S 3115 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO I I BUILIIING-ELECTRICAL PERFIIT NO. 3115
BUILDING DIVISION APPLICATION/PERMIT PLUMB ISIG.MECHANICAL.
_ BUILDING PROJECT IDENTIFICATION
�BUILDING ADDRESS: SANITARY NO APPLICATIO NN/SUBMI ITAL DATE
s Q RWrfhk
OWNER(�NAME: PHONE: TRACTOR'S NAME: LIC NO.1�S tom,._— ^ QF1. �O NIC CONTROL#
Al11TECVENGINEEW LIC NO: ADDRRESSS-L3[A1:1 •�2 Li
I7 O R.-22-
iCA
CONTACT': PHONE: 94 :5 BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
Y�'1:hettt �1 _ mss ❑ � ❑ ❑
LICLNSLECONTRACT SDFCLARATION Q'ry ELECTRIC'PBRMIT 1 - FEE' -
I hereby 11 on tl t 1 I' d I p f Ch pl 9( g JOB DESCRIPTION
oaz with S f 9OO(B fD .' .3.fohc larilmosicardPnfe- Cole andmyliczme is RESIDENTIAL:
u100 PERMIT ISSUANCE
N ly in f II[ c a d ❑tLIT CQ 1��1 4� ❑SPDWI. ❑KITCHEN REMODEL
Q,UU License CU. Lie.# 'W APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Qw Dnta Contmd r '
ARCIIITBC'1'SDF:CLARATION ❑MULTI-UNIT El STRUCTURAL
F rn PANELS
z O con zz 1 understand my plans shall be used as public records MODIFICATION
O Z UP TO 200 AMPS
p
L1 INTERIOR ❑CHIMNEYRFPAIR
F[rj FsWLicensed Professional _ 201-IBBIIAMPS IMPROVEMENT E]SWIMMINGPOOI,S
OWNER-BUILDER DECLARATION OVER IWB AMPS ❑IUOif REMODEWREPMR El DEMOLITION
W 6 1 hereby affirm that I nm exempt from the Contractors License Law name
50mu U following rennva..(Section 9031,5,Business and Pmfcomro ,,Code:Any city or countySIGNS P.LF.CTRICAL Zo [:1MH17R
3 W so which requires a permit to conctmch alter,improve,demolish,or repair any swcture
i-
,!!
� prior to its issuance,also requires the applicant For such permit to file a signed statement SPECIAL CIRCUI PMISC.
$ru�./]iI•�11
that he is licensed.unuuatto the provisionsorthe Contractors License I,me(Chapter9
G d40 (commencing with Section?000)of Division 3 of the lonamesstod Pmfnssions CWO)or TENOR METER OR POLE INS'('. COMMERCIAL'
F pv o c mal he is exanpt therefrom and the basis for the alleged exemption,Any violation of _ ❑NEW BLDG/ADDITION ElDEMOLITION
iC 4. Section 9031,5 by any applicant for a permll subjects the applicant In a civil penalty of POWER DEVIC is
ul�y ❑TENANT ❑FOOD SERVICE
m more than rivehundral dolor(SSW). IMPROVEMENT
Lo the work,the primary.
esionstmemyemployees with wages ed f as l.le(Se 7044, risnti e, SWIMMING POOL.ELECTRIC
�[FO
will dnthework,and Coals: stun rchar License
Once
at,,apply to
Business - 'fHl?H
wand'Pmfessions Coals: ON Contr ,r' Licence Laos sous not apply to an owner nF OUTLETS-SWITCHES-FIXTURES
progeny who builds or vides that
tsuchBacteria,and who does such conte himself or trough
sal own employers,provided thm such improvements are oat intendedoror offered far NEW RESIDENTIAL ELECTR SQ Pf.
own—,hnweveell hve'Ill harirof po m isat hedthinan aild or of completion,the SQ.FI'.FLOOR AREA S/SQ.FT.
own
e.1s uer will have Nc huNen of proving that he did nm build or improvefurpur
-
❑ stusowproperty.amexclusively cammdwithcontractors to OI
construct the purfect(See 704,Businessvnd Procedure CodefTheCommrchor,
Li-
censeLawdwsnotapplylnanownerofpmperlywhobuildsorimprovexlherwn.and QTY, PLUMBING PERMIT FEE
who contracts for such p jects with a commno,O)licensed pursuant to the Counselor
License Law. PERMIT ISSUANCE
❑ IraarWmptunder Sac. ,B&Pchaffivomman
waten Date ALTER-DRAIN&VE - ATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTE �\
I hereby affirm under pennity icene ofConeneoftheioname ingdedions Ceramic-
- Z'j C,J(J
❑(have and will maintain eCion 3700 of the
Code,
rthe Workersce open- DRAINS-FLOOR,ROOF AREA STORIES TYPE CONSTRUCTION
,Mien,its provided For mi Suction 3"1(Ill of the Labor Code for per(ormuaco nl the STORIES
for which This permit is issued. FIXTURES-PER TRAP
1 have vad will maintain Workers Compensation Insurance,as required by Section
37W ofthe Labor Code,for the performance oftbc work l'or which this permit is issued. GAS-EA.SYS'IEM-I INCA L S OCOGROUP APN
My W 'aCom nano lImo nee cdom Dmi,Policy p����er�r�i'
Carri�egr �s - I PolicyNn.: R X113210) GAS-EA.SYSTEM-OVER4(
S v O ERTIFICATEOFEXEMPTIONFROMWORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE.INTERC. i
(Thisaemion need notbccompldcd dimpermil is rnronchuninaddollars(SIW) s ° s BUICDIN 1 157DN PEEfik £ a
orlca,.) GREASETRAP PLANCHECK FEE
Icenify thnl in the perrormnnceof the work for which this permit is i....wk shall SEWER-SANITARY-S'I ORM EA.21X1 Fir
nal car,].,any person in any manner so as to became sobjecuo the Wnrkery Compen- ENERGY PEE
O ,Z smion Laws ofCrofomit,Dale WATER HEATER WNENT/ELECTR
O Applicant GRADING PER
NOTICETO APPLICANT.IL eftcnnaking this CeniCmmo of Excmptioq you should WATER SYSTEMG`REATINC, is
SOILS NEI?
hemmo subject to the Worken'a Compmtsnuon,.visna s of the Labor polo,you utas
forthwith comply with such Provisions or this permat shall he deemed revokeJ. WATER SERVICE
� z CONSTRUCTION LENDING,AGE NEW RESIDENTIAL PLMB. SQ.Fr. PAID
I Lemby urtinn that there isuwmwction l ugenry for the pertnnn:rn,:e of ale koceipt#
w the work ler enrich this permit is hcued 7;Civ.G)
Lenders Name TOTAL:
WLendefs Address TOTAL:
I ri fy hill 1 have read Elis a,di,at and:tt that ab 'nft anon is BUILD( ,FE
P. corzer,I g I ply with all city and c ly d OrdinateI Iafnglo QTY ,F MECHANICAL PERMIT ] FEE
building wnnmclon,and hereby authorize representatives ofths city to enter upon the SEISMICPE
above-mentioned prnlwny for inspection purposes.
(We)agree or save,indemnify and keep heroics,the City of Caperam,against PERMIT ISSUANCE ELECTRIC F E
Iinbiliso.judgments,costs and expenses which may in anywaynccme against said City AL'TEk OR AUU'TOMWH.
in asequence ofthe granting ofthis permit. PLUMBINGPLt
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Signature of ApplimnVContador Data EXHAUST HOOD WIDGET) HOUSING MITIGATION FRE
HAZARDOUS MATERIALS DISCLOSURE
Will the opplicarl or future building occupant store(ir handle h warlous material I(EATING UNIT fGh RaLp r(ITU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HHAq'ING UNIT(OVER OQWOFull V)
E3 yes INo PAID
VENTILATION FAN(SINGLE RESID) Ilme Rmcipt N
Will the applicant or future building occupant Aricase equipment Management
BOILER-COMP(3HPOR IOO,WOBTU)
mit hazardous air contaminants as defined by the Bay Ana Air Quality Menagmnanl A1,
District?
[3 yes YNo - - BOILER-COME(OVER I WAW BTU)
I have read the hawrdois materials requirements under Chapter 6.95 of the Cul i- AIR CONDITI ONER ISSUANCEDATE
Farm Health&Safety Code,Sections 25585,25533 and 25534,1 understand that if the NEW RESIDENTIAL MECH. SQ,Er.
M1nilJing doev nnlwrzenlly hn nmmnh shot it is myre,pomihility In notify the occupant
of e'rcyuireon come,d s be met prior as issuance nfu Cenifenm of Occupancy.
MIA
Ow l-alothe' dagent Date TOTAL: ISSUED BY:
OFFICE