S 1775 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'RICAh rlaltpal'r No.
1775
BUDAINGD ISRm APPLICATION/I'ERMIT - Pl.unmmc-MECHANICAL <V
BUILDING PROJECT IDEN11FTCATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITFAL DAL
v o Zb,
C WN 'S 'AME: HONE: CONI R'Sli' LIC-NO
NIC CONTROL#
fEII/li GIN E: LIC NO: ADDRiSS Ew!xV1 ❑
C)NTAC'I: ruorvla� BUILDING PERMI'P INFO
W ❑ Consultant Pecs Paid by Applicant(Initial) BLUO EL PLUMB MDCII
I.ICI!NSI!DCONTRACIoit5DECh A'rloN QTY ELECTRICPERMIT . FEE
1 hereby anirm Wm I a n licensed under provi,Wns Chapter 9(cmmmcnehng JON DESCRIPTION
D0Z with Scminn]f00) IDi" n 30fdte Business and l' 1s,i t cr,ve rimy license is RESIDENTIAL:
O O �j'j FERMI I'ISSUANCE
Fly in full farcusnJ ellecL G6 ❑SIVWI. ❑KUCH17N REMODEL
QR F' Licen.w Lisp APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE PIPIT
rFia a a Dam comram 1. -
RCIIII'IEC1"S UECLAItA1'lo ❑A1ULT1-UNIT ❑STRUCI'URAI.
F O rat I'ANI:LS
ZOy7�. IwWersr nal my phots nhnll he u,eA as pnhlic rec r MODIFICATION
OZ-, UP'I'O200AMPS ❑INTERIOR UCHIMNHYREPAIR
F��kJU Licemed PorRisional 201-1000AMPS IMPROVEMENT USWIMMING POOLS
OWNER-BUILDER DECLARATION OVER Bon AMPS
C1 BATH REMODEI/REPAIR UDEMGLITIDN
a C Q 1 hereby unto Thu 1 am estate,from the Conce ora License Law ht the
�x0.06 U
following w..(Section 7011.5.Business and Pntl Basions Code:Any city or case SIGNS ELECTRICAI. U OTHER
W W O y which requires s permh w cor..one,ober,improve,&t...ish,or repair any unmwa
5 m
prier its issuance,also«tryma
ires the applicant Btrsuch penn file a signed statement SPECIAL CIRCUIT/MISC.
99{ray}
that he is Eicensed pursuant o the provisions of the Contractor's License Law(Chapter 9
C, (commencing with Secnam'1,1X)ofDivisionJof,hc Bnsimcs,mN Pmfcscions Cn fe)or 'TEMP.METER OR POLE INST. COMMERCIAL:
m
a q a Thal he is csnnpl Iherefrnm and the basis for he alleged exemption.Any violmion of ❑NEW BLDG/ADDITION U DEMOLITION
if 4. Section AUl.5 by any.ppliNatforapromi.,abjeusdo,applicum loo civil penahy of OWER DEVICES'
W;a, ' ❑'I'IiNAN1' ❑1700D SERVICE
rn mote Than five hundred dollzrs 5500).
F Z Y IMPROVEMENT
pp Q ❑ I,u ow nerkf the pntpuct re is acmployeeswitM1fiend nsale(Se.compnsatlon, S MING POOL ELECTRIC
2=O will Jothe work,and the structure is nal imendeJ nntRercdlitrmle(Sec.]U1f.Bune 'if ❑GTHIER
4 and Professions Code:The Conaauars License law doer nal apply to an owner of OVfLI: S - 1 F
properly who builds or iol n uses thereon,nal who dos such work himself or through
his own employees,provided that.such improvements are not intended or offered fin NEW RISI , :. (•f. ♦� ..QQ 17..FLOOR AR13A $ISQ.F
ale lLhnwevu,tbc building urimpnwcmcm lnsolJwiWinnnc year nl'cnmplc,ion,Bm l ed prior to plan bee Co pletio11P.
ser-badder will base the border of pmvin6lhtu he did not build or improve Wr pur-
pose of Nile.).
0 I,as swnerof the pmpdy,out exchwincly contracting with licensed amaacle s(a Von actor and/Ori qner accept complete
comwo the project Sec.71144,Ilasincs,and Prtfe,sions Ccdc:)The Cauca,,arr hi
ccnwLawdoesnotapplytnanownerofprcpeaywhobuildsorimpervcatheroanand QTY, 11&8 Ipy or eon eetin add' I�
who contracts for such projects with a contraatons)licensed pursuant o the Contractor
I.iccnse law. PIERMI'F IS.
0 I.oto exempt under Sec. ,B&P C for this mason
ADDER-D . ) p�VALlJA1'ION
Owner pre IYI
WORKER;SCOMI'ENSATIONDI!CLARATION HACK PLO
I hereby aRnn under penalty of perjury one of the Ildkwing declarations:
I have and will maintain a Certificate of Consent to self-insum for Worker's Conic,, DRAINS-P )O R.ROOF.ARTA, N TVI'E CONSTHUCI'ION
salon,ata pmenlid lot by Section 3]a)of the Udia Cade,for the performance of Wa Iti
work far which,his pemto is issued. FIX'1'U RES- � A
0 1 have and will maintain Worker's Compensation Insurance,as require)by Section
B]OOafrhe labor Code,fon da,1, of work for which this perr�ititti�iis/ss(sss�ra��ed. GAS-EA.. - )UF CGROUP APN
r Work Cy n J I'oliry �F
Tries/,�{ on e 1 dey No.: GAS-IEA,SVS iM"OVF.Ri(F.A)
IliHR IIP CA'1'E OP EXEM ION FROM WORKERS'
COMPENSATION INSURANCE GHFASFII AS'fIi
JlW)ING DIVISION FEELS" _
(ITis actionnttd not be compkteA if the pini,ix lirconc hundrcJ dnllarr($11)i GREASETRAP
nr less) r1.ANCHI!CKI '1
I seri fy that i n the perfonlanceafthe work for which this Permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any Pusan in any manner.so as m Become subjectto the Workers Conten- ENERG E
Z salion laws of Cali funis.Date WATER HEATER WNENF/ELECIR
ZO Applicaul ' GRA NG 'L'
� � NCOIC1E TO A PPLICANT:I L after making this Certi ficate of Exemption,you should WATER SYSTIEMG REATI NG
a, become subject to the Worker's Coopvmlon provisions of We Labor Colo,you nm,t Of"FE
falhnih,ounply wilhsuchpmvision,or Juspu'mi„hall bedecnmd revoked. WATER SI?RVICE
aQ
Uz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT. PAID
0, I hcoforhe perrmane of Date Receipt k
We work 6n wich This mond is issued(Sce.30],
Civ.CJ
O Lender,Nnne "1GOAL:
LenJer'.AJdfTO'T'AL
I :
,,if,
l Thal I h:rvc read❑,i,xpplicminn and cram rbm,he udwc information is 9UILU1 'G F
ti
ti correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEB.
V Z building amswelion,and hereby nuthorne Teenssentullves of city menter upon theSEISMIJ IZE
above incur toned property fur inspection purintses. -
1 WeE a m save,indemnif J kec humtless the Cil fCu ninm s t PERMIT ISSUANCE ELECT C FEE
gree yon P Yo p gains
liabilities.judgnmms,ceras vnd exposes which may in any way rectos against said City ALTER OR AUDIO MEC,.
in ant+cyuein goo ,god this permit PLUMIiI GPIEF.
APPLICAN fNDLRST ND.l'AND COMPLY WIT ALL NON-POINT AIR HANDLING UNITfI'O H)X,CFM)
M1II!CI1AN 'ALFT
SOURCE EGULA'IOs
AIR I HANDLING UNIT(OVER 10,0n)CFM) CONSTRUC'ION TAX
tore of ammeter Dam EXIIAUS'THOOO(W/DUCT)
mnHAZAkDOUS MATERIALS DISC,DSII 3 HOUSING MI' OA'PION FEE
HEATING UNIT(TD 100.00)BTU)
teed by the Cuptino Municipal Cswle,Chapter 9.12,and the Hmlth vnd Safely
Code,Section 25532(aU HEATING UNIT(OVER 100,00 BTIH
El Its, CNo V IEN'I ILATION CAN SINGLE REST DI PAID
Dam ReceiptI
Will the air rouslit inarasra building hy,he Ba,
Air Qualitn it y
views en, ROILER-COME(31 IP OR I)OJ00 B J)
Dir huagrdnua Dir cunluminanrs as dcfnul by rbc Iluy Arco Air Qanlity Managanent TO'I'AI:
Distort? Yes CNo BOILER-COMP(OVEN 00.10X1 B"I'Of
❑
I have real the hnvodou.s materials mquiremem,under chapter 6.95 of the Cali- AIR CON DI IONER ISSUANCE DATE
foods Health&Safety Cale,Seniors 25505,25533 vad 8534.1 understand that if the NEW RESIDENTIAL MECH, SQ.FI.
building Jens not currently have a[count,War i,Is my responsibility to notify the orc,vni
of the Icquirancnta which mu91 he sect prior to Issuance of a Cer,if ime,of Ovenpanq..
Owner or authorized agent Dar TOTAL ISSUED IIY:
OFFICE