S 1522 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CIT}•OF CUPERTINO HIM'DING-I-[ECTRICAL PEgIT ND. 1522
ISION APPLICAT ERMIT PLUMB NG-ni
BUILDING DIVecxnNICAL L`J
BUILDING PROJECTIDENOFICAT
BUILDING ADDRESS: SANITARY NO. APPL.ICAI'[ON SUBMI I IAL DATE,
L-'c1Sinter
O�tE.R'S NAME: PHONE: C( ACTORS ME:
ditpEcS �� L NIC ^CONfRailis
I y9�HI'ISCT/ENGINEER: LE NO�: C )DRESS ❑ /�U
C..�A-R-L I k- C Y52S L.ps�A-�t a G4 G
CONTACT: �xPyH✓ONE: / BUILDING PERMIT INFO
/I fix �S 1 ❑ Consultant Fees Paid by Applicant(Initial) R1.1'G ELECT PLUMB MOH
L/L ELLE/dBEe6isa ."ONE oe X L1� gq2
LICENSED CONTRACTOR'S DECLARATION OTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WZ with Section TO))ofDivision 30 he Business and Pmfereions Cod,,.nd o'becnscis RESIDENTIAL:
OO I'IiRM1'T ISSUANCE
FI_ in full force and effect. 0SFDWL ❑KITCHEN REMODEL
OF License Claw Lic.tl b'
U APPLIANCES—RESIDENTIAL Iov.DDITION [3 PLUMBING RP.-PIPE
F Z•WDate Commnnr
mQd ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F m Z 1 undeWmai my Plans droll be used us public records PANELS MODIFICATION
OZ4— UP DO 200AMPS [I IN]ER10R EJ CHIMNEY REPAIR
i,4I❑W Licensed Professional 201-1000AMIS IMPROVFMENT E]SWIMMING POOLS
gxy OWNER-BUILDER DECLARATION OVER I(X10AMPS LJn>\TH REMODFIAREPAIR 0DEMOLITION
OW G 1 hereby emmm that 1 am exempt from the Comrachn s License law fnr the ❑OTHER
pX,3 d V following nernon.(Senlom 70315,Business and Profession,Code,Any city or county SIGNS ELECTRICAL.
IY LL N which require,a permit to ronslmel,a ncc improve,demolish,or repair any structure
0< pnorm its issuance,alsoeequireatheapplicam rorsucM1 permit to file a signed statement SPECIAL CIRCUMMISC.
that he is licensed pursuant to lire provl,mrsof the Counanm',License Law(Chepter 9 COMMERCIAL:
YW1 R'Q0 (smdm,ncing with Section 700Xb.f Diviorm 3 afthe Businessond Professions Cattle, TEAR METER OR POLE INS'1'.
6 o that he is.xempt therefrom and the basis for the alleged exemption,Any violation of E3 NEW BLDG/ADDITION ❑DEh10LITION
Section 7031.5 by any applicant fora permit subjects the applicant In.civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
p=} I.,mote than five hundred dollars($500f IMPROVEMENT
OD1,a.s ownerot the property.or my employees with wages as theirnoleca i,emation• SWIMMING POOL ELECT RIC ,�OTi1ER
C2• will death,w.rk...d,h.,tmaum is not intended or offered(Or sale Dim.70W.Business
W m and Professions Code:The Commaors License Law docs not apply m an owner of OUTLET S—SWITCHES—FIXTURE—9
pommy who builds or Improves thereon,and who does such work himself e,through
his own employees,pmvided that such improvements are not intended or offered for NEW RESIDENTIAL.ELECI'R SQ FI'.
,alt.It.however lM1e bnllding mrimpnwemenr ix solA within uneyun of compldion,the O SQ,P7.FLOOR AREA ASSQ.FT
-
n ver,hoilder will have the burden of moving that he did not build or improve fnr ,pit,
Ile of m owner
'00.
1, owner of the propu'ty,am exclusively contracting with licensed contractors to
..wet the pmjmt(Sec.]OW.Business and Professions Code)The Commcmr's Li-
seLaw does not apply manowner ofpd+mcny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with o ommractorno licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
❑1mor exe order Site ,B&P C for this reason
ALTER—DRAIN& WATER(EAii VALUATION
Ow
n nmy t
WUR 'SCOMI'ENSAIION DECI.ARAT )N BACK FLOW PR iC.1)
I hereby aRran "penalty of perjury one of the following dedarr iom:
❑ I huvennd will maintain uCconicateof Cousentio xel6insure fnr Worker's C.mpen- DRAINS—FLOOR, R' ST TYPE CONSTRULTION
sation,as provided fur by Section 3700 of the Labor Cwle,for the performance rat he �.�
work for which this permit is issued. Ff1JES—PER TR
IAi /
❑ I lave and will n uintma Worker's C.arra,ion Insurance,aQ required by Section _ _.. v
370Oof1he Labor Care.forthe peefin.mofthe work her whichmis parmit is issued. GAS—IiA.SYSTEM-11 TS _ -I o •A `itJTCC.GRt 1' AI'N
My Worker's Compeallirn Lnsumnce carie,and Policy number am: �,y � UL' - k.
Carom: Policy No.: GAS-IiA.SYSTEM-(wsatt{(EA
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF/INUUSTRI.WASTE. T E
COMPENSATION INSURANCE BU NG (VISION FIEFS
(Thil"Ation need not hecomplemd ifthepernit is ftnone hundred dollars(SIM) GREASE TRAP
or lcssJ CK FEE �
[cenily that in the performance ofthe work lit which this permit is issued,l shall SEWER-SANITARY-STORM RA.2W Ill'.
not employ any person in any manner so as to become subject to the Workers Comped- ENERGY PEI
O Z sation laws of California.Duce WATER HEATER WIVENT/IiLECfR GRADING PEE
O Applicant
NOTICE TO APPLICANT:If,after making this Cenificme of Exemption,you should WATER SYSTESIT REATING
F ; SOILS FEE
bee subject to the Worker's Cammm
pemnm provisions of the Lnhrr Cndr,you must
com
Lakl forthwith comply with such provisions or this psmmit shall be deemed revoked. WATER SERVICE
Q
�z CONS'I'R=ON LENDINGAGENCY NEW ItF.SIDENT1ALl'hMB, SQ,IT. PAID —)am Receipt#
LJ O I hereby atTrtm that there is a construction lending agency forthe perf rmarri c of
[P. F the work for which this permit is issued(See,3097,Civ.C.1
TOTAL:U Lendsex Name
Lead rel AJdr„s AI
y 1 mail,that I have read this apmlicmion and sate that the above iof.manion', BUILDING FIiE
to correct.l agree to comply with all city and county recurrences and site laws relating to QTY. MECIIANICALPERMIT FEE
U Z building conntmdinn,and hereby uuthorim represv'nWtivex nflhir city ns enterurym rhe SEISMIC IEE
stove-mentionsd property for inspection purposes. PERMIT'ISSUANCE' co
(We)agme m save,indemnify and kcep hamlew the Ciry of Cis c naagainst ELECTRIC FE
liabilities,judgments,...fraud expenses which cony nanny wayacere,against sail City AL:1'ER OR ADD TO MECIL
PI.UMBI
in consequencethe gSTAN thispermit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00I CFM( ME CA
SOURCE RIiGULA'TIONS,
AIR HANDLING UNIT(OVER 10,000 CFM) CO .TR TI NT X
Signature ofAMlicant/Comraemr, Date I? HAUST HOOD(WIDUCT) HOU.I MITIGATION FEE
HAZARDOUS MAT17RIALS DISCLOSURE
Will the applicant or future holliingmerpmn storcorh.ndle hazuNous material HP,AYING UNLT'('1'0100,00a BTU)
as defined by the Cosentino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)7 HEATING UNIT(OVER IW,"BTIA
fens
O Yea AAJJ N. VENTILATION FAN(SINGLE RESID) PAID
Dam Receipt#
Will the applimm or Faure building occupant use equipment or dovices which BOLI ER—COMP(3HP OR 100,000 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management T
Dlxtricfl o BOILER—COMP(OVER 100,01X1 BTU)
❑Yes
I have read the haenedousnwtecials requirement,ander Chupterho5 mirth,Cali- AIR CONDITIONIiN ISSUANCE,DATE
fomiu H l r Sid ly Cods.Sections 25505,25533 and 25534.1 andersmnd thut if the NEW RESIDENTIAL MECH. SQ.FI'.
bo (din a any have a renan,rbar,,is my esspom,mility to notify mhe,acumantGIP
of h' stbein rartoissumaccolit C,ni rent✓=p:+9T
COmirimolaindrunut ' O Dae 4JqLISSUEDRY
OFFICE