29384 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPC`RTINO BUILDING-ELECTRICAL - PERMITNO. 3`XJ 4 29384^ 'a ^ q
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL L l9A
BUILDING PROJECT IDENTIFICATION
BUILDIN ADDRESS: SANITARY NO, APPLICATION SUBMITTAL.DATE
O 'R'S A R" N PHONE: C N R CTO ' NAME� LICN
s l NAC
CONTROL
Ai-112, LAM -PA iFMC'I'/ENOINHHR: L :NO: ADURI 5: I ❑
Q N 1 A
CONTACT. PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ QQ ❑
LICENSED CONTRACfOR'SDECLARATION QTY ELECTRIC PERMIT FEE
Iimn70(gmf i,iIIant licensed underpmvisios ol'Churyer9(romme.cln8 JOB DESCRIPTION
AWZ with Section]1itaef0ivisi.nJof the Nuxinessand Professinna Code,and mylicensc is PERMIT ISSUANCE RESIDENTIAL:
FUS in full force mJ eE ❑SFDWL El KITCHEN REMODEL
U U Li«mc a Lic
I
u1 Dme ' n crnr APPLIANCES-RCSIUIiNT1AL � ❑ADDITION ❑PLUMHING RE-PIPE
F�
1N,pss'ea RC CDECLARATION PANELS [I MULTI-UNIT [I STRUCTURAL
Z0t ? Ise an all usNas old a MODIFICATION
OZ—Q UPT0200AMPS CINTHRIOR [D CHIMNEY REPAIR
P4 ; I.ic edr(ISI-ti(I
- 201-IWOAMPS IMPROVEMENT
�d WNER-BUILDER DECLARATION OVER Ifb11AMPS
y a( Q 1 hhat I em exempt from the Contractor's License(taw for the [-I BATH REMODEVREPAIR DEMOLITION
x a a U follo ingn]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W Oyq which regm construct,ahem tmpmvc,demolish,or ,repay any ,m,m e / N
N..I prior to its issuance,also mains the applicant for such Permute file a signed statement SPECIAL CIRCUIT/MISC. '. -
�. that he is licensed pursuant to Ne provisions of the Competitor License Law(Chapter 9
00 Los
(commencing with Section]000)of Division 3 of the Business and Professions Cosamia TEMP.METER OR POLE INSTCOMMERCIAL' l
that be is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
R N Section 7031.1 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
F Z Y not more than five hundred dollars(4500). ❑TENANT El FOOD SERVICE.
6 I,as owner of the IMPROVEMENT
C ❑ propeny,or many wiNwagesmthei(tele 0,14,8 sines SWIMMING POOL ELECfRI ❑OTHER
will dothework,ands: Bo Contradicts
Intend..mantafor sale(See,70,14,Business
end Professions builds
o The Convector's License Law does not apply s if owner of OUTLETS-SWITCHES-
63^ hper,surtyis...whobuilds orimproves,harem,and who does m is wad himself onhmugh
his own employe.,building(hat psuchrov improvements thin not intended or offered for NEW RESIDI?NTIAL F.LECDt S -
oner,bcower will have the
impvwanint issoldh did none tbuild rofcontpletforpare SQ FT FLOOR'AREA^ $ISQ.FT.
pose of
sale.). lhavethehardenofprovingthehedidnotbuildsimproveforpur-
El1,-sal<.). MAR 71996
❑I, oowrmrofthepov.70, ,Bexclusively contacting with:)Theedconadmr a ns
onatmn Nc project(Sec.71143,Busincsx and Pmtbaxions GsleD The C.mmcmr'x Li-
cause Low does not apply it)an owner of property who builds or improves thereon. ad QTY PLUMBING PERMIT EE
who contracts for such projects with a comeeons)licensed pursuant in the Comteeorc (:II I Vf vUf CoII IIYl1
License Law'
❑ lam exempn under Sec. ,B&PCfor this rcosnn PERMIT ISSUANCE So
Owner Data ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declaetionc
❑ I have and will maintain u Certificate of Consent to self-insure fm Workers Compete DRAINS-FLOOR.SOOFAREA,COND.
ration,as provided for by Section 37W of the tabor Cone,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PF.R TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Saluda
37011ofthe Labor Code,fin rhe Performance afthe work for which thispermir is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS &L Vd OCC.GROUP - APN
My Worker's Compensation Insurance carrier snit Policy number are:
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
(This section need not he completed Base permit is(Drone hundred Jolles($100) BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
I certify Nat in the performance ofthe work for which this permit is issued,I shall ' SEWER-SANIB'ARY-STORM EA.200 FT.
not employ any person in any toner to as to become subject to the Workers'Compen- ENERGY FEE
O Z pLaws of California.Uma
Applicant 1 WATER HEATER W/VFNT/ELECTR 1 eSp
O AppliGRADING FEE
syNr NOTICE TO APPLICANT:If.afill making his Ccnificam of Exemption,you should WATER SYSTTiM/1BEATING
abecome subject m rhe Works,',Comparison..provisions of the Lobo Code,you most SOILS EEE
fa7 forthwith comply with such provisions or this Permit hall be deemed revoked. WATER SERVICE
0. Q
CONSTRULTIOmadi..LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FII PAID
VO l herebyich hithatthereisacd(Sce.3N7,Cis,agencylin the performance of Dem ' RecciptN
U' t-�. Newark for which this permit is issued(Sec.JB9].Civ.CJ
O L) Lenders Name TOTAL:
Oil Leaderscountess � TOTAL.: iI
y 1I ceni(y that 1 have rend this application and suite that the uMwe information is - .43 BUILDING FEE
tti UJ tortes[.l agree to comply withal]city and county ordinances and state laws refuting to QTY. MECHANICAL PERMIT FEE
G FZ-t building construction,end hereby authorize representatives of this city to enter upon the SEISMIC PEE
above mentioned property for inspection purposes. PERMIT ISSUANCE
(Wc)agree in save,indemnify and keep handless the City III Cupertino against ELECTRIC ME
liabilum,judgments,cosuand expenses whit in any way accrue against mid City ALTER OR ADD TO MECH.
in consequence of the tin fNlsse PLUMBING FEE
APPLICANT U' . DS AN L COMPLY ALL NON.POIN AIR HANDLING UNIT(TO TO."Oust)
SOURCERE MECHANICAL FEE
3 AIR HANDLING UNIT(OVER IBM BCFM) CONSTAUCTIONTAX
SigMR.,
p nnvoc'of ae EXHAUST HOOD(W/DUCT)
AZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
ill Ne pliant or future building occupant score or handle hazallom maunel HGTING UNIT RO I(IO.fNq BTU)
as defined by th Cupertino Municipal Code,Chapter 9.12.and the Health mal Safety
Code,Section 2553260? HEATING UNIT(OVER 100,000 BN)
❑Yes ' Fl No VEN]'ILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt N
emit hazthdous air comaminents m definW by the Bay Arca Air Quality Management ENTER-COMP(3HP OR 100,)DO BTU)
District? 'TOTAL:
❑Yen nNo BOILER-COME(OVER I MOST BTU)
1 have mail the homadnus materials p AIR CONDITIONER ISSUANCE DATE
ro,25533 ax u2553 .1 Chapter if the if
fordogoes&t curry Cotlerea'tions2thati is my and25574.1 understand thusif No NEW RESIDENTIAL MECH. SQ.IT.
building Jos ern currently have a tenon[.that o is my rcapnnsCerityca notify the smcupant
of Ne requiremcnte which must h amt prior m iamantt of a Certificate of Occupthmy.
Owner or amhorized agent Dare TOTAL: ISSUED BY:
OFFICE