S 1438 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPERTINO BUILDING.ELECTRICAL PEIt ITNO
HmIAINGDIVIS10N APPLICATION/PERMIT Pl. kJ 1438
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. AI'PhICATION SUBMITTAL DATE
6 j/6
61-/FFo2O Oa, '27
OWNER'S NAME! �J P ONE: CONTRACDOICS NAME: LIC NO:
V LO E' S 7,?/I' NIC CONTROL4
ON ARCHITECT(E- GINEER: LIC NO: ADDRESS: ❑
COMPACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) LD ELECT LOMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby alRnn Nat 1 um licensed under provisions of Chap¢r 9(commencing JOB DESCRI ION
WOO with Section 1000)of Division 3 ofthe Business and ProfessionsCMe.and my license is RESIDENTIAL:
I�-`�� in full force andeRea.p N� PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL.
�UU Date Plass .O Cement;
JSIC APPLIANCES-RESIDENTIAL []ADDITION
❑PLUMBING RE-PIPE
hZZW Da¢—�!^'x 4— COolfadm
rnQa �� ❑MULTI-UNR L1 STRUCTURAL
7th ARCHITECTS DECLARATION rt/(r PANIiLS
Z p N Z 1 understand my plans shill he soil ax public renrNs MODIFICATION
O Z.y-p UI'TU 200 AMPS ❑INTERIOR C)CHIMNEY REPAIR
r4Laj Lioensed Professional 201-IfgOAMPS 1 OVEMENT []SWIMMING POOLS
OWNER-BUILDER DECLARATION
6 1 hereby aflimt that 1 em exempt from the Cnnvacun's License Law for the OVER 1000AMPS TH REMODIEVREPAIR ❑DEMOLITION
iqqi55 SU following reason.(Section 7031.5,Business unit Professions CMc:Any cityor county SIGNS ELECTRICAL ❑O ER
us 3 LLE' which rexpanis u permit to construct,alter,improve,demolish,or repair any nmcere
prior to its issuance.also requires the applicant for such permit to file a signal statement SPECIAL CIRCUTT/MISC.
fyy that he is licensed pursued to the pnwisiomm'Ihe Connectors License Law(Chapter 9
QAC (commencing with Section 4011)of Division 3 ofthe Business and Professions Cade)or TEMP.METER OR POLE INSI'. COMMERCIAL;
6 q e U that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION [I DEMOLITION
earlI I+. Section 703 IS by any appbram for.permit subjects theoIdtho n civil penalty of POWER DEVICES [ITENANT ❑FOODSERVICE
Q oramore than five hundred dollars(550(0. IMPROVEMENT
❑
[,.is owner of the arvIat,or my employees with wages as their sole compensalon. SWIMMING POOL ELECTRIC
Sap.,9p will do the work,and the surfaceis not intended mothered for sole(Sec.11144,Business ❑OTHER
LL13 and Professions Costs:The Contractor.License Law docs am apply to an owner of OUTLETS-SWITCHES FIXTURES
property who builds or impmves thacnn,and who does such work himself nr homgh
his own employees,provided that such impovemenb are not recoiled or offered for NEW RESIDENTIAL ELELTR SQ IT.
sale.If.however,he building m improm
veent ix sold wi thin one year of armpletion.the SQ.FT.FLOOR AREA SISQ.IT.
ser-builder will have the burden of proving that he did not build or improve for pur- p
poscofsaleJ. P4 D
I,vs owner of the propertJo all,exclusively connecting with licensed amtrucmrs ro ] L
casae the pejed(Sec.1044,Business and Professions Code:)The Contractors Li-
censelawdoesnmupply to anowncrnfpmmywho build,orimprovexthereo..and QTY. PLUMBING PERMIT MAR 80 ANS'D
who contracts for such projects with a contmemHs)licensed puevantto the Committers
License law. PERMIT ISSUANCE
❑1 um exempt under Sec. .B&P C for Nis reason ---------------- Y Ur Ut
ALTER-DRAIN&VENT'-WATER(EA) VALUATE N
Owner DIM
WORKERS COMPENSATION DECLARATION BACK PLOW PROI'ECf.DEVICE
I hereby affirm under Penalty reperjuryoneofthefollowing Workers Co
nIhave and will for byneCion 37 a oft3msenta Code,
for no
WorkersConifer-
of th- DRAINS-FLOOR,ROOI(ARIiA,CONE). STORIES TYPF:CONSTRUCI'ION
.mart,as hick this
for by Section 3]00 of the Labor Cole,for the performance of the
work for which this permit is issued. FIXTURES-PEN TRAP
1 have Lwill maintain Workers Compensation Insurance, required d i Section
P00of NLabor rz Codc,fenhc performance ofthe work for whichh Trendthis pes issued. GAS-EA.SYSTEM-1 INC.40U'fLE]'S OCC.GROUP APN
My Workers Compensation Inwence carrier and Policy p�M arc
Cerner. STA�6 �'//A/A Policy N &Ib GAS-P.A.SYSTEMOVEN 4(EA)
CERTIFICA'I'F.OF E%EMITION FROM WORKERS' GREASEJINDUSTRL WASTE INTERCEPTOR
COMP17NSATION INSURANCE BUILDING DIVISION FT.fiS
EITis.seationncMnm GREASEI'RAP
or less.) PLANCHECK FEE
I tmifytha in the perhardsmcof the work far which this permit is issued,Ishall SEWER-SANITARY-STORM EA.210 FI'.
not emrsonploy any peIn any maooer.so as a becnmt mbiceuo the Workers'Compete ENERGY FEE
O Z moron laws of Callforrim.Date WATER BEATER WHEN DELECTR GRADING FEE
O AFpliaem `
N NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMNREATING
(~ become subject te the Workers Compemaion provisions of the Labor Code,year must SORB FEE
forthwith comply with such provisions or this permit shall he decided revoked. WATER SERVICE
0
a' CONSemRUCTION LENDING
ng a enY NEW RESIDENTIAL PhMR. SQ.FT. PAID Use aciptN
U Ihereby whicaffirm his
issued(ec.30lending agency lnnhc perGommnce of
R. e_t the work for which this gamer is Issued(Sec.3091,Co.CJ
O U Lenders Name TOTAL:
Lenders Address TOTAL
W
y 1 certify that have read this application and Into the the ubwe information is BUILDING t
V) correct l agree to comply with all city and county ordinancesand state laws relining to QTY. MECHANICAL PERMIT NEE
SEISMIC Ek.
U Z
building construction,and hereby millionic repecontatives ofthis city tocreer upon the
above-mentioned progeny for inspection Purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree te save,Indemnify and keep toneless the City of Cance o against
liabiliticapidgences,emo, ad expenses which may in any way acerae against said City ALTERORADDTONJ PLUMBING 41
nsegpence of the granting of this permit.
APPLIC^UNDERSTANDS ANI)WI LL COMPLY W 11 IT ALL NON-POINT AIR HANDLING ON]'I'(1'010.00l CFM) MECHANIC1.
SOURC R GULATIONS.{�u
AIR HANDLING UNIT(OVER 10,WCFM) CONSTRUCTION TAX
Slgnu of Applicaro Contmc r Date EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupam.aom orhandle hamrdous material HEATING UNIT(TO I00.000 BTU)
as defined by the Cupertino Municipal CMc,Chapter 9.12,and the Health and Safety
CMc,Section 25532(0? HEATING UNIT(OVER 100,0DO BTU)
❑Yes C]No VENTILATION FAN(SINGLE RESID) PAID
Doc RmeipnN
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100.011 13TU)
emit hazardous air contaminants re defined by the Bay Arca Air Quality Management TOTAL:
Diarct9 BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
In...read dmauma
hrdouserms rcu yuirerncnunder Chapter 6.95of the Cali- AIR CONDITIONER ISSUANC
Come.Health ek Safety Code.Sections 25505,25533 and 25534.1 understand Na if the NEW RESIDENTIAL.MECH. SQ.IT.
building does not currently have a tenant that it is my rexponeibility m notify the occupant
of the reyuireesntn which must be met prior to issuance of a Cenifcate of Occupancy
Owner or auNonzed agent Dae TOTAL ISSUED BY:
OFFICE