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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF,RTINU BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT TING PROJECT Three'
BUILDING 1'ROdF.CI' I1lEN"IIPICA'rION
PF.R TIT NO.
$ 3369
BIIILIIINGADDRESS:
-21j30 41 ✓IL
SANITARY NO.
APPLICA'UON SUBMI MAL DATE
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OWN17R'SNP.ME: PHONE
CON' CI OR'S NAM1t E: LIC NO, `
N/C
❑
CON TROL#
ARCIII'rELT/ENC INEI:k: LIC NO:
ADD- 6 NIiiy 14 fir f+lv J"
CON9'ACr: PHONE:
BUILDING PERMI'I'INFO
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❑Consultant Fees Paid by Applicant (Initial)
HI-uC / Lu❑'.C'T PLUMB M[❑GI{
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LICENSED CONTRACTOR'S DECLARATIIO.IIN,
1 bcmby affimt that 1 inn Eant,ee under pro,i,ion, .t Chapter v (commencing
QTY F,LECTRIC PERN11'f - FEE
_
]OB DESCRIPTION
RMI'r ISSUANCE
with Section9WlptfD vlxiun 3n1tbCBnxinessnn Ic.xionx Code,a Imy liueusc lx
in full litres and eff 2022 (�
License Class X'"t( sLiC.N
Dae Contra..,
RESIDENTIAL'
❑SPDW'L El KITCHEN RCM011131,
❑ADDITION [-1PLUMBING REPIPE
❑MULTI -UNIT [I STRUCTURAL
_� MODIFICATION
LLNm OR C3 CIE MNEY REPAIR
IMPROVEMENT SWIMMING POOLS
APPLIANCES - RESIDENTIAL
ARCHITECT'S DECLARATION
I un ifeamnd my plans shall he used as puhI c uC(...1,,�
PANELS
UP10200 AMPS
Licensed Professional
""A"NI AMPS
OWNERBUILDERDECLARATION
I hereby affirm that i am exempt from the Confiner... License Law for the
fullo.....Czvnt.(Sort ...0 7031,5, Im,ancs, and Wolin au Coda: Any City or County
which a circ, a Penni( to Conswct, flat, improve, den ... kh, or n,ru any ,no ,.tc
❑ BATH REMODELIRF.PAIR ❑DEMOLITION
COLDER
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OVER I(XMI AMPS
SIGNS ELECT RICAI,
SPFCIALCIRCUIDMISC.
4—P
pnonois.,i.auanca aka requircs(hc upplicum lrt.uch'conium EleasignNsfa¢mcns
that he is licensed pueuam m me prorisiuns of the Comment's License law (Chapter Y
(commencing with Section 7") at Division 3 of the Business and Pmfcrxions Cale) or
that he is exempt monloan and the ha..is for the alleged exemption. Any violation ill
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION C DEMOLITION
Seed... 7031.5 by any npplieam fur a penni(,.bjea, the applicant m a civil'cooly of
POWER DEVICES
❑ "117NAN'1' ❑ FOOD SERVICE?
not mom than five hundred mill... ($50X).
❑I, as owner of the propcny. or my employtts with wages as theinole comlzn,ainn,
rill do the work, and the%incture is not intended or offend for sale (Sec. ]f W. Business
IMPROVEMENT
El 01 HER
SW1M1iM1NG POOI. ELE
and Profuxsions Code: *I he Contractors License Law does not apply to an owner of
OUTLEGS -SWE ICH65 FI URE.
-
N17W RESIDEN I IMILB111O I"
property h bid: r' 1 thereJ hod"', h k 1' o."IF If...... h
lisovirt pr al d bar such -on,mccoent, aret'amend,d it E red far
wile. IL the hmlJ ng orimprovuwmistaid withnone yamofconpletion, the
SQ. EL FLOOR AREA
$/SQ. 14.
v
crboilder will base the burdif of pm m, the he did nor build or imx pecfor par
pose of nmlc),
I, as owner of the property, am evchni,01 mnfaning with If ... eed umtnc o , m
TOTAL:
enrrs(mel ate vreject (See. TETT, Bu,inec, and PrnR,,mn Code:) rhe Contractor, Li-
Car, Lawdoas net uPPly(oan ownerrd propcny who Milds ocomprises thereof. and
QTY. PLUMBING PERMIT FEE
who contracts for such pmjets with a contmclorts) licensed pursuant to the Conuaaor.,
PERMIT ISSUANCE:
License law.
Ism exempt under Sea. ,B&PC f.. distension
ALI'EIt -DRAIN & VENT- WAt ER (EA)
Owner Date
VALUA'T'ION
n
`U�
V
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of me following declarations:
BACK PLOW PROIF.CT. DEVICE
5'ORIES
"1'YPE CONS' 1'R UCI'ION
❑ I have and will maintain a Certificate of Consent to self -insure for Worker. Conpem
DRAINS- FLOOR. ROOF, AREA, COND.
.mean, ns noluLl fur by Sanian 3710 of the Labor Conic. for We perfonmuce of the
work lin which this porno( is issued. -
FIX ( ORES -P12R'I RAP
C] 1 base and will maintain Worker's G.mparrono m Insuran, as required by Section
37W of labor Gde.for the perfarromwe of the work for whiCh,hi, Penn((:, i ... ad.
GAS -EA. YSsEm-I INC,\ rLErS
(ICC. GROUT'
APN
/
CAS-I?A.. 'iMOVB i IiA
My Wcrj�,rlt�, Conflicts In // ca canner and Polity nu tura
Carrice_��WFi T7Y-n Policy Nn.;
- CER'UFICAIF, Oi EXEMITION FROM WORKIJiS
COMPENSATION INSURANCE,
GRI3ASU1 'Irl 31 STB 1 'I'IiHCEI'IY)k
P
D
BUILDING DIVISION FEES _
(This eved.nmednot he completed:Tule permit is(atone hundred dollars IS 10X1
.r less)
GREASET �� D
#rrARY-STORM
PLANCI I[CK FEE
SEWER -S EA. 210 FT.
-
ENERGY PEE
Icenifyshm in the performance of the work for which the, pent:t ixissued, l shall
nm employ any pe,u:n in on, manner xo as 1. before snhjcct a he Worker,' C.mtpen-
salla 1 aws of California. Date
Api Iicant
WAI ER HE TOS WLV ll I/F:LI;C'I R
h
GRAVING FE
NOTICE TO APPLICANT: If, afar making this Certificate of Exemption, you should
become ,ubjecf to the Workers Compem,mion pawkiar, of the Labor Cale. you emet
WATER SYSTfiE,EORF,ATING
SOUS FF,
forthwith comply with such pmvi-no, or this Permit shall he deemed revoked
WAI'12R SERVICE
CONSTRUCTION LENDING AGENCY
I hercbyaffinrvhanhare is a constmctinn lending agency forth, pcutremnneof
NEW RESIDENT AL PLMB. SQ, ITR
PAID
ate Rcccipif
Tf11AL:
flit work for which this parent is issued (See. 3097, Cls. C.)
Lenders Name
TO'D
Lander', Address
BUIIJ. % W?P,
1 certify thin I bane read the, opplic,nme and an the( the above momtaion Ia
correct. l agree to comply with all city and ... myordinances and Tac law,rcmfingn
building construction, and hereby authorize representatives of this city a enter alxm the
QTY. MECHANICAL PERMITFEE
S.S 1 'FIiE
PERMIT ISSUANCE:
aMrvcmeminand property for inspection purposes.
(We) agree m,:wa, indemnify and keep hannlea, the Chy.f Cupenlon ugalnm
AUII:It ORADD'10 MECH.
tELERICFEF.Imbinali,,tidgmad......
PEE
10
/APPLICAN
ane uxpcnscxwhich may in:uty wvY .arae ugvinst saidCity
in cerrequence of the granting of this permit.
AIR I{ANDLING UNIT(fO IB,(NX)CFhO
ALFEE
UNDERSTAND. A')WI COM1IPLY WITH ALI. NON -POINT
SOURCE GULAI'IONS.
/Y-y�
till V
NH HANDLING UNIT (OVER 10.UfX1CPM)
EXHAUST HOOD WIDUCT)
CONST CTIONTAX
SIg' of ppIwont/Cnntr Date
HOUSING MITIGATION FEE
IIAlARDOUK MATERIALS DISCLOSURE
ill me apple arro m future building occupant mom or handle hazardous mmenal
I417Ai 1NG UNIT ('I0 100,010 BT BE
d meJ by the Cupertino Municipal Code Chapter 9.12, and the Health and Safety
Ca a. Section 2553910!
HEATING UNIT (OVER 100,000 [11 U)
VENTILATION IAN NINGLI! BESIDE
Ej Vc, D No
PAID Date RmciptM
Will due applimnt or future building occupant., equipment ar devices which
mit hazardous air contaminants a, defined by the Bay Area Air Qualify Management
BOILER -COME' OHP OR IMI000 BTU)
"IO AL:
Deena(
❑Ycs No
BOILER -COME'(OVER "ONX)BTU)
AIR CONDITIONER
I have read she huzarshoommedul, necrommrma unwer Chapter Of 95ofine Cali
IS.UANC 1)AT'.
NEW RESIDENTIALMECH. SQ. E4.
Room Health&Safety Craft. Sections 25505.25533 and 25531. 1 unlcmatd that if the
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building does not curendy have a tenant. that it is my re,rymslbili(y to notify fhe.ccu,sed
/
of the reg.ina tem, ,d,, mem h ane( pnuno :,sumac of u Ccnilieua of lXcupnncy.
ISSUED BY.
TOTAL: -
Owner or authorized agent Data
OFFICE