S 0373APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO BUILDING - ELECTRICAL PE�RRMILf NO
ItU11.DING DIYISIDN APPLICATION/PERMIT rrt—iou,Mae'.r'x— so,LnrGrla rrr,.+. .l n;73
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ARCHITECUENGINEER'. LIC NO
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ADDRESS:
CONT�����I��.�` ��PHONE:
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BUILDING PERMIT INFO
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El Consultant Fees Paid by Applicant (Initial)
IiI DQ PLIi PLUMY MEC
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LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chup¢r 9 (commencing
svuh Sr,ion701k0ofnivi.ien 3enno Baanea:and rro[ewsi...awenndmyua
in full force and effect.
Dole Clam Coma
nam
QTY ELECTRIC PERMIT
FEE
JOB DESCRIPTION
L:n.eta RESIDENTIA
DSFDN'I. ❑KITCHEN REMODELQUU
DDUDON DPLUMBING RIi-PIPE
MULTI-0NIT [I STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
APPLIANCES-RESIDEN'I'[Al.
7pS DECLARATION
AHCfiIT13CT5 D13CLARATION
IunJersmnd my plans shall he muff., puM1lic records
PANELS
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UP T021%TAMPS
INTERIOR ❑IMMING REPAIR
IMPROVEMENT �SWIMMIN'C POOLS
❑ BATH REMODE11REPAIR D DEMOLITION
THER
Licensed!Pmfcwnienal
I M1ereby affirm thOWNER at Bexempl fmmEme C ntreOor's Lianm Taw fnr the
hollowing rcu.an. (Section 9031 s, Bruimros and Profession, Cade Any city or county
which examines. pone m tata4ma, utter, Improve, demolish, or repair any stmcmrc
prior to its issuance, also requires the applicant for such permit file a signed statement
that he is licensed ..r.....it)o the provisions ul'the Cmdmaux, Liceme taw(Chapter9
(commencing wish Smtion]I%p)nf DivisienJof the ifusincse and lhnfusinnc Calcl or
that he is exempt meafmm and the basis for the alleged exemption. Any violation of
201 -IOW AMPS
OVER 1030AMPS
SIGNS ELECTRICAL
SPECI AI. CIRCUIT/M ISC.
TEMP. MIS ER OR POLE INST.
COMMERCIAL:
D NEW BLDG/AUDITION D DE2,10LITION
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w--tn
F-ZQ
$y�19.p
Sectio 7031.5 by any applicant for a permit 0joic, he applicants. a civil penalty of
n moa than five hundred dollen, (550(b.
Q
wtlldvIhcwark.ardthc%mmtrrcrinser intended or offered for sale lSccJ(EW,Business
POWER DEVICES
DIENAN'I` FOOD SERVICE
IMPROVEMENT
El OTHER
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHES-FI%TURF_S
ly3 m
and Ihnli,,om, Code'. The Convucmrs License Law does not apply m an net of
properly who builds aT impnrves thereon, and who does such work himself or broach
his own employees, provided that such improvements am not intended or offered for
NEW RESIDENTIAL ELECTR SU FT.
rule. If, however, the building or unproventent is sold within one year ofcomplerian,the
ner-builder will have the burden of proving that he did rte build or improve for pur,
SU. FT FLOOR IREA
S/SQ, E..
pnm of sale.).
D 1, us ewner of the pntpeoy, am exewsively contracting with licensed remnants to
cenemcl the project (sec 7044. Business and Preressiens Com,)'Ure Cortmoor, Li -
cerise Low does not apply to an owner of profery who builds or improver thereon. and
QTY, PLUMPING PERMIT FEE
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
PERMIT ISSUANCE
Licence law.
[] I am exempt under Sec. . B k P C for ihk m:eon
ALTER - DRAIN h VENT _ WAILER CA)
BACK FL 91-7 )EVICE
Owner Dam
VALUATION
WORKER COMPENSATION DECLARATION
tfim
I hereby at ..do,
er ispenalty of perjury one of the following dcdantionn:
DRAINS- x)H. H(IOF.AHEA, NO
Ihavc and will main by ection 370)ofGtmentmCode. for Cher Worker'sce or he
satins, as for by Sieben 37f%f of the Labor CMc, for the perbmnanec of the
S'1'O ES
TYPE CONSTRUCTIG
FIXTU -P
hick his permit issued.
ark have
and ill Insurance, by Section
37 1 have and will maintain
doe ped's ConroheCompensation
n his par
My okers Cor Code, for Insurace carrier and [number are .emit is isnued.
My Workers Compensation Insurance carrier and Policy number arc:
-EA.SYSTE - L"f5
OCC. GROUT'
MIN
Carver: Policy No.:
GAS - EA. SY. VF,RJIF.
C17RI'IFICATii Olt EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nm be completed Burr permit is for one hundred dollars (511.)
or le.ccd
GkEA51JINDUSTHL WASTE 'IiRCEi'TOH
BUILDING DIVISION FEES
GREASE THAI'
PLANCHECK FEE
SEWER - SANITARY - STORM En. 1. FT.
C) Z
z O
Loy any Noominn the ptry..aunceof tbeworktinwMch thlspermit i kc,,' on chill
nm employ any .often in any manner w as m become subject m the WorkecC Gmmpen-
.cation Laws ol'California. Data
Applies, I
ENERGY FEE
WATER HEATER WAIEN'VELECIR
GRADING FEE
NOTICE TO APPLICANT: IL aper corking this Cenificac of Exemption, yon should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith complywithsuch provisions or this pemilsh,l] be deemed revoked.
WATER SYSTFM/TREATING
WATER SERVICE
y
a>
SOILS FEE
PAID
Date oiplk
95.
= Z
U O
F
CONSTRUCTION LENDING AGENCY
I hereby atfimt that here is a construction lending agency for the performance of
the work for which this permit i. iasnwl (Sec. 3097, Civ. Cr
Lenders Name
NEW RESIDENTIAL PLMB. SQ. IW.
0 TOTAL:
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Lender's Address
T A ..
1 certify that I have read this application and state that the above nomination is
comet l agree to comply with all city and county ordinances and state laws relating to
huHdr,corstntaioaad herebyauthnim repre¢mauves ofthtseay tomm..rynthe
shave-noci ioned property tis inpedio i purposes.
(We) agree hlsam, indemnify and ker, harmless the City ol'Cupcnbto,gaiter
Imbilities,judgments. costs and expenses which may in anyway accmc against said City
in asequence of the granting of this period.
BU ILDI KG �+
QTY. MECHANICAL PERMIT FEE
SEISMIC] 1 O
PERMIT ISSUANCE
ELECT ' FEE -
PLUMRIN FEI, C2_ CP
ALTER DR ADD IY)MECH.
AIR HANDLING UNIT (TO IOIpO CFhi)
.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
MECHANIC,IBE
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSI'kUCT1f Tn%
Signamrc of ApplicanUComrenor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCE)
HOUSING MITIGATION FIiE
IIEATING UNIT (TO 100,000 BTU)
Will the.,hoaa or future bmId ng secupant.dorc or handle ha madous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the health and Safety
Code Scene. 25532m)P
D Yes [] No
BEATING UNIT (OVER 100,000 BTU)
VEN'1'11.A'TION INN (SINGLE RESII7)
Will [be air contmnor fumrc buiWirg byoccupant Buse.Ar Qu nrdeviceswhi' h
cmitictuNom air wmmminunu ac defined by the Bay Arca Air Umlity Maoagcmcnr
PAID
Dom Reecipt a
BOILER-COME ORE OR IW.(I(p BTU)
District?
TOTAL:
BOIL[R-CONI (7VpN I(%,fX%t RTU)
�
❑Yes DNo
I have read the haeadnus mamrals requirements under Chapter 6,95 of the Cali-
fomia Health gdm%no Safely Code. e a Sectors 25505, 2553) and 25534.1 undenumd Thal if the
have tenant, Pharr is reof.Cilirymnotify occupant
AIR CONDITIONER
^ ISSUANCE I7ATIi
(y(/, ^) /•1
r 0
-77
NEW RESIDENTIAL MECH. SU. FL
,if do,ngdomnoeumndy
k
of Ncreuiremcnw which most he son .trona issuans ofu CrniC� sac of Oraupancy.
U,the er,
ISSUED 1 Y: —��
Owner or antbor¢ed agent Dam
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