S 1081APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING - ELECI'RICM, PERMIT NO.
HUILDINOnIVIS1ON APPLICATIONA'F.RMIT TING PROTEBING. TIDENTIFIC S 1081
xnn nING PROTECT IDENTIFICATION
OFFICE
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•NGINEF LIC NO'.
ADDRESS:
r,7r
PHONE:
II kM 4%
CtlLICENSED
❑ConsulFanf Fees Pald 6y Applicant(Initial)
BUILUIERMIT INFO
ol.l)G EL PI UMB MECII
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CONTRACTORS DECLARATION
by uffnn Ghat 1 nm Ilrcnsed under Prvvixians nr Chapter 9lcommeneingOaZ]INN))nl Nofes,amoCm,andmy license lis
nd c" a I.
Lic.N
Dale Cnnlmetnr
ARCHITECT'S DECLARATION
I understand my plans shall he used as Public records
QTY ELECTRIC PERMIT FEE
JQH DESCRIPTION
IAI'
❑SfVWI❑ KITCHEN REMODEI,-ZU
[I ADDITION ❑PLUMBING RE -PIPE
❑MUl:fl-UNIT El STRUCTURAL
MODIFICATION
[I INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ❑DEMOLITI NOOIS
❑BATH RF:MODF:UREPAIR [I DEMOLITION
❑ OTHER
PERMIT ISSUANCE.
APPLIANCES — RISIUENTIAL
PANELS
UPT0200AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby firm mat I and exempt from the Commemr's License Law for the
following reams. !section 7031.3. Nosiness and Rnfessions Cade Any city or county
201-1NNIAMPS
OVER 1000 AMPS
SIGNS ELECTRICAL.
- C y
Ey
itl �c
L %ey
_{Iyy
F'ZY
SQp
F
which acquires a peunit m aonarua, alter, impmve, demolish, ar relent, any .structure
prim,. its issuance.alxn requraxfleapplicam for such ma, 1. file fsignedxaentem
mut he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 70010) of Division Sof the BardoesImd pimficowns Cale)or
that he is exempt therefrom unit the basis for the alleged exemption. Any vmalion of
Section7031S flyer, applicant for a permit subjects the applicant to a civil Penally of
mantra, than rive hundred dollars ($500).
❑ I, ,
as owner of the property, or my employees with wagesmtheirenlemmpeusiness
will doth, work, and the acture is nal intended muffetee for sole (SecJ(N4. Businesstructure
and Bandelier,, Code: IT, Connector's License Law docs sat apply m an owner of
Propeny who builds or improves Thereon, and who fres such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If, however, the headline or improvement is sold within one yen, of completion, theFLOOR
e, -builder will have the burden of proving that he did not builder improve for par-
pose of sale.).
❑ I, us owner affect See 70, ant exclusively nmnec'ing with IicenseC cnm Connector's
Boniness rope Pro1"cssinns GvIri The Comracmrs I.i-
Dreamer the project!Sea loan mond
whosedpor ant
SPECIAL CIRCUITIMISC.
]LMBMETERORPOLC•INS'E
COMMERCIAL:
EliLDG/ADDITION E3DIiMOLITION
NTQQ�� ❑FOODSERVICE
IMPROVEhIEN'f4�' T
OTHER
' • ^ V !J
ARE 3/SQ. FT.
c Ur,� IN
�S•� ��+. ,11
POWI'.R DEVICES
SWIMMING POOL ELT:
1 OUTI.ETS—SWITCH : —IT% R S
NEW RESIDENT [At, ELELTR FT.
I..
PLUMBING PERMIT FEE
whocLfwdoesnmuppnGoanviaaafpmpety
toteCona
who comracrs I'or each projats with a eomracmrls) licensed pursuant to the Conwcmr's
I.icenso Law.
❑ IanI tlllI urSa .R&PCfor this nem
Dore
WOR❑'.I TION DECLARATION
I hereby Timm unite pe rynf leerjury Inc of the following declrrerinns:
❑ I have andwillmuinwin a nificaeof Cansem toself-insure for Workers Compen-
cation, as provided fm by Section J]W of the Latin Cale, for the performance of the
work far which this permit is issued.
ERMIT ISSUANC E.
A Ell —DRAIN &VONT—WATER (EA)
VAI
/-�
BACLOW PROTECT. DEVICE
DRAINS— LOORROORAHEA.COND,
STORM.
TYPE CONSTRUCTION
PIX FURFS— 'RTRAP
❑ I have and will maintain Workers Compensated Insurance, ax required by Section
3700ofrhe Lahr Cale. fortheperfnrmaneeof the work for which Nispennil isissued.
GAS—EA.SYS'1'F. 1INC.4 OUTLITS
OCC.GROUP APN
GAS—EA.SYSTEM-O 7R4(UA)
My Wtnkers Compersahaa Inmrance carrier and Policy nonuser arc:
Carver: Policy Nn.:
CERTIFICATE OF EXEMPTION FROM WORKERS"
COMPENSATION INSURANCE
BUIL 114C, DIVIMON FE'S
GNEASITNDUSTRL WAS ' INTERCEPTOR
GREASETRAP
PLANCUECK FI?L /e
O,Z
T (]
p
a[
(This section need not he completed ifthe permit is tartare handled dollar, is Hot
or lean.)
I cenify than in the perfounance of Ne work forwhich this permit is issued, l shall
nor employ any person in any manner sn es m hcnme suhjcn nt the Worker.' QtmPem
samr Laws of California. Data
Applicant
SEWER — SANITARY — STORM F.A. IFT.
ENERGY IEE /'r
WATER HEATER W/VENT/ELECTR
GRADYIG
NOTICE TO APPLICANT: If, aper making his Cadificae of Exemption, you should
b.come subject tolhe Workers Compensminn provisions of rhe Labor coal, yarmed
G forthwith comply withsuch Provisions or this period shall he Deemed revnkeJ.
WATER SYSTEMRREATING
ti011.5 YBIs��
WA'1'IiR SERVICE
41)
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IU
1:1.,cenify
rA
V
q
CONSTRUCTION LENDING AGENCY
z
1 hereby kfar,affims Permit I,Sec.i30lendingagencyfarthe peRaunance of
the work for which this permit Is isucJ Sec. 71N1]. Co. C.)
PAID
Da Receiplk
NEW RESIDENT IAL PLMIL SQ. FT.
T'OTAU.
F Lender's Name
Lenders Address
TOTAL:
MAL GF
that 1 have at this application and state that the above information Is
cnnect, l agree,. comply with.11 city and county ordinancesand store laws rela0ngm
a building cnmwaion, and heresy iahorire a,precolidives.'his city m ewer.". the
id ave -mentioned pmpeny for inspection Purposes.
(We) agree ,a save, indemnify and keep harmless the City of Cupertino against
IirbBities,judgmems, costs and expenses which may in any way accme against said City
QTY. MECHANICAL PERMIT HE
SEISMIC FEI •�
PERMIT ISSUANCE
'2 ALTER OR AUD TO MECH.
J
ELECTRIC F E
PLUMBING FL
in cam seyucncc 11 at6 ranting of his unit.
APPLIC ER LANDS t I ILL COMPLY WITH ALL NON -POINT
AIR HANDLING ON[ P JO 10,IN00 CFM)
MECHANICAL FEE
SOU .f ATR S.
"`iJ%_
q
N 0!10
R HANDLING UNI 10.CPM?
CONSTRUCTION FAR
Sig arc pplicaluConma or Data
HAZARD MATERIALS DISCLOSURE
Will the uppllefmor furor. Noldingnccupuntsmmorhandle horadausovilloal
as defined by the Cupeniva Municipal Cale, Chapter 9.12, and the health and Safety
Cale, Section 25532m)P
EXHAUST HOOD(W/yucr)
HOUSING MITIGATIONF
HEATING UNIT (10 lN).(NNI BTU)
HEATING UNIT (OVER 100,000 BTU)
VENTILATION CAN (SINGLE RESIDI
Cl yes QNo
PAID Dam Hmcipl
ROIhEN—COMP(JfIPOR 100,000BITE
Will the applicant or future building occupant use equipment or devices which
emir hawdous sir crmaninunp av derned by the Hay Area Air Quality Management
TO AL:
BOILER — COMP (OVER 100,N)O RTU)
District?
Cl Yes 0 N
AIR CONE]GONER
ISSUANC ATE
I have mud the haaaNnos maaiak reformers under Chapter 6.95 of the Cali-
NEW RESIDENTIAL. MECH. SQ. FT.
humin Health & Safety Coca. Smlions 255115, 255]3 and 25534.1 uldror ad that if he
building does nor currently have u craft. than is is my reslvansihility to notify the occupant
of me legvircments which must he ma pain, or issuance of a Cmirwm of Occulaney.
f0
ISSUED BY:
Owner or aumodsed agent Data
OFFICE