'
1 hereby affirm that 1 am Ticar eal.niter pnwisiva,of Chapter 9(mmmcncing JOB DESCRIPTION
O0Z with Section7(N0)ofDivision Sof the Business and Professions Core,and my license is RESIDENTIAL.
PERMIT ISSUANCE
cg"� L License
Class Lit.
e0ec �71l;t 3 ❑SFDWL ❑KITCHEN REMODEL
aVrJ 1.icenx ClassLIGN APPLIANCES-RESIDENTIAL C:1 ADDITION ❑PLUMBING RE-PIPE
I Z w Date Commcmr
m<L ARCHITLCTS DECLARATION (]MULTIUNIT ❑STRUCTURAL
ee PANELS MODIFICATION
Z O 1 underxtamd my.tuns shall be used us Public rccoN,
O Z.�O UP TO 200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
FQ.'�.Lw Licensed Professional 20I-10RAMPS IMPROVEMENT
CYT; OWNER-BUILDER DECLARATION OVER 100AM1'S ❑BATH REMODELiREPAIR El DEMOLITION
C C 6 1 hereby affirm that I am exempt from the Commnor's License Law for the
iy(O iU hollowing reuwar(Section]031.5.Business and Protestors Code:Any city or mndy SIGNS ELECFRICAL ❑OTHER
{L 3
LLy which comics a.choir m construct,aher.improve,demolish,rn repmr any n a
�-5 prison hs i...cars.also ovaries the applicant for such permino lileusigneJ sm¢mem SPF:CIALCIRCUII/h .
f�} ohm he is licensed atnuam to the provisions of the Commerce,limnse[.a(Chapter 9 COMMERCIAL,
Wy'�Q (mmmcncing with Smlinn 7tl0B.1Di,inion Sof the Business and Professions Code)a, TEMP.METER ORI ST. -
a a e�y that he is exempt therefrom and the basis for the alleged exemption Any violation of NF�M'RhDG/ADDFfION ❑DIiMOLITIO
Xm4 Section 7031.5 by any applicantfor.scrmitsubjects the applicam tn.civil penalty.( POWER DEVICIS eW�/F.NAM'
r of mom than five hundred dollars(SSW). a
Q ❑I,as owner ofthe properld,or my employees with wages as their sole lompensaton, SWIMMING POOL ELECTRIC OTHER EMIiNT ({
will do the work.and thmm
esa.ere is ern mnderimuffered forsale(Sm.70M.Business OTHER p I�s -r---
ol
W 3 m and Pnteadons Code:The Comrnes',License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXT f"'�f'�Ix 1`v
property who holds or improves thereon,and who does such work himself or through C1�
his own employees,provided that such improvements are nm intended mounted for NEW RESIDF,M'IAL ELECTR T.
sale.IL however,the building or improvement i,sold within one year of completion,the SQ.17.FLOOR AREA SsSQFT.
,
own
tar-builder will have the burden of proving that he did not build no improve for pur-
pose nt'salcJ. TO
❑ 1,as owner of the property,am exclusively connecting with licensed contractors to
construct the project(Sm.7617.Business and Professions Cite:)The Connoca is Li- $O O
cense taw does not epplym an owner of pmpeny whe builds or improves horecto and QTY, PLUMBING PERMIT EE
who camects for such projects with a mrdracaa(s)licensed pursuant to the Conuactoes
License law. ERMIT ISSUANCE
C]I am exempt under Sec. .B&P C for this reassm
ALTIiR-DRAIN&VENT-WATER(EA) VALUATION
Ow¢r Dam
wOR neterp COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE 20 000
co'y affirm under pcnaltY of perjuryone..(the following d.<Iaelionr
I have and will maintains Certificate..(Consent mself-ireareftr Nbrker's Col.,.- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES 11 TYPECONSTRUCTION
ration,as provided for by Section 37M of the Luka Code,for the performance of the
work ler which or,pensineEnsued. FIXTURES-PER TRAP Og/Y_ /�/k�
M_ I
Fj I have and will maintain Worker',Compensation Insurance,m required by Smoot Our- �l f V
3700 ollhe"hor Cxle,Emhe perform nee ofthe work for which this permit is issued. GAS-LA.SYSTEM-11NC.J OUThEFg OCC.GROUF APN
Cay eerk C m uon imumnce rri t !nr6e Poli Policy�bevaye .t,� � GAS-EA.SYSTEMOVER J(EA)
r CERTIFICATEOF EXEMPOON FROM WORKERS' 7L GRHASI%INDUSTRL WASTE INTERCEPIDR
COMPENSATION INSURANCE BUILDING DIVISION FEES
fRtis cation need nonMarmpletediOM1,pc me,is Torose hundmlJullars lSlW) GREASE TRAP
ar less) PIANCHECK PEI2 9S'
I certify that int he per(anra¢eaftre work for wnellais Permit i...W,[,hall SEWER-SANITARY-STORM EA.200 IT,
not employ any person in anynearerm as m bee na,uhjemtothe Workers'Comsen- ENERGYPEE Q
Z wtinn laws of California Dam WATER HEATER WNENT/ELECfR
Z C) Applicant
GRADING IEE
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WAFER SYSTEMTREATING SOILS PER
F , became subject to the W..Ja ,Compensation provisions of the Labor Code.gnu must
forthwith comply with such proli in.,or this pcmhit shall bednnted revoked. WATER SERVICE
014
CONSTRUCTION LENDING AGENCY NEW RESIDE KIJAL PI,MB. SQ,FL PAID
U 0 1herehyaffiml Nat more is u carolled.lc.d,.,.,e.y for the perlomlameeof Date Ran
the work for which this permit is issued(Sec 3007.Civ.C.) TOTAL:
Lenders Name
0 U Lenders Address / TOTAL'.
0. 1 certify that I have read this application and state that the above information i, BUILDINGFEE
2 M�
N coned.I agrtem comply with all ciyindenunry,omimmnces candidate laws relating m QTY. MECHANICAL PERMIT FEE
Q sZ building construction,and hereby authorize representatives of this city m en ter....nine SEISMIC IEC V
abavrmentaned properly Iia inspection p odsor, PI7RMIT ISSUANCE
Wel agree to save,hWm
enify unit keep harmless the City of Coleman against C:LECTRIC FEE
(
Iiahiliticsjudgmenls,costs and expenses which may in any way name against said City ALTERORADDTOMECIL PLUMBING FEE i�
in c granting of this permit.
APPI,CANT UNDE T SANIJ/WIL1,C 'LY WITH ALL ON-POINT AIR HANDLING UNIT(TO 10,"CFM) MECHANICAL FEE
SOUR .REGULAI'
AIR HANDLING UNI'F(OVER 111.000 CFM) CONSTRUCT ION TAX
rc..(Applin ommcmr Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION TEE
HAZARDOUS ATERIALS DISCLOSURE
Will the applicant or fumrc nuilJing uc.upum,sere ur booths h:nuNom mmerml HEATING UNIT TO 100.1100 BIL)
as de inal by the Cupertino Municipal Code,Chapter 9.12,and rte IfcalN and Suffers,
Code.Section 25532(a)7 HEATING UNIT(OVER 100.0(.BTU)
❑Yes [I No VENTILATION FAN(SINGLE RESID) PAID
—Dale RttNpt M
Will the applicam or fume.building oeolooan use cyuipment or devices which BOL[ER-COMP(JfiY OR 100,1101 BTU)
nein hanallons air contaminan6 as defined by the Bay Arca Air Quality Management TOTAL:
Dietrich BOILER-COMP(OVER 100,00 BTU)
❑yes ❑No
I have readthe hazardous materials a rs under Chaser 6.95 ofthc Cali AIR COND11IONLR ISSUANCE DATE
air D
imm
humin gdoes&Safety Cale,a atena 25505,is my and nsill .I .. nit Dun if the NEW RESIDENTIAL MECH. SQ.FT.
building there Jncsnot amhich have atenant,that it ismyresponsibili......nothe,ncjy
tItsf the rtquimments which must be sen poor to ixsuanm of a CeNlicate of Occupancy. /
Owner or autharxJ a gent Date TOTAL: ISSUED BY: �