30201 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ^/ 1
CITY OF CUPF.RTINO BUILDING.FI,FCfRICAL PERMIT NO. 30201 O L O 1
BUILDINGDIVISION - APPLICATIONIPERMIT PLUMBING-MRCHANICA I, 3
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: / SANITARY NO. APPLICATION SUBMITTAL DATI
OWNERS NA B: PHONE: CONTRACTOR'S NAME: LIC NO:
/1�'kZc ���u7'O�� 141 le l�y�' / 2/!� al/ NIC CONTI.,
ARCHITECT/ENGINEER: LIC NO. ADDRESS: '/' ,L� ❑
Co`aNTCACr PHONE: ❑ onsuluant Fees Paid by Applicant(Initial) BLDG BUI ELECT PERMIT INFO
CMECx
CXn
LICENSED CONTRACTOR1:1 EJ'S DECLARATION QTY ELECTRIC PERMIT FEE
Iheaby alBrn but Iamftha IT traderProvisionsPrconaof Chapter my
tmmg JOB DESCRIPTION
�O"z thllfurcn'nIIrtEnfllivision3of the Business and Prnfensions Cale,and mylicarea is RESIDENTIAL:
O wn PERMIT ISSUANCE DSFDWL D KITCHEN REMODEL
r in full force end effut. 9
aVZU License Class _Lie.p OC.b APPLIANCES-RMIDENT1AL DADDITION ❑PLUMBING RE-PIPE
�6G ante � �i Commcn,r
ARCHITF.CI'SDECLARATION [I MULTI-UNIT [ISTRUCTURAL
PANELS
IIIA...5 Z I understand my p...hall be used s puhllc recotxdMODIFICATION
Z8�+oo UPTO 200 AMPS
W Licensed Professional [:1 INTERIOR El CHIMNEY REPAIR
201-HIMAMPS IMPROVEMENT
�� , OWNER-BUILDER DECLARATION OVER 10f1flAMPS D BATH REMODEUREPAIR DDEMOLITION
a 1 hereby ids.that I am exempt fmm the Contractors Liver.Law for the
06 U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
tL F which reptiles a permit to constmet,alter,improve,demolish,or repair any structure
pmum its issueace,also requites theapploomfn...ch permit m filctsigned statement SPECIAL CIRCUIT/MISC.
p.
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter9
GAO (commencing with Section 7(gg))of Division 341he Beeinessaad Professions Code)., TEMP.METER OR POLO INST. COMMERCIAL:
G y m y. that he is exempt thesefrem and me basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
W 4. Seeder,1011,1 by any applicant for a permit subjects the applicant 11 a civil penalty of POWER DEVICES
^sn TENANT []FOOD SERVICE
not more then five hundred dollars($510).
q Q ❑ 1,as owner ofthc prepeny,or my employees with wages as their solo contramation, SWIMMING TOOL ELECTRIC IMPROVEMENT
22 will do the work,and the alment re is not intended Or Offered for sale(See 71 ,Business []OTHER
W"� and Pmfessions Cone:The Contractors License Law does net apply to an owner of OUTLETS-SWITCHES-FI%TURES
pmpeny who builds or improves theaon,and who does such work himself or through
his own employees.Provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.Lf.however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA $/SQ.FT.
puser-huilder will have the burden of proving that he did not build or impose for pur-
snnTxaln). 'A1 ry e,
D1,as owner of the propmy,am exclusively rontmcfieg with licemmdrs
ed nmaour 'TOTAL: A g E)
mmuct the project(Sec.7094.Business and Professions Cale)The Commucmr's Li-
cense taw does not apply oanowner ofproperty who builds orimproves thereon,and QTY. PLUMBING PERMIT FEE JUL 11 ]996
who contracts for such projects with a contmetor(s)licensed pursuanno the Contractor's's
License Law. PERMIT ISSUANCE Jo
IameumptunderSu. ,B&PCforthismamn L IV r ,_
Owner DALTER-DRAIN&VENT-WATER(EA) `^-VALUATIOf,
IO
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTCCT.DEVICE
I herebyaffirm train a Penalty of perjuryoneofthe following Works's Co
Dcan. apro ide maintain etion 37me of he Lial m eelle,furcl'or Wnnkerme.of the DRAINS R,ROOP,A STORIES TYPE CONSTRUCTION
moon,os provided!thi for mi Section J]f0 of me labor Celle,for me performen¢of the
work for Which
this
permit is orW. FIXTURES-PER TRAP
❑I have and will maintain Worker's ante ofshewrkfor whihrequiredby Section
3]00 of the Labor Code,for pedannance of the work for which this permit is issued. GAS-EA.SYSTEM.I INCA OUTLETS OCG GROUP APN
MyWork 's N inion Insure d policy n��nmQ�L ne�
Cartier. a Policy No.:�✓`�gG D GAS-EA.SYSTEM-OVER 4TEA)
CERTIFICATE OF I .MPTION FROM WORKERS' - -
COMPENSATION INSURANCE GREASE/INDUSTRL.WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section treed not he completed ifthe permh is torose huniaddollow(SIM) GREASETRAP
or less.) PLANCHF.CK HE
I armory that in the performance orthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 T.
not employ any person in any mareers te ub'ecno the Workets'Compen- ENERGY FEE
,Z roonl.awaof Caliform para WATER HEATER WNENT/ELECTR
Q Applicant `�'`���^� GRADING HE
ti NOTICE TO APPLICANT:IL aftcdA4iakmgT(iis enificam of Exemption,you should WATER SYSTENYTREATING
abecome subject to the Workers Compensation provisions of the Lor Code,you must SOILS FEE
W forthwith comply with such provisions Or this permitshall be deemed revoked. WAI'ERSERVICE
nQ
.7z CONSTRUCTION LENDING AGENCY NEW R6SIDENTIALPLMB. SQ.FT. PAID Dam Ruci #
U Thereby affirm thunhert istamstmdinn lending agency fnnhe performance of W
the work for which this permit is Issued(Sec.3097,Civ.C.)
Q U Lenders Name TOTAL:
WLenders Address - TOTAL:
I certify that I have mad this application and mate that the above information is BUILDING FEE
V) collect.l agree to comply with all city and county ordinances and sate laws relining to QTY. MECHANICAL PERMITFEE
U buildingronswdiun,and herebyamhone,reprevenativatefthiscitymenmr uncomic SEISMIC FEE
above-mentioned property for inspection purposes, PIiRMIT ISSUANCE
(We)agile to save,indemnity and keep hmmlesv the City of Cnpin
ara against ELECTRIC PEE
Iiabilities.judgmcros.co,amd expenses semahmay in any wayaccmengaimtmid City ALTER OR ADD TO MECH.
in consequence of the gaiting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,M)CFM)
SOURCE REGULATIONS, MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUC11ONTAX
Mgnmure of AppdicannContmcter - Data EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle Thrombosis material HEATING UNIT(TO I W."BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,middle Health and Safety
Code.Section 2553200? H17ATING UNIT(OV ER I llgt1110 BTU)
[3 yes UNo
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Dam Receipt#
emit humrdous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(311POR 100,1100 BTU), _ TOTAL:
Dtstna?
❑Yes [I No BOILER-COMP(OVER 100,000 BTU)
I have read the hamNous materials recommends under Chapter 6.95 of the Cali- I AIRCONDITIONER I ISSUANCE DATE
fomite Health&SafetyCone.Sedions 25505,25533 and 25534.L undmand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my rapomsmility fo re iry the occupant
of mie requirements which must be met prior to issuance win Cenificam of Occupancy.
Owner m nuthoriom agent Data TOTAL: ISSUED BY:
OFFICE