S 0577 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CCPERTINO
BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT r1.EMBwc-MRcxnrvlcAl.
NUILDING PROJECT IDEN'rIFICATION it) 77
UILDINGADDRESS: n SANITARY NO. APPLICATIONSUBMITTAI,DATE
030 IA . Es a EJcrf�
O NER'S NAME: I'HONF,: )H'S NAMIi: LIC NO:
�' NIC CON'I'HOI,N
( If
\� ARCHITECT/ENGINEER: LIC NOtr. I _ 1 ❑
1'
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECiI
❑ ❑ eying
LICENSED hat!D licenON sed
TORunder S DECLARATIONTION QTY. ELECTRIC"PERMIT PL^E
I hereby affirm tom 1 am licensed under proviciom of Chapter 9(commencing JOB DES RIPTION
DMZ with Section 7000m Division 3oflhe Buxirm,irrd Professions Cede.and my license's RESIDENTIAL:
PERMIT ISSUANCE
in full farce and ellen. ❑SFDWI. ❑ ITC1111N RIiMODGL
aUU U,va,Class Lia# APPLIANCES-RESIDENTIAL ❑ADDITION IMBING RE-P[PF.
F-Z W Date Contract.,
mQa ❑MULTI-UNIT STRUCTURAI.
Drn ARCHITECTS D[CLAHATION PANELS
ZOAZ Iunder+mnd my plans shallM used as puhli,records MUUIhICAT10N
oy_o GP 1()200 AMPS El INTERIOR El CHIMNEY REPAIR
u: Licensed poom"iosd 201-1(1B(IAMPs IMPROVEMENT E]SWIMMING POOLS
CL WQ 1 hereby alien OWNER-BUILDER�am ,D1'Ae Contractor,License Law 1^r the OVER 1000 AMPS CLARATIO ❑BATH REMODHI/REPAIR C]DEMOLITION
GX L U following reason.(Section 7031.5,Bteinesa and Ford..sinns Code:Any rotor rut ly SIGNS ELECTRICAL ❑OTHIiR
ty 3
C F" which requires permit to construct,alter,improve,demolish,or repair any swcmre
�< prior to its issuance.also requites the applicant for such permit m file a.signed statement SPECIAL CIRCUITIMISC.
f!!(Y that he is licensed p^nuanuo'be Provisions offle Contractors License Law Chaffer
Pumm,ucing withSection 9IXq)^f Division Sof the B^sine,and probe..... CmE)., TEMP METER OR
POLF,INSC COMMERCIAL:
d d e K that he is exempt therefrom and the basis for the alleged exemponn.Any violation of ❑NEN'BLDG/ADDITION ❑DETMOLITION
X m_LL Section 7031.5 by any applicant for a permit wbjects the applicant to a civil Penalty of POWER DEVICES
W w nnnnorc than five hundred aollan($5(0). IMPRO❑TENAM ❑FOOD SERVICE
^'Z'Q Las owner of the property, bees with wages us their-sole compensalion. SWIMMING POOL ELECT RIC OTHER EMEN'I'
Z ❑ these y Yotin Y b p
[- will Jo the work,and the nmcwreisnnt,Licauva Law
entaloes et ItIlec.o,an rane,of []OTHER
all m and Por ioss Code:The Camino.rs License Law does net apply to an owner or OUThITS-SWITCHES- TU
pntPe ry who builds m,improves thereon,and Who docs such work Idowelf or through
his own employees,provided that such improvements arc not intended or of(mrcU for NEW RESIDEM'IAL BLEC'I' SQ F'.
aster.IT.however the building or inprovemem i—mld within one yea,ofcompletinn.the SQ.17.FTIX)R AREA SISQ.IT.
pewr-builder will have the burden of proving that he did not build or impmvo for pur- AUG
ofsdcd' TOTAL: ��'1t11 (a 18 eft��
❑1,as owner of the property,ant exclusively contracting with licensed contractors set ^ TICL
instruct the project(Sec.7616.Business and Professions Calc)The Contractor's Li- kP�
cense Lawdoes not apply to an owner of Pmpcny who builds orimpmves mcmon.and QTY. PLUMBING PERMIT FEE lir Ul• �ur�M)/NU
whit contracts for such projects with a,ommeloos)licensed pursuant to the Convectors
License Law, PERMIT ISSUANCE
❑I am exempt^nae,Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER([s) VAIAA'ITON
u Delc
w WORnderPCOM PENrjury on DECLARATION BACK FLOW PROTECT.DEVICE
I hereby off,m under Penalty oeperjury one of the following W rker sons:
❑ Ibave and will maintain ection ofConsen to he Labor
Code,
for Worker eculComdi- DRAINS-PLUGH.HOOP,AREA,COAD' STORIES TYPE CONST"RUCI'101
satin^,as provided for by Section 37N)of IM1e Lobar t]da,fur the scrfnrmnntz nl the
work for which this pcnnit In i.uwea, FIX'I'UHF.S-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as realm ed by Satins
3700ofthe labor Cetde.fortheperfonnanceofthe work for which this Permit is issued. GAS-EA.SYSTEM-1 INC.4 OUT'LIE OCC,GROUP APN
My Wnrkcr's Compensation Insumince cunierud Policy^vaster are:
Currier: Policy No.: OAS-P.A.SYS'll?M-0V ER 6(EA)
CERTIFICATE OF EXIb P ION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
fThisucdios reed...Owc, nplcmddinepa-mais Barone hundred dollars is 100) GREASETRAV
or less) I'LANCFIIiCK FEB
Icenif,lind imheffe,fomuhecofthe wunkfor whichthispennit isissued.Ishall SHWCR-SANITARY-STORM EA.200 FT
sol employ any person in any manner so as to become.wbject to the Workers Counties- IiNF.HG1']HE
zz wtina Use,of California.Dam WAI HE HEATER W/VENT717LECI'R
Applicant GRADING PEE
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should WATER SYSTENU BEATING f� SOILS ITE
> become subject to the Workers Compensation provision of the LaMar Calc•you muss
forthwith comply with such provisions to fa,permit shall he decniedrev^ked, WNI ITR SERVICI? ro /
a CONSTRUCTION LENDING AGENCY NEW RESIDE TIAT,PLMB. Q.FI'. PAID
UO Ihachy uR,m that there isettmstmninn lending agency forthe PeHommnce of Date #
W H thewnrkhowhoubrbisff irsi...III(Sce.3090.Civ.C)
lender's Name TOTAL:
W Lende,'s Address TOTAL:
1 certify that 1 have read this application and state the the above infnrmuunn a BUILDING FEE
Cpal correct 1 agree to comply with ell city and comnty ominsnres and same Inwx rcluting to QTY. MECHANICAL PERMIT FEE
) Z huilding construction.and hereby authorim representatives oflhiseny to enterupm the SEISMIC FEE
above-meati^tied prtpeny for inspection Fungi. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupemino against ELECTRIC Izl_'
labiuties,judgmcriv.costs and expenses which may in any way arena,against sail City ALTER OR ADD'1D MECH.
in nmporee of the grunting of this pertnil. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE REGULATIONS. MECHANICAL FEF
' AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION AN
Signature M Applicant(Contracor Date EXHAUST HUGE)(W/DUCT) HOUSING MITIT�E NME
HAZARDOUS MATERIALS DISCLOSURE
Will theupPlicam or Towne 1,61dnguccuaim stnco,handle ha',mmvehta,coal HE'A'TING UNI'I'('10 I(N)•IXXI BTU)
as defined by the Cupedlno Municipal Cale.Chapter 9.12.and the Bedth aad Safety
Code,Section 255321a)'I HEATING UNIT(OVER 100.(00 BTU)
E]Yes Fl No
VP.NI'l1.AT10N FAN IS]NGLI?REST U) PAID Will the applicant or future building occupant use equipment or device,which Dam Rettipr M
emit Formation air,Dominants as deined by the Bay Area Air Quality Management BOILER-COME(3HP OR 100.000 BTU)
District? TOTAL:
L]Ye, ❑Nit BOILER-COMP(OVER III(I,fgU BTU)
I have read the havudous materials requirements under Calmer 6.95 ofthc Cali- AIR CONDITIONER ISSUANCE DATE
boron Health&Safety Code,Sections 25505,2.5533 and 25536.1 understand that tithe NEW RESIDENTIAL MECH. SQ.Pr.
building does nol currently have a mnant,that it ix my rcsryinsibiliry w easily the ovcupum
of the ha uirements which must be met prior to issuance of a Cm,ficate of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE