S 3046 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.F.I.ECrRICAI. PlitIT NO. 3046
BUILDING DIVISION APPLICATIONIPERMIT PLOMRING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLI��^^I ION SUBMITTAL DATE
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OWNERS NVkML: ]�RoPE1ZTlF5 PHONE: CONTRACTOR'S NAME. LIC NO'.
J(�-(�- NIC C(Nl
l 'ROLN
ARCH'1'E GIN R: LIC NO ADDRESS:
r �ac +ew q�s5sc� c6Z(a ° o
CONTACT, y P 8.,,,r��, It ILDING PERMIT INFO
=1 /tel O ❑ Consultant Fees Paid by'Applicant(Initial) RL ELISCf/ PLUM MECN
LICENSED CON TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE Lrh/
I hereby antro that 1 am he...at under provisions of chapter 9 Nmourenem, JOB DESCRIPTION
OaZ with SeNan RXG)of Division 3 of the Business and Professions Code.and my license isRESIDENTIAL:
4100 PERMIT ISSUANCE ,��
F In full RecruiteBucr ❑SFDWI, ❑KITCHEN REMODEL
ae UU Liceme Class Lic.R APPLIANCES-RESIDENTIAL. []ADDITION Ll PLUMBING RE-PIPE
HZ41 Doc Contract.,
an¢a. ❑MULTI-UNIT []STRUCTURAL
ARCHITECTS G A'TI N MODIFICATION
b)ooz ) PANELS
Z Oy2 Iundersmnd my Gla r be us las Ps i�_ r l ��`///
_ UI'To 2(XIAMPS �Z. GLV B['NTF.RIOR ❑CHIMNEY REPAIR
Oytag Licensed Professional 201-10IVAMPS ,IMPROVEMENT ❑SWIMMING POOLS
ZY5; W ER-BU Illi > RATION OVER IIX%TAMPS ❑BATH REMODEUREPAIR ❑D17MOLITION
6'W Q I hereby erlint di I am ex mpl train the Contractor's License Law for the
(1150 a U following reason.(Sec' 703 1.5,B sinew and Professions Code:Any city or county SIGNS ELECIRICAI. ❑f7fFlliR
tar 3�y which requires a panni, ,,c,momi ,alcor,improve,demolish,m repair any structure
X4.06 print.its ionance,aku"aim,mcapphem,fmwch Permit file.signedstmement SPECIAL CIRCUIT/MISC.
Ihmheisliamsodparsoanuo lheprovil.m.fth,C.macurts license Low(Chapter 9
apo Ic.mmencing wit.Section 9lg0)n(Division 3nRM1a Business and Pmlessinre Gtde).r TEMP.METER OR POLE INST. COMMERCIAL_
6 q m C tom he in exempt therefrom and the basis for the alleged exemption.Any violation of ❑ EW NLUG/ADDITION ❑DEMOLITION
4Xl 4N, Section 7031.5 by any applicant for a permit objects the applicant a civil penalty of POWER DEVICES �ENAZ ❑FOODSERVICE
nnnn.m than five hundred dollars 05(ft PROVEMENT
�=Q1]I,as owner of the property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC - TIER
L.m wdl do the wurk,and theswemre is not mtendedo,offered beside Set 70,14 Bmineks
it Promssions Care:The Commnar's Licenu Law does not apply to artowner Q OUO.ETS-SWITCHES-PI%TUFFS
property who builds or improves thereon,and who docs such work himself nr through
his awn employees,provided Thal such impmvemenn arc not intended orr.Berad for NEW RESIDENTIAL ELEC 11 SQ
sale.If,however.thchalldingor improvement is soldwilhinone year ofmmpletuarthe SQ FT.FLOOR AREA ASQ,IT.
owner-builder will have the burden of proving that he did not build or improve for par- n G/1
pose of sola.). TO11, / U •t
❑I,as owner of the progeny,am exclusively contrenin,with licenced conuagnrs t. PP-- L v
.n.hurl the project(Sec.7014.Business and premodern,Code:)The Contract.,.Li-
censeUsedoesnotapplylnunownerofprnpertywhohuildsorimproveslhereon,and QTY. PLUMBING PERMIT
who commas for such projects with a contractor(s)licensed pursuan to the Convenor's
License Law. PERMITISSUANCE
❑I am the
under See .B&P C far nils canon
1LP-71ry
ALTER-D14AIN&VI7W-WATER(EA) VALUATION
Date
. Ownerlhereby alWORf I(1.�COMP-rallyUul DECLe't tolowinga '.inns: BACK FLOW PROTECT D12VICE /OP coo ,
❑I have and will reainm JQ n4.Jcamof CnnonnnCdf-Insure fnrpeH once of�ihe DRAINS-FLOOR.ROOP,AREA,CoND. STORIES TYPECONSTRUCTION
worn,as Provided for h M e� l�he 11,1 n�A�ftjm
work for which this perm sad I (,r IJ D _ FIXTUR[S-PIiR'TRAP
❑I have and will mason I cake Compensation I...move,as mTL by Secdnn
37Ylof the Whsv Cole,f eperformx.ceollhe weak for which lhi. nit is rowed. GAS-IIA.SYSTEM-I INC.J OU'I'LETS OCC.GROUP M'N
My Workers C.mpensatit sumnce carric,ead Policy nambcr.m: GAS-EA.SYSTEM OVER 6(CA)
Cartier: I'micy No.:
cli"U I GREASE9INDUSTRL WASTE INTERCEPTOR
INSURANCIi - BUILDING DIVISION PEES
(Thl .lanneWnmbaemu,homdiflhe pennilis foronehuntlrcd Jollurs(Slflfll GRF.ASETRAP
nr
loss) PLANCHECK FI;R JO
Icmifythm in lhu iwrfnmwnce of the work lbr whichthispemut isinsueJ,Ishall SEWER-SANITARY-STORM IIA.20 Fr.
co
t employ any person in any runner sa nm
s ,,become object'.the W..keci Con.peit- ENERGY FEE '2A
O 2 .iron Laws ofc..lifomin.Date WATER HEATER W/VENT/F.I.FCI'R GRADING 17EE
0 Applicant
rNi NOTICE TO APPLICANT If,after making this Cenificate of Exemption,you should WATER SYSTEM/TREATING SOBS FEE
f" became subject to doe Worker's Compensation provisions of the Labor Cude,you must
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
J Q
CONSTRUCTION LENDING AGENCY NEW RESIDIulJAI.PLMB. SQ.FT. PAID
U RaciplX
LlQ Thereby affirm that them is acunswmion lending agency for the performance of
the work for which Ibis petmil is issued(See.3097,Civ.C.) TOTAL,:
Llfender,Name Z
Lenders Addmss TOTAL: ,l
1 rectify that 1 have read this application and state Nat the above Information is RUILDI
Fr 0.V, correct l agree to comply with all city and county ordinances and slate lnwsmiding I. QTY. MECHANICAL PFRMIT FEF SEISM T �! f0
VZ M1uilding ttmstnmti.n,anJ hereby aumndre represendtives of mss city mance,upon the .t
above-mentioned Property for hopection purpows. PF.RMG'ISSUANCE 35,5C) ELEMRI zEE
(We)agree to save,indemnify and keep harmless the City.f Cugaimm�against
I
liabilities.judgmemhcosts and expenses which may in any way accrue against wiJCW,'LO ALTER OR ADD TO MECN. ,W PLUMH GFEE 3aSG
in consequence of the,mming of this pnmit !�� G
APPLICANT UNDERS'TA N US AN D WI LL COM PLY WITH ALL NON-POEM' AIR HANDLING UNIT(TO Espor CFM) MECHANIC FEE 27 ,5C
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.001)CFM) CONSTRUCTIO TAX
SignamreofAPPlue.nt/Commmo, Data EXHAUST HOOD(W/DUCI HOUSING MITIGATION FEE
H"ARDOUS MAT ERIALS DISCLOSURE
Will theapplicam or future build,.,aeupnm It em handle ho,milus malloal HEATING UNIT(ID IW,m)BTU)
as defined by the Capomen Municipal C.E.Chapter 9.12,and the I Icahn and Safety
Core.Section 255320)7 HEATING UNIT(OVER AXIL)RTUI
❑Yes 0 N VENTILATION FAN(SINGLE RESID) PAID
Data ReceiPlX
Will the applicant or future building.ccupant use equipment or devices which BOILER-COMP CHP OR 100,000 BTU)
emit hemrdum air contaminants as demand by the tiny Area Air Qaalily Management
Dislnct? BOILER-COME(OVER LW,OW BTU)
EJ Yes ❑Nn
L have read the bvuNo r,ouncialn matimmcnB under Chapter 6.95of the Ceti- AIR CONDITIONER ISSUANCE DATE
form.Health&Safety Gide,Sections 25505,25533 and 25534.1 understand Thal if the NEW RESIDENTIAL.MECIL SQ ET. / D Z•! +' 8
building does not currently have a tenant,that it is my responsibility to unity the occupant
of the requirements which most be met prior to issuance of o Cenificam of Occupancy. '7 T
Owner oriuthurioed agent Date TOTAL' 21 1 ISSUED BY:
OFFICE