30895 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCOPERTINO BUILDING-ELECTRICAL PERMITNO. Qr^
BUILDING DIVISION APPLICATIONIPERMIT PLUMB ING-MECHA.N'ICAL O H J V
BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
10591 Let "I)A -257 -Br3o. S0341g 5 tA`q `
�VNF.R'S NAME. 1'fiONE: C VTRACTOR'S NAME: LIC N0:
R r 0 L L _ NC wG COM'NOLp
ARCHITECT GINEER: LiC NO: A KESS: 0 ❑
UN ( W
NTACT:. PHONE: BUILDING PERMITINFO
�°`�l �fi ��R$ 4������ ❑ Consultant Forest PaidbyApplicant(Initial) BLD F.hF.CT PLUMB MECH
I.ICENSEDCONTRACTON:SDECI.ARA'I'ION QTY ELECTRIC PERMIT F-F
I nereny arfirrm mar 1 am uan,ed enter provi,nma ar cnapter 9(eammendng JOB DESCRIPTION �s�
�pZO with Section Z0001ofDivision3ofthe Business and Professions Cee,and mylivmnmis RESIDENTIAL,
��f/,,._ a�yy
�U Lifull fromcense
and effort. PERMIT ISSUANCE ❑SFOWL `�rSy CHFNf!MODEL
U Licenu Clay Lic.X
6 V APPLIANCES-RESIDENTIAL �DITION ❑PLUMBING RE-PIPE
ot, Dam ContractorDECLARATION
FOrj ARCHITECTS DECLARATION PANELS MULTI-UNIT ❑STRUCTURAL
Z O res -shall be used az puNic rtcoms MODIFICATION
r" UPTO 2W AMPS
O Zt0 C3 INTERIOR ❑CHIMNEY REPAIR
1-�f-u1 c sed Professional 201-1000AMPSi IMPROVEMENT
OWNER-BUILDER DECLARATION - OVER 1000 AMPS ❑BATH REM0DEL/REPAIR ❑DEMOLITION
C C Q 1 hereby affirm mut I am exempt(torn the Contractor's License Law for rhe -
�°d• a U following reason.(Section]0315,Business and Professions Cee:Any city or county SIGNS ELECTRICAL ❑OTHER
ID'3 LL Ut which require.,a permit no constrain,she,,improve,de IM,m rey sw
pair,trecture
prions t I rqurc the applicant) r cI perdu 11 a.goccistmerrom SPLCIAI.CIRCUI'I'/MISC
Ihuth n. Ip u d p u flh C t 't :I law(Chnmer9 COMMERCIAL:
'2T
gwth Setlirm700)ofD\i,iaa3dmciius m,autlYr f::ionsCode)or TEMP MEI81t OR POLE INST.
d d ca that he is exempt therefrom and the basis for the alleged exemption.Any violation of [INEW BLDG/ADDITION ❑DEMOLITION
WMN Section 7031.5 by any applicant for a pemsir subjects the applicant to o civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not marc than five hundred dollars(5500}TSC IMPROVEMENT
[3 1,as owner of me property,of my employees with wages as their sole compensation, SWI MMING POOL ELECTRIC .
F- will do the work.and the structure is not intended or offered for sale(Sec.7GPL Business ❑OTHER
Lural m and Professions Code:The Comractors License Law dues net apply In an owner of OUTLET'S-SWITCHES-FIXTURES
0.3 property who builds or improves thereon•and who dos such week himself or through
his own employees,provided mar such improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale,ILhowesxn the buddingorimpmvemem ksold withitiotin,arofcomplerim,the SQ.FT.FLOOR AREA USQ.ET.
ownerbuilder ll have the burden f provingthth JJ norbuild or improvefor pur
µa (: 1 )
❑ 1,as owner t the property,am exclusively
' contracting with licensed contractors,to
m IIh p ) t ]Dna B d Pr CWc:)TC t tx Lt
cncla i ppono mn builds p :m ,and
Ql'YPLUMBING PERMIT FEE
wbos taus lorseh projects withacomrat Ul wnvd
pursuant rolls,Contractors �� Y
Licenu Low. PERMITISSUANCH R
❑ lamexempt soder Scc. B
, &I'C fnrmixmazon �(
Owner 'Date ALI12R-DRAIN&VENT'-WATER TA) VAL
WORKER'S COMPENSATION DECLARATION 13ACK PLOW PROTECT DEVICE Y,.
Iheresy if rte under penally ofperjmy orient me following declarminnc H
•FlIhmeandwill maimaina Cerificam of Consenuoself-insure for Worker's Co.,.- DRAINS-FLOOR.ROOF AREA,COND.
satins,as provided for by Section 37W of the Labor Cee.for Ibe perfommnce of rhe STORIES YPIi CONSTRUCf10N
week for which this permit is issue. FIXTURCS-PER TRAP
❑I have and will maintain Workers Compscmarion Insurance,as required by Section
37W of the Labor Code.for the performance of rhe%ork for{w hich thiissgmm is issued. GAS-EA.SYSTEM-I INC J OUTLETS OCC,GROUP APN
MY WCoco 's nn cnsatietRtosu e<arrier and Yol'cY Nny�JlhS yteT'I -h D¢o CAS-EA.SYSTEM-OVER S(EA)
CERTI CATE F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSI'RI.WASTE INTERCEPTOR
BUIL H IVISION FEES
(Thin section Deed not becompleted if the permit is for one hundreddollars($IW) GREASETRAP
or less'.) PHANCHBCK FEE
1 Certify that theprf cc mf the work for which this pet.'issued,l shall SEWER-SANITARY-STORM EA.2W FT
ore ply yp Y manner zn as to become.nbeut theW k CCampen- 'ENERGYFEE ^•,
zZ I n Law, ,ICal 6t WATER HEAI'IiR WNLNIILLLC'1'R
C) Applicant -- GRADING FEFM
.�. NOTICE TO APPLICANT:If.after making this CeniFcote of Exemption,you should WATER SYSTEM/IREATING
�., become subject o the Worker's Compensation previsions of the Labor Code,you must SOILS FEE'
W fuMwiN comply with such provisions or this w m i shall be deemed revoked. WATER SERVICE
C6 O
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM B. SQ.ET. PAID Date action pN
V O thereby affirm thounere is a constructed lending agency for the performance of
the work for which ibis permit is issued(Sec.3119"/.Civ.C.)
0 F-' lender,Name TOTAL:
V tenders Address
�" I cenif that 1 have read this application d sura that rhe above information is BUILDING FEE �
y an
Z coma.1 ogre m comply with all city and representatives
ordinances os and sou laws relining m QTY. MECHANICAL PERMIT FF,E
V Z building nmumction,and hereby amhorize repreummives nfmis city reenter upon the SEISMIC FEE �
above-mcminned property To inspections propose.'.
0-27
(We)agree to save,indemnify and keep harmless the City of'Cowman,agairvw PERMIT ISSUANCE ELECTRIC FEE
liabll" mnr,,msuandcxpensx which may in any way accrue again said City ALTER OR ADD'10 MECH. -
nscqucncco gr arcing aphis permit. PLUMBING FEE
APPLICANT UNDE STANDS AND WILL COMPLY WITH ALL NON-POINT Alk HANDLING UNIT(TO I0.000 CEM) MECHANICAL FEE
URCE NECULAT )NS.
9 AIR HANDLING UNIT(OVER 10,(X)0 CFM) CONSTRUCTIONTAX
of p ¢unV went Dale EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSU E
Will the applicant or future building eccupant.lore or handle ha>ardous material HEATING UNIT(TO IW.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(x):' HEATING UNIT(OVER IW.WO BTU)
❑Yes ❑Nm PAID
VENTILATION PAN(SINGLE.RFSID) Dam kccciptX
Will the applicant or future building occupant use equipment or devices which
t.emit Infamous air contaminants as defined by the Bay Area Air Quality Management BOILHR-COMP(3HPOR IW,000BTU) TOTAL:
Ld(vv
, BOILER-COM P(OVER 100,000 BTU)
' n ❑No � -
e iced the hazardous momirials ne ' I,under Chnmr 6.95 ofde,Cali- AI R COND I IONI'.R ISSUANCEDATB
wrcmm� p
&Svfery Code.Sections 255115.25593 and 2553q. understand rent if the NBW kESIUIiN'HAI.MECH. SQ.PT.
nal currently have a tenant.that it is my resposibility to notify rhe occupant
menfs which must be met prior to issuance of a Certificate of Occupancy.
der, dagem - Date ISSUED BY:
OFFICE