S 1794 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPERTINO BUILDING-ELECTRICAL PUtITNO
BUILDING DIVNION APPWCATION/PERMIT m.umulNc.w!CDANICAL J 1794
Bl1ILDING PROJECP IDENI'IFICATH)N
BUILDING ADDRESS: SANITARY NO, APPLICA9'ION SUHMITTAI.DATE
o q 3l ,,E LAME eVP61`riA10 6,-1(- 4-9
OWNER'S NAME.
R. LTE AE Nlo F.: GSoPIRRBNA�'ANiMa1+DFsl LIC 63o�
N/C CONTROL If
CHI'fl!Cr?NG111 ER: I.]CNO: DDRESS ❑
e �a JOSy MCNLO AKtc
CpN.pACt_ PHONE: BUILDING PF:RMI'I'INFG
�•
El Consultant Fees Paid by Applicant(Initial) HI,DG ELE PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby arum that I am Heen.ed under provisions of Chapter 9(onsunteming - JOB DESCRIPTION
Ix�l QZO
with Section TOM)of Divi ase 3ofam Bmine,,amt par s!oe,Coda and any 4EItMIT 1SSUANISSUANCEeenseI, RESIDENTIAL:
I'
~�F in full force and eHse�t. ❑SPUWI, [I KITCHEN REMODEL
�UU I.tcmrse Class Lick APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
H U Dare nn
Crmun
d ARCHITECTS DECLARATION ❑ MODIFICATION❑S'rRUC'I'
y URAL
I-„O
zOmz InndersmnJ my plane shall be used as public rccenH PANEIS
O Z.v-30 TIP T021X1AMPS ❑INTIikIOR [I CHIMNEY REPAIR
{.�.h'.W Inenloed Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
�J OWNER-BUILDER DECLARATIONOVGR 1000AMPS ❑RATH REMODEIJREPAIR ❑DEMOLI'T'ION
� W Q I hereby,affirm That I an excion from the Contractors License Law for the
ipkx$,O L U following mason.(Section 911.11.5,11 im,,,nal Nofies,iuns Code:Any city u r alY SIGNS ELECTRICAL ❑OTHER
W 3U.N which .1 a Permit I construct,atm p J lkh p Y t tcture
F.,.i0 prior to itsa c alsol requiresthe applicant fsuch pmoth ts File a signed statement SPICIAI CIRCU)'r/MISC. m
Or,J Ihntl IPnrsu II Ih p Imnn fl C t r C 1 w(Chnpar9
ad p0 (commesingwilt Scchon 9lXXpofUlvlsion3of meBus mssand PnnessonsC ale)r' I'IIMP M I I I'IIR OR POLE INS'1'. COMMERCIAL'
1.q o y that he is exempt therefrom and the basis for the alleged exemption Any violation of ❑NIiW BLDG/ADDITION ❑DEMOLH ION
W.+y Scott.,,7031.5 hy any applicant fora permit ulbjec¢the uPPlicantmucivil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
not mom than live hundrul Jnllars(55(g). IMPROVEMENT❑l,ns nxner of the progeny.or my cmployns with wages ns lheirsole compca,mion, SWIMMING POOL IiI.EC'I'RIG
f. will do the work,vnd the structum is notimended ont8emd fasale lSsuA(H4,Rosiness ❑O'THER
and Pndos'a I,Code:The Conuamm's Licenvo Law,dna not apply to on owner of OUTLETS-SWITCHES-FIXTURES
pmpeny who huilds nr impmvos thereon,and who doe,ouch work himself nr Ihrough
his own employees,provided that such improvements artnot intended or offered for NEW RIISIDENT'll ELECfR SQ FE
ionic. f,however.the huild'rag nr impmvcmem is sold within one year o[eamplminn,rho SQ.PI'.FLOOR AREA LSQ.fT.
owner-Inilder will hive the lmden M proving Thin he did not build or improve fin pur-
pose nl sale.).
❑ I,m owner of the pmpcny,vat exclusively armraming with licensed counselors In �
msrnet the pnaja:l(Sec.0144,Business and I'ndcssions Cedc:)The Con mono?,Li"
cencclawdws on apply In an owner of Prnpcny who builds or i;nPrnvo-thereon,and QTY. PLUMBING 111?14MIT _E
who contracts for such projects with a comes logs)lumousl Financial to the Comrennrs
License Law. ppRNUt ISSUANCIi
I an exempt ratio,Site ,B M PC for this fosonn
ALTER-DRAIN A VENT-WATER(EA) VALUATION
Owner Date
WORKI;RSCOMPIiNSAI'[ON DECLARATION HACK FLOW PROTECT.DEVICE
I Thereby affirm under penalty of pelpl one of the k ilnwin,dcclar:aians:
I have and will maintain a Conti ficate of Conten mself-insure for Worker'.Collagen- DRAINS-BOOR,RO011.AR P,COND, STORIES TYPE CONSTIE UCfIOb
s imam.it,Provided for by Section 30(t8 of the Labor Calc,far the performance of he
walk ler which this permit is is,uaL - FIXTURIIS-PER TRAP
Fl 1 have and wElimination Worker's Compensation Iwurance,as required by Section
JAM of the Labor Cale,for the performance of the work for which this permit is issued. GAS-EA.SYSTEb1-I INC.4 OUTLETS C.GROUT' APN
My Wader x Con,emsation Insurance carrier and Policy nnmher oro:
Carrier: Policy No, GAS-PA.SYS'I'IM-OVER 4JEiO AkeV
CERTIFICATE OF GRPASNINDUSTRI. TG
EXEMPTION FROM WORKERS' WASTE:INRCEI'MR
COMPENSATION INSURANCE: f' s BUILDING DIVISION FEES
fl'his seCllan neeA mol henmtpletedif lhepennit lX lits anehundrcddullmsSI00) GREASE'I'RAP
or lean.) PL.tiyiHECK FEE
I certify mat in the performance ofthe work for which this tomtit is issucd,]shall SEWER-SANITARY-STORM EA.200 FT.
nm employ any!urson io rmy n�}nor s ave he h,iat Io the Wolke9 Compen" ENERGY FEE
,� s'minn laws Cattle 'tI^ / ��� �• NS\TIik III!ATER WNEN'I'll!LECTR
ZApplicant GRADING FET!
..t .N.a NOTICE APPLICANT:It,after m4 ng this Certificate of Exemption,you should WATER SYSTEM/I'BEATINO
(~
Iscoan all rot nt Ilse Wodery Cmnpemation Pmv!slnns of The Lather Cods,yon mull SOILS I'P.E
Laky forhwilh curably withsnch provisian.v nr this permit shall he deemed revoked. WATER SERVICH
0.
CONSI'RUC'I'ION LENDING AGENCY NEWRESIDENTIALPLMH. SQ.I.T. PAID
V O IM1creby al'f that mere is ucnnstmninn lending agency far lbs terlitrmm�ce of Dulu its, IN
the work for which this pem;it is issued(Sec.7892.Civ.C.)
Q f~ Lenders Name TOTAL:
TU4AI.
r "i Lender's Aill
y I certify That 1 have read this application and state that me ati ve information is BUILDING Flill
correcr.I agree tnmmply with.11 city and county anlimmes and sone law,rdming In QTY. MECHANICAL PERMIT FEE
U bnildiugmn,mtetilm,and hemby nothni.. ...tennnl...of This city m one,upon the SEISMIC FF.Ii
abovomentioncd progeny for inspectmn purposes. PERMIT ISSUANCE ELECTRIC FEE O
(We)agree to nave,indemnify and keep harmless the City of Cupertino against I
Ilahiliiies,judgntnnts,co,tslmdenNiiveswhichmnyinnnywayaccnmagvinstsaid Cly ALTER ORADDTO MECII.
PLUMBING FEE
conICAN Iof the 6SIAnorN SANpermit.
SOURCARI'UNOBRS'1'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,nDa CPM)
MIiCl1ANICAI.PEC
SOURCE REf 111.AT IONS.
AIR HANDLING UNIT(OVER 10,00a CAM) CONSTRUCTION TAX
Signature of'ApplicamuContraclor Dam EXHAUST HOOD(W/DDC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future hnllding occupant store nr handle bownlons onnodal I IEATING UNI"r(HY)1001X111 IITII)
as define)by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)1 HEATING UNIT(OVER 100,000 BTU)
❑Yea EJ No PAID
V LIN (SINGLE It
'I'ILAI'ION PAN(SINGLE REST U;nc Receipt M
Will the applicant or future building necupanl use equipmcm or devices which
mil hmudnusnir comamiamts av defined by the Huy Area Air Quality Management BOILER-COMPTEPOR UTTBOOBTLU TOTAL D
Olson'r? • BOILER-COMP(OVER 1010,000111U)
❑Yes E]No
I have mud the In,andomarnonals re,montents under Cle,sc,6.950 the Cull- AIk CONDITIONER ISSUANCE DATE
famed Health.@ Safety Carle,Sections 25505,255]3 end 255311 undetatvnd Thal if the NEW RISIDFNTIAL MECII. SQ.FE e'
building doev not cmrendy have a tenant.that it is my responsibility m notify the eventual
of ran ns,aretncnts which nasal be oPI prior on is,mnm of a Crab Beate of Qcupancy.
owner art authorisd agent Date TOTAL: ISSUED RY: MCA A'
OFFICE