S 0312 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-F.LECLRICAL PEJNIIT NO, 0312
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J
_ffi
BUILDING PROJF,LT IDENTIFICATION
BrU/I�LDINGADDRUSS1 SANITARY NO, APPLICATION SOHMITTAL DATE
OW 'S AME: PONE: C NACI'OR'SN MU ( .IC NIyI
Y IS, CONTHOLM
�A ITELT/ENGINEEK: F.IC NO: Ab 1) U's a a/ ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MUCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT i1i
1 hereby alarm that 1 stn licensed under previsions of Chapter 9lcommencing JOB DESCRIPTION
O�Z with Section 7")of Division 3of Ne Business and Professions Cute,wJ my license is TIAL:
WOO PERMIT ISSUANCE
F1_ in full tome and effect. ❑KITCHIENREMODEL
�U License Class Lid.# APPLIANCES-RESIDENTIAL N ❑PLUMBING RE-PIPE
N�S D' C Cnnlractnr
ARCHITE 'Tact., N PANELS NIT ❑MODIFI URAOZp deem +y ssM1 Ibe ee n. uhMODIDCATION
Oz, UPT02MAMPS R ❑CHIMNEY REPAIR
F mel 211-1001AMPS IMPROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEURIEPAIR (]DEMOLITION
IY < I hem y affirm That I am exempt from the Commctor's Licens<Law for the
ig506U following roman.ISectinn7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
W WEJ O F' which requires u permit m cunswe6 alter,improve,demolish,or mimic any structure
[- ww.a7 prior to its issuance.uixn requires the applimin,for.mch permluo file.mKiro A.mmenenl SPECIAL CLI C /MISC.
that he is licensed pursuant o the previsions of the Contractor's License Law(Chapter 9
rOO (commencing with Secllon70100)of Division J ofthc Business and Profcsions Code) TF.MP.MET O .P INST. COMMERCIAL:
d that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for apermit subjects the applicant e<ivii penalty of POWERD VICUS ❑TENANT ❑1'001)SERVICE
^y} not more than Eve hundred dollars(ESWL. IMPROVEMENT
p6
El Las owner ofthe property,or my employees with wages m their sole compensation, SWIMMING L •CTRIC
f 0 will do the work,and the structure is not intended oroRered for sale(Sad.9BM,Business [I OTHER
63�^ and Professions Cole:The Cianompr's License Law dces not apply to ua uwnef of OUTLETS-SWI'Cf S TXT RFS
properly who builds or Improves thereon,and who doessuch work himself ar Ibmugh
his own employees,provided that suchIntprovem on,are not intended or olTead for NI?W RESIDENTIAL ELEC SQ 17T.
one.If,however.the building or improvement is sold within one year of completion,theSQ.F]'.FLOOR AREA VSQ.FF
iter-builds,will have the butler of proving that he did not build or improve for For
PAID pose of sale J. P D
❑ I,as owner of the prolixity am exclusively contracting with licensed contractors to 'IDl'AL:
c mstact the project(See](W.Business and Professions Coal:)'Me Contracars Li.
cense Law does not apply m an owner of propeny who builds or improves thereon.and QTY PLUMBING PERMIT FEF, 1111
who contracts for such ptniems with a countmngx)licensed pursuant m the Convector's
Camerae Law. PERMIT ISSUANCE ]�a/�
❑1 am exempt under Sec. ,II N P C for this reaann ' • V�' L'
ALTER-DRAIN&VCNT-WATER(EA) ATIIN
Owner Dale
Wm under SORofCOMPENSATION, on
HACK FLOW PROTECT.DEVICE
I heady alarm under penalty peperjury one of the following WmInz iCra
❑Ihave and will maintainsCenihcem of the LabrLord,sus for Worker'sce of the DRAINS-!BOOR,ROOF,ARCA,COND. STORIES TYPECONSTRUCTION
smirk,as provided for by Section J]W of the labor CWe,for the Performance of the
work for which This permit is Issued FIXTURES-PEH'TRAP
1 have and will cold,Car Workers Compensation hummiwork
which
required by Satin,
1]W of the Lahnr Cadc,for Ne perfomtunce of the work for which this permit is issued. GAS-EA.SYSTCM.I INC.000TLIiTS OCC.GROUP APN
My Wor r t cn Minn lnsurancejamer enJ Policy n
Cartier. yNo.: GAS-FA.SYSTEMOVERaIEA)
CRRTIFI'ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPFOR
BUILDING DIVISION
(This section need..be completed ifthe permit is forane hundred dnllms($100) I• S
or less) GREASE TRAP PIANCHECK PIiIi
I cenify thata the ,to rmanccrfthcwo.IS for which this all...at is i.sued.l shall SEWER-SANITARY-STORM EA.210 FF.
not employ any person in any manner on as In tecoma subject o the Workers'Compso- IIiNERGY FEE
OZ muton laws of California.Date WATCft HF.AILR W/VI;NT/ELECTR GRADING FEE
Z Applicant
NOTICE TO APPLICANT:IL after making this Cerdfcaa M Exemption,you should WATER SYSTEMACREATING
a , become subject m the Workers Compensation provisions of the Latmr Cale,you most
SOILS HE
W faMwith comply with such provisions nr this permitshall be deemed revoked. WATER SERVICE
Z CONSTRUCTION LENDING lending
NEW RESIDENTIAL,PCMB. SQ 1-7. PAID [)aid Receipt#
V. Iberewyd�imuM1at there lasued(Sec.309ending agency tix;lm performance of
lin aworkl for which this pcmtit is issue)(Sec.309],Clv,CJ
U Lender's Name TOl'AI.:
0 a Lenders Address TOTAL: BUILDING PEE
1 cenify that I have Rad this application and state that the above Information Is
F"tA correct.l agree to comply with all city and county ordinances and state laws relating In QTY. MECHANICAL PERMIT FEE
building nmshu"wart.and hereby authorize reprexmutiveso(this city menterupon the SEISMIC HE
a socancruciand properly for impectiim purpnsea. PERMIT ISSUANCE
(We),aped to muse,indemnify and keep harmless the Chy of CoNdra n.,.a.,] ELECTRIC FCC
liabilities,judgments,casts and expenses which may in anywayucuuc against said City ALTERORADDTOMECH.
sequen of the granting of this permit. PLUMBING PEI?
AP+nAJNDERSTANDS AND WILL .OMPLY WIT LL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
URCL FiULATIONS. MECHANICAL IFF.
C n , / AIR HANDLING UNIT(OVER 10.000 CF MI CONSTRUCTION TAX
li Commcmr —c EXHAUST HOOD(WIDUCI)
HOUSING MI❑CATION FEEfA29R0005 MATERIALS DISCLOSURE
Il the pmam or fuwre huilJingt+'cupam score nrhanJle bnzurdous material IIh:ATING UNITOD 100,000 RTU)
es defined by the Cupertino Municipal Camc.Chapter 9.12,and the Health and Safety
Came,Section 25532(a)? HEATING UNIT(OVER 1110,000 BTU)
❑Yes ON. VENTILATION FAN(SINGLE REBID) PAID
I. Will the applicant or future building occupant use equipment or devices which Date Receipt s
,ohnit hazardous air contaminants as define)by the Buy Arta Air Quality Management BOILER-COME(JHP OR W,OW BTU) TOLAL.
I raw."ISao"
? BOILER-COMP(OVER 100,000 BTU)
❑Ye.. ON.
I have mad the hmandous materialseyuima under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health na Safely Code.have
25505,25531 and 355)4.I undersand that if the NEW ftESIDFMIAI.MECH. SQ.FT.
building dues oat currently have a,met p that o is ua responsibility Certificate
re ratify the occupant
of the muiremems which mon be ma prior m issuance of a Cenificaa of Occupancy.
Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE