S 3320APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO PRALDING- ELECTRICAL PE18IT NO /.�3
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECIIANICAL v �J V Z O
BUILDING PROJELT IDENTIFICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
BUILDING ADDRE-S&
U H V ✓—
ARCHITECUENGINEER: LIC NO.
ADDRESS: I IM
TBUILDING
CONTACT. PHONE:
PERMIT INFO❑
ELEC PLUMB MUCH
Consultant Fees Paid by Appl
�/I
El
LICENSE[) CONTRACTOR'S DECLARATION
herebymErm Nm I am licensed under provisions ofChapter 9 (em rcurioy
thSectlon]0(MyfDlvisinn3ofthm Bcoar.andPmfmsslon. Code,endmylicenseisuIOO ""
nfullfo sandellen
Liccn LicM
Date �—TS DELLI-UNIT
ARCHITfiCTS D[CLA 1
1 understand my plans shall W used as pubL ecoMs
QTY ELECTRIC PERMJOB
DESCRIPTION
ENTIALO0Z
I. ❑KITCHEN REMOUEhlUU
❑PLUMBIURAL PIPEoft
❑STRUCTURAL�m
❑CHIMNEY REPAIRI:•�
SWIMMING POOLS
❑BATHREMODELREPAIR ❑DEMOLITION
❑ OTHER
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PERMIT ISSUANCE
APPLIANCES-RESIDENTIALTION
PANELSMODIFICATIONZ8mZ
UPTO200AMPSRIOR
Licensed Professional
OWNER -BUILDER DECLARATION
herehy affirm that 1 am exempt from the Commcmr's License Law fnr the
allowinkimason.(Section 1031.5, Brdnessand Formouns Calc: Any city., county
201-1(M)AMPSOVEMENT
OVERHt0AMPg
SIGNS HLEMRICAL
SPECIAL CIRCUIT/MISC.
�f
1+1 Oh'
which acquires a permit to contract, dmr, improve, demolish, err repair any structure
prior to its issuance, also requires the applicant for such Proof to file a signed statement
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that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter Y
(commencing with Section 7") of Division J of the Business and Professions Code)or
that he is exempt therefrom and the basic for the alleged exemption. Any violatinn of
Section 7031.5 by any applicant (or a permit subjects the upplicat m a civil penalty of
nut room Nan five hundred dollars ($500),
as owner of the property, or my employees with wages us their sole compensation,
will do the wak,und thesauctum is not inuadednroffeacd for Oil (See 7044, Business
he Contractors License Law does nm apply an owner Of
and Professions Code: Contractorsus
property who builds or improves thereon, and who does such work himself or threagM1
his Own employees, provided that such improvements are not intended or offered for
sale. IL however, the building or improvement is sold within One yearof completion, the
TEMP. METER OR POLE INST.
COMMERCIAL
❑NEW BLDG/ADDTTION ❑ UEMOLTfION
❑TENANT ❑ FOOD SERVICE
IMPROVEM12W
[]OTHERF,
POWER DEVICES
SWIMMING POOL ELECTRIC
OVI'I.E. I'S -SWITCHES -FIXTURES
NEW RISIDEMIAL ELECIR SQ FT.
SQ. FT. FLOOR AREA
$/SQ. PT.
mer -Wilder will have the burden of proving that he did not build or improve for pur-
'TOTAL:
pose Of sale.).
❑ 1, us owner Of the property, am exclusively contracting with licensed contractors to
nnnhnn the project (Sec. ]Bis. Bueitar" and Professions Cone'.,Iis, Contrac'm L
ase Taw does not apply to an Owner ofpropeny who builds or improves daemon. and
who contracts for such projects with a contractors) licensed pu mart m the Contractor's
QTY. PLUMBING PERMIT HE
Limn. low.
❑ I nm exempt uraa Sec. . H & P C for dai. rea..n
PERMIT ISSUANCE
e
ALTER -DRAIN&VENT-WATER(EA)
VALUATION
Date
,
Owner
WOR KHR'S COMPEN SA'TION DECLARATION
BACK PLOW FROM, T. DEVICE
.
1 hereby affirm under Penalty Of perjury One of the following decimations
❑ I haveand will maintain a Certificate ofConsent In self-insum for Workers Cooper-
DRAINS- FLUOR, ROOF, AREA, COND.
STORIES
'TYPE CONSTRUCTION
titian, as pmvlJed for by Section 3100 of the Labor Code, fill the Penn nnaace of the
work for which this permit is issued.
TSI have and will maintain Workers Compensation Insurance, as required by Section
] Iof one lamer Cale, for the perfamanw of the work for which this permit is istical.
OCC. GROUP
APN
FIX TURES - PER TRAP
CAS-EA.SYSTEM-IINCAOUTLETS
GAS-EA.SYSTEMOVER4(IiA7
My Workers C�om�ti Insuandcamrier end Pnlic 0ym
Carricr._�'��I\l5H �1`. PolicY Nn.YL rI Bib ��
I N PROM WORKERS'
CERTII4CCO Op COMPENSATION
COMPIiNSAT10N INSURANCE
GRIiASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FEE
(Otis section need not becumpl<ted if the permit is fonmm M1undred Jullars l8l(p)
or less.)
I cerify that in the perfnnWnceof the work for which this permit is issued, l shall
not employ any person in any manner m as to become subject to the Workers' Compen-
SEWT3R- SANITARY -STORM BA. 200 IT,
ENERGY FEE
WATER HEAT(?R WIVENT/ELECTR
GRADING FEE
OZ
z 0
(�
t~
sation Laws Of Culifomiu. Date
Applicant
NOTICE TO APPLICANT: IL allot making this Canniest, of Exemption, you should
become subject to the Workers Compensation provisions of Ne labor Coale, you must
forthwith comply with such provisions or this permit shall be dammed revoked.
WATER SYSTIMTREATING
SOILS ME
WATER SERVICE
+ Q
0.
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U
Q("'
{UTI
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CONSTRUCTION LENDING AGENCY
(hereby affirm thin them is a construction lending for the rformance of
O r gagemmy pm
the work for whicA this permit is issued (Sec. 3097. Cm. C)
PAID
Use eceiptp
NEW RESIDENTIAL PLMB. SQ. FT.
'TOTAL:
Lenders Name
Landers Address
y 1 rattly that I hove reaA this uppli:aninn anA nolo thio the ab:we information is
h aildin Iagrtetoio, andhemby city and coontyoNiivesofunJ state lantrelmingm
Z buildingcomtrvctiun,andherebyauthorize representativesofNiscity toen¢rurymNc
TOTAL:
BUILDING FRE
QTY MECHANICAL PERMIT FE8
SEISMIC FEC
ulswm-nseminned pmpcny for inspection purposes.
PERMIT ISSUANCE
ELECTRIC FEF.
(We) agtee m save, moronity end keep harmless the City of Cupeninn against
liabilities,judgmems, costs andeapenus which may in any wuyucerm against said City
ALTER OR ADD TO MECH.
PLUMHING FEE
I. consequence of the grunting Of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI. NON.POINT
MECHANICAL FEE
Atli HANDLING UNIT (TO FfT00CFM)
50ta(tCT�BEGULATIONS.
II IJ. C" , (\ (lull ICs�I
��II ry
AIR HANDLING UNIT (OVER U1,00(ICFM)
CONSTRUCTION TAX
/V, care 1
'ig am sof ApplicaHAZA DO
HAZARDOUS MATERIALS DISCLOSURE
Will tM applicant or future bu.1Co ac larpmr 12, handle h rain, and Sure,,
as defined by the Cuperam, Munlcip_al Code, Chupmr 9.12, and the IIcv101 end Surety
Code, Section 25532(0)? TJL c
❑Yes No
VXI IAUS'T HOOD(W/DUCT')
HOUSING MITIGATION FEE
l
HPATING UNIT TO 1W,0(ID BTU)
HEATING UNIT (OVER 100,000 BTU)
PAID Dae Receipt a
VENTILATION FAN (SINGLE RL --SID)
Will the applicant or future building Occupant use equipment or devices which
emit broadens air contaminants as defined by the Bay Area Air Quality Management
BOILER -COMP (3HP OR 100.000 BTU)
TOTAL:
District R
BOILER- COMP(OVER 100,000 BTIp
❑ Yes [�'N/
AIR CONDI'T'IONER
/�ISSUANCED E`jn'
I have real he hararJnu.v nmteriuls requiacmcnw under Chapter 6.95 of the Cali-
NEW RESIDENTIAL MECH. SQ. FT.
1'nmin Health & Safety Code, Sections 2550.5, 25533 and 255)4.1 maim tnad fund the
/ '
Wildingdms nut currently have a mmtn6 dytl h is my responsibility w naify the acupant
anb..,.a,.i."nems which matt bu met u( r ais50Dter.f. Cri iricae of Occupant.
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