29366 (2) APPLICANT MFILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF COPERTINO BUILDING-ELECTRICAL PERMIT NO. ^^ w
BUILDINGDIVISION P ICATIONIPERMIT PLUMBING-MECHANICAL L l\JJ II•�J yVg
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
VI San 1'i A04Ce4i'n n 3'D Il ?49' y_ ^i,
OWNER' NA E: 0 7Q OHNE•^. CONTRACro NAME: ��5 L�
� IaCS y,
'OV 7/`\/ N/C CONTROLa
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: - PHONE: BUILDING PERMIT INFO
G 606 ❑ Consultant Fees Paid'by Applicant(Initial) BLDG ELECT PLUMB M1EECCH�
ICJ N E pt
LI NSEDCONTRACORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�0ZO with Section Division Businessand Profeasioas Cwle,and mylianse is PERMIT ISSUANCE RESIDENTIAL'
full fomeasdefrec0 ❑SFDWL ❑KITCHEN REMODEL
License Class - Lic,a
�TaRw Dote Contractor APPLIANCF,S-RESIDENTIAL ❑ADDITION ED PLUMBING RE-PIPE
on ARCHITECTS DECLARATION
Z O t Z I understand my plans shall be used as public recntds PANELS ❑MULTI-UNIT ❑STRUCTURAL
O Z UP TO 2M AMPS MODIFICATION
H 4�Q. Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
cN4 281-I(XILIAMPS IMPROVEMENT
Fa%6 OWNER-BUILDER DECLARATION
Car ION OVER HXm AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
R� 1 hereby affirm that 1 1. exempt from the Commcmrs License tow for the
3O L V following rezwa.(Section]831.5,Business and Professions Code:Any city or county SIGNS ELGCTRICAI. []OTHER
1y,F which reyuires o permit to nmswa,alter,improve,detnnlieh,or rcpun any structure _
m•� poor to its issuance,also requirestheapplicom formth permit to file a signed stammers SPECIAL CIRCUIT/MISC. -'
<f that he is licensed purmm�tto 0,provisionsof the Committees License Low(Chapter 9
t]O (c acing with Sethan]Igl()of Division3 of the Business and Professions GMe)nr TEMP.METER OR POLF,INST.
d q m y that he is exempt thcrefmm and the basis for the alleged exemption.Any violation of ❑NEW BLD. 1 111T1Oj.` DEMOLITION
W..y
Section by any applicant for a permit subjects the applicant m u civil penalty or POWER DEVICES I d.(t
>p„ not mom than Eve hundred doll.($500). _ FF BL 6 BSERVICE
� < Las owner of the IMPROVEMENT tJJ
❑ property,or myemployees with wages as their sale compensation, SWIMMING POOL L•LECI'RiC
O will do the work,dnd thestrunure is not intended oroffeted for sale(Sec.]M4,Business ❑ HERII 110- r
W m end Pmfessiom CNe:The Commnors Licenu Law Jces oat tppiY to an owner of OUTLETS-SWITCHES-FIXTURPS • ',f11/M(J
�•a properly who builds or improves thereon,and who does such work himself or through
his own emplayies,provided that such improvements are not intended or offered for NEW RESIDENTIAL.ELECTR 'SQ FT.
We.IL however,the building or improvement is sold within one yearn('completion*the SQ.FT.FLUOR AR EA _ SISQ.FT
owner-builder will have the holden of proving that he did not build or improve fill put- h/sM1/s/,/�
pose of sale.). c2 a Fl41
1,u ownerof the TOTAL:
❑ properly,tat exclusively[antmtllllg with flC[ns[d ntntmctms ill J
construct the protan(sec..an i Business and Professions Code:I TheextriContracmrs Li- p e..
ulawdoeor suchpir tots with
aofpmttoo wcesed prrimprovee thereonand QTY. PLUMBING PERMIT FEE 3 �V
who commas far such projects with a commnnr(s)licensed pursuant m the Commcmrs
License Law. PERMIT ISSUANCE
❑I an exempt under Sec. ,B&P C for this reason
Owner Dam ALTER DRAIN&.VENT-WATER IRA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �� 6V
Ihereby affirm under penalty of perjury one of the following declarations: V V
❑ I have and will mainmin a Certificate ofConsent to self-insure for Workers Common. DRAINS-FLOOR.ROOF,AREA,CONED.
action,as provided for by Section 3]80 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXO'URLS-PERI RAP
❑I have and will maintain Workers Compensation Imumnce,as required by Section
37M of the Labor
yCode,�fpolydeyplegrpformance of the work for which daisy Permit
smiitt is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
MyW.k
tax
Carrier
ns�A3 ^TUAL}ex ame Policy Na.y m GAS-EA.SYSTEM-OVER 4BEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(This seainn need ern be completedifthe perrtdt is(Drone hunOred dollar BUILDING DIVISION FEES(5100) GRBASETRAP
or less) •' PLANCHECK FEE O OO
Loy any thatinthe Performance of work for which this pcmnit is ism Ca shall SEWER-SANITARY-STORM EA,200 IT.
nm employ any Nixon. my manner s tothe Workers'Camper- ENERGY FEE
Z cation laws of Cable Date
Q O Applicant WATER HEATER WIVENTIIiLECTR
77 �(_- i.� GRADING FEE
a7 h NOTICE TO�i IPLICANT.If,after mr ing this Certificate of Exemption,you should WATER SYSTEM[IFREATING
ai 5 become subject o the Workers Compensation provisions of the Labor Cade,you must SOILS FEE
fid fonbwith comply With such Provisions or this permit shall he deemed invoked. WATER SERVICE
Q
UZ CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID
V O k for
thi theme¢isucd(See,ion lending agency Ford¢perronnunce of Date Raeipta
pmt Lead work for which this permit is issued(Sec.30W7,Civ.C.)
t" Leaders Name TOTAL:
{Ui.) finders Address TOTAL:
gL 1 certify that 1 have revel this application and amts that Ne above information's BUILDING FEE
V2 correct.l agree to comply with Wl city and county ordinances and stain laws refuting to QTY. MECHANICAL PERMIT FEE
w
V 4 building conschon,add hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned tympany for inspection purposes. PERMIT ISSUANCE y
(We)agree to save,indemnify and keep hmmless the City or Cupertino against ELECTRIC FEE �V s3O
liabilities,judgments,costs and expenses which may in any way accmc against said City ALTER OR ADD TO MECH, PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR DANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAUME �Q
AIR HANDLING UNIT(OVER 10,00a CFM) CONSTRUCTIONTAX ugsar
Signetureol'Applicant(Conuacmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building accupam store or handle hurricanes materiel HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Csde,Sermon 25532m)? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Dam Receipt#
Will me air coentorfuture building occupantuse equipment ordevices
ement BOILER-COMP(3HP OR 100000 BTU)
anir harrNous alt cnnuuninents as defined by the Buy Arca Air Quality Management d<tTOTA /
Dix ?
❑Yes No BOILER-COMP(OVER I00,IM)O BTU)
I have read the hazatdsms materialsp AIR CONDITIONER'S
requiremenu under Chapter 6.95 of the Cali ISSUANCE DATE
forma Health&Safety Cale.Sections 25505,25533 and 25534.I understand that if the NEW RU16L'NTIAL MECH. SQ.FT.
building Banes not urmmfy have a tenant,that it is my respannsihility to notify me mcupam
of the.,,. iswhit tlemetpriortoissuameefa Ceriftam of Occupancy.
•,.� ice-9�
Owner outhorizeJ� Date TOTAL: ISSUED BY:
OFFICE