S 0468 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOFCUPFRTINO BUILDING-ELECTRICAL 79"NO
BUILDING DIVISION' APPLICATION/PERMIT PLUMBING-MECHANICAL 0468
II BUILDING PROJECT IDENTIFICATION
' SANITARY NO, APVLICA'I' N SUHMITTAI.DAT(
BUILDING ADDRESS:
0 y Cr e
OWNER'S NAME: PHONE: CONTRACfON' NA it, LIC NO: NIC CONTROLp
f .•ARCHITECT/ENGINEER: LIC NO: DDHESS: ❑
CONTACT PHONE: BUILDING PERMIT INFO
Z� ❑ Consultant Fees Paid by Applicant(Initial) I-
I
ELECT PLUMB MECH
Vy� ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT JOB DESCRIPTION
1 hereby affirm that I am licensed under provisions of Chapmr 9(commencing _ -
„D+0Z with Seemed Division 3.Ohe Business unit Prnl'essions Code,vndmy license is PERMIT ISSUANCE • TIAL'
f•O O in full force and effect. rx
i- Ll KITCHEN REMODEL
�UFgq' Liremc"ass hiap� pPPL1ANCE5-RESIDENTIAL. ON ❑PLUMBING R6PIPE
N 7e-6 Doe Cmdod`7 NIT CSTRUCTURAL
ARCHITECTS UEC A 1 PANELS DIFICATION
F�inf K Iundersmnd my ponds shot[he used us Public reomd' UPTO200AMPS OR - PINEY REPAIR
r y Vl",•110y Licensed Professional 201-10JOAMPS VEMENT ❑S MING POOLS
OWNER BUILDER DECLARATION OVER IIgg1AMP5 EMODEUREPAIR ❑DEMOLITION
I hereby affirm that I am exempt from the Camracmrs License Luw for the
yy ..1
X O6 U following reason.(Section 703 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
W 3 W I- which requires a permit to construct,alter,improve,demolish,or repair any simemre
Opriorm its issuance,also requires theapplicam far such Permit to file a signed statement SPECIAL CIRCUITIMISC.
y
that he is licensed parsuunt to the provisions of the Contractor's License Law(Chapter 9 COMMERCIAL'
00 (commencing with Sectirn 7o W)or Division 3 ofthe Business and Professions Crdn)or TEMP.METER OR POLE(NST.
that he is exempt therefrom and the basis far rhe alleged corruption.Any visland.of ❑NEW BLDGIADDITION [I DEMOLITION
_ Sedinn]OJ LS by any applicant fora perform subjects the app ran civil penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
m t more Nan five hundred dollars($500). IMPROVEMENT
�aQ ❑Lens owner of thepropery,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC ❑OTHER
�1 will do the work,and theswcture is not intended or offered formle(Sec.)094,Business
tV�� and Professions Code:The Comrecmrs License Law does not apply a+an owner nr OI1TI.ETS-SWITCHIiS-FlXTURFS
a' Properly who builds or improves thea..,and who docs such work himself err Ihrrugh
hos own employees,provided Nm such improvements ore nor inanded nr offered for NEW RCSIDEN L BLECT'R SQ FT.
sale.If,however,the buildingm improvement is sold within one yearof completion, FT FLOnR AREA SISQ.14.
.wrenbuilder will have the burden of proving Nm W did rot Wed nr improve for p.r D z
Ewa.fealeJ. TOTAL: A
I,as owner of the properly,nom exclusively contracting with licensed contractors m ;0
construct the project soc.7044,Business and Professions Cede:)The Comtncmrs Lo-
c ane Law does not apply to an owner of proparly who bands or improves mereon.ad QTY. - PLC BI R 1'F tib¢r v
who comma¢forxuch pmjttu with a c.mmewrls)IicensW punuam m tae Cnntmemor'x (/
License La, PERMIT ISSUANCE
❑Lem exempt under Sec. .B&P C far this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm amfer Penalty.f perjury one of the following declarations:
EJ I have and will maintain a Certificate of Consenrto self-inaa for Workers Compen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCfIC
cation,is provided for by Section 37M of the Labor Code,for the performance of]he
work for which this Permit is issued. FIXTURES-PER TRAP
I have mud will maintain Workers Compensation Insurance,as reyuitW by Section 40UTLITS
37(k Of Ne Labor Code,for the Performance of the work for which this mit is issuGAS-EA.SYSTEM-I INC. OCCGROUP
ed. . APN
per
My Wnrkcrs Compensation Insurance ca ' dl'oliey'u2hcd2:9 GAS-EA.SYSTEM-OVER 4(EA)
Cnnricc� PolicyNn_++--��
CF.RTI KATE OF BXEM TION FROM W(IRKLR.SQCI;I?fPi GREASBIINDUS'IR1.WASTE INTERCEPTOR
COMPENSATION INSURANCE 1 BUILDING DIVISION FEES
(This rection decd notbewmplered ifthc permit is f.nmethndredd.11ars($100) GREASETRAP PLANCHECK FEE
or less)
I.yimy that in in anyno oence0 work rwa Lotto theW ekes Co.,.- SLWIiR-SANITARY-STORM EA.2fa1 FT. ENERGY FF.E
no,employ nny Persorn in any moot e y suhjem m the Workers'Cnmpen- '
Z smion Laws of nli min.D e WATER HEATER WIVENT/ELECTR GRADING FEE
O0 Applicant
NOTICFi PPLIC ' .aficr making this Certificate of EsempOrn,you should WATER SYSTEMRREATING SOILS FEE
a ; become subject m the Werke Compensation provisions of Ibe lahnr Csde,you must
forthwith comply with such pmcision,o,this permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL FILMS. $Q.FT. Date ei a
thereby eb hi(ham them is issued
set.
7,Cing agency for the perfannance.f
U O the work for which thio permit is iwued(Soo.1097,C1v.C.) TOTAL:
L) lender's Name - TOTAL:
O
0 U Lender's Address BUILDING ME,
G I certify Net 1 hove read this application unJ sNm[hot the shove inLrrmmion is
(A correct,I.gree m comply with all city end coug m Outlay nuounnees a ad state lawc elating QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
V z building conswcfinmand hereby unh.rize mpreseratives of Nis city it)enter upon be
uhove-maddened pmpeny for inspection Purposes. PERMIT ISSUANCE
ELECTRIC FET:
(We)agree m rove,indemnify dd keep harries.the City of Cuperrmo against
liabilitienodgmeats, Istndex nary way acemeag.insm said City ALTER OR ADD TO MECH. PLUMBING FEE
in c.nsequcnce of gmmin•
sr
APPLICANT ERST 1) DLI 'OMPLY W TH T AIR HANDLING UNIT LTO L0d0CFM) MECHANICAL FEE
SOURCE R ATIO .. (/^7V
AIH HANDLING UNIT(OVER I0,II00 CFM) CONSTRUCTION TAX
gnamreofAppman nmmcmr Doe IIHAUS'f HooDIWIDUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wll the applicant or future building occupant store or handle hazualom material HEATING UNIT(TO[00.0110 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I00,o1V1 BTU)
Code,Section 255321a)?
❑Yes ONO VENTILATION FAN(SINGLE RESID) - PAID Dae Rttciptg
Will the applicant or future Wilding occupant use equipment or devices which BOLI IiR-111P(11P OR HE(0)BTU)
mit hnesNous air condominiums as defined by the Buy Area Air Quality Management TOTAL:
District? BOILER-COMP(OVER Ifq.00011TID _
❑Yes ❑No
I have mad the hazardous materials ms under Chnp[cr 695 of the Cali- AIRCONDIDONER ISSUANCE DATE
5.2.5fomia Healthgdoes&Safety Code,Sections 25505,25577 and 255)4.1 understand that if the NEW R[SIUENTIAL MECH. SQ,FT.
huilding does not currently have o mass,that it is my responsibility to notify the acupant
of the d,umments which in.,,be fact prim to issuance of a CMificme of Occulo ey.
Owner or awhodzN agent
Date TOTAL: ISSUED BY:
OFFICE