B 0308APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITYENO BUILDING - ELECTRICAL
BUN APPLICATION/PERMIT PLUMBING-MECHANICAL
/1 P17RMITNO. �ra03000
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5000 1
BUILDING PROJECT IDEMPIFIC7'ION
BUILD
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SANITA ).
APPLICATION SUBMI17AA,L DATE
OWNIniS NAME: PH�� /` V
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CONTNAp'TOR'S NAME LIC NO:
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BUILDING PPPERMITINFO
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❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR S DECLARATION
I hereby affirm that 1 licensed under provisions of Chapter 9(commene g
with Scctiot ]1X10) of D":' i fthe Basi :and Pr teoiare Cade,mma Ictt
in y
(all force and effect
License Class Contractor
Date Contmnor
QTY ELECPRIC PERMIT FEE
L.
JOB DESCRIPTION
RESIDP.N'PIAI.
❑SFDWL E3 KITCHEN RIz_PI E
OPTION 1:1 PLUMBING kIi-PIPE,
���1L
IJ MULTI-UNIT ❑STRUCTURAL.
MODIFICATION
[_cal -1 El CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATA REM(IDEUREPAIR ❑ DEMOLITION
❑ OTHER
1'1?RMITISSUANCE
1
AI'PUANCES-RE51DItNT1Al•
ARCHITECT'S DIiCI ARA'I'ION
Iunderstandm Insshtll be uscdas blie records
Y P n pu
Licensed Pmfecsiroal
OWNER-BUILDER DECLARATION
1 hereby match that I am exempt from the Contractors Licome law far the
following reason. (Section 7031.5, Business and Professions Cadd: Any city or countySIGNS
which requires a permit to construct, alter, improve, derialisb, or repair any atmemre
p,for la it, issunum..Ixore,dis,theapplieant brach permit to file. signed Hanntent
he is licensed pursuanua the provisionsof Ibe Conrad License Law (Chapter 9
fcontmencing wim Seufnn](NN])of Division3uf me Business.nd Prol'esainns Gule)ar
that he is exempt therefrom and the basis for me alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mare than live hundred dolien, $510).,
I, us ownerofine pro n,nrm ala ccs wim we. their solecoat
a Y yet P Y geso pensmlit)
will do the work. and the drucwrc is not intended oroRercd for sale (Sm.]044, Business
and Padessions Code: The Contractor's License Law does not apply to an owner of
propeny who builds or improves thereon, and who does such work himself or through
his awn employees, provided that such improvements .re not intended or offered for
sale. If. howevaq the building or lmpowmacnt is sold within one year ofcotnpluion,the
owner builder will have the burden of proving that he did not build or improve for For
you of -ac am exclusively umlruuting wird Ilrcnsul i-
al er of the pec.
PANELS
UP TO 200 AMPY
201-1000AMPS
OVER I000AMPS
ELECTRICAL
SPECIAL CIRCUIT/MISC.
1
'TEMP. MEI' ER OR POLE INST.
COMMERCIAL
❑NEW 131DC/ADD1770N ❑ DEM(ILITI(lN
❑TENANT ❑FOODSERVICE.
IMPROVEMHN'f
❑OTHER
POWER DEVICES
SWIM POO1, ELECTRIC
OUT, SWIT -PLX'I URES
NEW RESB AL ELECCm SQ FT.
I
S0. FT.Iq,00R AkEA
ot as
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$ISQ. Irl',
q
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1
704 roman',
onse La the project (Sec. o an Business and Irowho builds
Codei The Convenor's and
cense Law Jrcs not apply roan ithst ofpropeny wmuseddaorimproves thereon,and
who conlraetn rs ltpmjectx wim mm�nranorlsl licensed pursauntmmc ConvnenaLs
t
QTY PLU NG RMIT FEE,
License law
❑lam exe tpnu a o. ,13&P -rmisre o
PERMIT ISSUANCE
xi`�••,CJ
ALTER - DRAIN & VENT- WATER (EA)
Owner me
w1 VAIILUATION e�
1 �� lVJ••��
W KERS COMP; TIO ?CLARATION
Thereby m[Enu underpumlry of pepuryoe the following declurationr,
El I have and will maintain a Certificate ofConsenno self-inmm for Workers Compen-
sdion, as provided for by Section 37M of the Labor Code, for the performance of me
BACK FLOW PROTECT DEVICE
DRAINS- FLOOR, ROOK AREA, COND.
STORIES
TYPE CONS'IHUCf10N
MIXTURES -PER TRAP
work for which this wrinit is issued.
❑ 1 have and will maintain Workers Compensation Insmm de. as required by Section
3700 of the lahar Cade, for the performance ofthe work for which this permit is issued,
My Workers Compensation Painful. carrier and Policy number are:
GAS -EA. SYSTEM-I INC. 4 OUTLET
.
OCCGROUP r.
1Cs '
GAS - EA. SYSTEM -OVER 4 WA)
Carie'. Policy No,
CERTIFICATIi OF EXEMPTION FROM WORKERS'
q^
D `{..
GRE.ASIJINDUS'ML WASTE NO ERCHITOR
Z Q
y
COMPENSATION INSURANCE
(This section need not be completed ifNc pemdt is for one hundrN dollars (Slat)
or levo)
Toy say thatinure any....mof s,work for whiceOponse Wardiaeued,l,n
noion Lim any person in any manner so as to become subject m the Workers' Campers'
onion Laws of California. Date
Applicant i -
pP
,
s SIGN AEE `
PI,ANCIIIic- �a
GREASE TRAP
SEWER- SANITARY -STORM EA. 200 Ity.
ENERGY '
WATER HEATER WNEMUELEC'PR
GRADING FEE P
NOTICE TOAPPLICANT.If. after iodyou
rapeoonghis Certificate he atimshould
became xa compct ly
the Wichkc,, o Coons or is panic bbl of the labor Code you must
forthwith cnmplY with such provisions nr this permfnhnllthe tleemed rcvnked
WATERSYSTEM?RFAl7N0
WATER SERVICE
SOILS FI?li
PAID
Uam Receipt#
4Q
�z
U
W F
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(O
L) z
CONSTRUCTION LENDINGnlead AGENCY
ofirm that hthisemit i isaco(Sec.397,Cis, agency for Ne perfarm.nce of
k for which
the work for which this permit is issued (Sec. Jo9], Civ. CJ
Lender's Name
NEW RI?SIDENTIALPLMB. SQ, FI'.
'TOTAL:
Lender's Address
L cenffy that I have read this application and swat mat the above information is
correct. Islam or comply with tdl city nod county ordinaries tat I smm laws relating to
building construction, and hereby mmorire repmmntativas of this city m entarupon the
.W,cmcmaimed property for inspection Aurposes..
(Lac) agree m xava, indemnify and keep hmmlcas the City of Cnpeniuo ugninsd
TOTAL: -
BUIL ( F �•
SEL, 11C 1E f1 /tf
QTY, MECHANICAL PERMIT FEE
PERMIT ISSUANCE "`-'---.-.�_•,
-\ ^-
R : P • r
liabilitie. menu, minimal expenses which may in any wayaccrue against said City
at oil queue ofnhegrantfngofffimpemtil.
ALTER OR ADD TO MICH. !1 / .' 1it
III L/� _..4-•-
P.
AIR HANDLING UNITfI'O III,, ICfM
AP ACA' UNDERSTANDSA WILL COMPLY WITH ALL ON-P LINT
Sf N iGULA'1'1 'S
M FI?E !�
AIR HANDLING UNIT(OVER 1 AllCIVV V Z 2 199
a
TION'IAX
EXHAUST HOOD (W/DUCT) 11
nm fAp cn •onuamo a
aIIAZARDOUS A RIALS DISCLOSURE
Will the applicant or furore hu g occupied store or handle hazardous material
ITIGATION IEE
t�a- . -
IIEATINGI)N1'1'(fOIIIB,IN101 'I ,J----._
jQ—
as defined by the Cupertino Municipal Cade. Chapter 9,17, arta the Health and Safety
-
Code, Section 25532io?
HEATING UNIT (OVER HOLDS) I TU)
El Yes ❑No
VCNDLATION PAN ($INGLE HF_SID)
Willrhe a licant or tenure buildin
pp g by the Btuse equipment or Devices which
if huserdous air nmtaminentx os defined by the Bay Area Air Quality Managimem-
Uistrfct?
❑Ya ❑No
to Neceia, p
BOILER- COMPLHP OR 100,1011 HTIJI
T 1
BOILER- COMI'(OVER 100,001) BTU) '
AIR CONDITIONER
I mad me laudations materials aqui eats under Chapter 6.95 of the Calf-
it the'T'IAL
home,^gicdah`- o Scaucmenty CY�.icut y�dhm5it�icn Jad 25534. 1 mspm Mlity.m�mrt the cezc�,an1
///,•y �{SSUANCf{J'iii'
NEW RESIDENl MI?CH. SQ. Pf.
SAI" 1/ /If / / I ISSUED BY:
OFFICE —