S 1677 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE II'NO. 1677
BUILDING DIVISION APPLICATION/PERMIT PLUMBING—MECHANICAL
BUILDING PROJECT IDEN'I IF'ICATION
BUILDINGADDRfSS: SANITARY NO. At PLICATION SUBMITTAL.DAPI
G
N[R> AME: 19 ONI:. .'1'H TO NA>1E: LEE NO:
- �• NIC. 'ON'OR,4
i'!Il'IiCf IJGINEG LIC NO: AOI ':S: ❑
rr o
CONTnCI': �(� PlioNll: Q BUILDING PERMFIINFO
r I' ❑ Consultant Fees Paid by Applicant(Initial) HL❑DC ELEC1 yeUMB MECI I _
LICENSED(ON RACIOR'S DECLARATION f QTY ELECTRIC PERMIT FEE rrLvll/ Lrf�i/
1 hereby nmmt ma I am hermod under nrm;amw of chapter 9(comtmemcing JOB DESCRIPTION
WED, Ana Seer ear vodo)of Division Sof the Boone,amt Prom,sionx Cale.mtd my E«Amit RESIDENTIAL.
FOO x full farce an I PERM I ISSUANCE, 3�/ t
W- in 14 G p ❑SFDWL ❑KI'ICHIiN REMODEL.
aUU LicaLica •J AI'PhIANCfS-RF:SIDIiNTIAL C" El ADDITION ❑I'LUMHING RE-PIPE
N Q y Dale Contralto
ARCIII'IEC'1'S UEC RATION 564-G L s ❑MULTI-UNIT []STRUCTURAL
LetZOyz lunders.adney phre-hall berondirl blic mcnrds �'C-T,s PANELS MODIFICATION
OZ�L, UV TO 200 AMPS
El INTERIOR El CHIMNEY REPAIR
�mFW Licensed Profasaional 201-10011AMPSi IMPROVEMENT C]SWIMMING POOLS
6_~'a OWNER-BUILDER DEC.ARA'1'ION
K Y', BATH REMODEIJ HPAIR ❑DEMOI(TION
ref C 6 I hereby I firma that 1 on exempt from the Cnntmcmrs Licenm l.aw for the /.J
C U following nevem.(Section 9031,5.Bromeus and Pmic,.ions Calc:Any city lir county SIGNS ELECTRICAL HER C S:9,
TI
31i y which requires a permlt m eon.amet,alter.improve,demolish,aro repair any smiclum G C C(
f•'LL��' primo its issuances alsmm,me-theapplicaut ter such Mrniuo lite a signed statement SPECIAL CIRCU ITIMISC. ,1 G
W r that he in licensed pursuant to IM1e pro.wonsofthe Commands License Lvw(Chapmr9 {{
00 (c"Inlmencingw'uh SCCIIon9(MX))of Uivlsimt3aflhe Businesxandi'mtcnsions CWl)ar TEMP.MMEk OR POLEINST. COMMERCIAL
Q.d '
Z that he is exempt therefrom and IM1e b:sis for the alleged exemption.Any viola.inn of ❑NEW HI,UG/AUUI'DON El DEMOLITION
W R' Section 90315 pe
by any applicant lar a rmit subjects the applicant m a civil Penalty of MOWER DEVICES
tel-,� C1 TENANT' ❑FOOD SFJ2VICF:
not marc woe five t h propo dolours y cropl.
IMPROVEMENT
❑ Las owner of propuny.nr mycntpleycedo,utiwages ustheir(See compensation. SWIMMING POOL ELECTRIC
F will Jnthe work Cord, The
I,an, Law
nxule(Sm.91H111usineti< ❑OTHER
63 m and property
sionx CWe The Comodors Licence law Jces net apply m an tuner of OUTLET'S-SWITCHES-FI%TURFS
his own wM10 builds lir mtpmvm thsuch i and who docs such work himself orcad f M1
his Awn employeese provided that web onan old are not intended or offered for NEW RESIDENTIAL ELGC!'H
salt.If.M1nwcvaq IM1e building or impnrvcmcm is nnlAwithin Ane Ycsn of canbPlation.the SQ.IT.Il,OUlt AIt S
EA /SQ.1'1'.
erlwilder will bave the burden of pmving that undid nal build lir improve for pur-
pose of s
1, owner
mlb
Las owner of the pany,am exclusively contracting with licensed comrmmnre to
construct the Froind(Sec.mU4.Bus nd Prams o Code)Or Cnmmaots I I-
wlawdoesnolapplylnanoxnet Property who binds or improves thereon,and QTY. PLUMBING PERMIT FEE
who,dandi fnrsmd,p rices wish aumnnamr(s)InconwJ pursuant tithe Comrncmra
license law. PERMIT ISSUANCE,
0 1 am astern under See. .B k P C for els reason
Owner Date AUI£R-TRAIN%VENT-WNTER(EA) 7J 1 VAALLUXI ON
WORKER'S COMPENSATION DECLARATION BACK FLOW PRUI EC..DEVICE. / e/ 11.i
I hereby affirm under penally of perjtlty Ane of the l dluwing declarnim,r cr k/(-/
❑
[have and rill maintain a Cenibcateof Consent to mlf-insure for W'orkch Comlbcn- DRAINS-FLOOR,ROOF,AREA,COND. S'1 ORIES TY IT CONS'I'RUC'I 10h
,anon,av provided for by S¢linu 370ul the Labor Code lar Thu,ta k.mtance of Ills
work for which,his permit is i wed. FIXTURES-PER"IRAI'
I have and will m:dame Work—Crmpenaminn Ilulm ince,as required by Serum
3 lufthe"For Cale.for the perfomtanecufthe work forwhich this permit in issued. GAS-EA.SYSTEM-1 INC.4 OUTLET (OCC.GROUP APN
My W� kcrx Cm1iP�'n. I' I )Tnc caer tied Pohcy G
Cama�'!lyy� (I/'/" I e r Policy No.:bM Y GAS-EA.SYSTEM-OVER 4(EA)
CEH'l H:jCn'rF.Op F.XEMPI'ION FROM WORKERS'
CONR1I2NSAFION INSURANCE GREASEANDUSTRI.WASTE INTERCEI R
IUDING DIVISION ITES _
(Thi,ecction Aced urn bccnmpklcd ilEhccourt is firzonu M1mWnJ dollars($IIXry CREAST:TRAP
or least PLANCI G
I mosify Ilan In the per f nnunccnl the work lot wHen Ibis peril is issued,Ishuli SEWER-SANITARY-STORM EA.2(X1 I
not employ any Person in any manner m as to became subject to the Workers'Comper- li - tilCN
zZ Intron Law'of Califontia.UMee WATER HEATER W/VEN'I'/RLECFB
O Applicata GRADING FEF
y NO'HCE TO APIIJCAN'1':If,nlYar maAing This Cmiticmc nl Exmnphnn,you xbonW WAFER SYSTEMCFREATI.N`Gju
become subject h,the WorkeLs ComPensnlinn provisions of,he 1,N),Code yam must IItt SOILS FF
hmhw'uhmmtply with suchprov....amor lhls pvnnit shill be decmmrcvokN. WAFER SERVICE p
� Z CCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLh1B. SQ.FT PAID ¢ Rcacipla
V O l herebyvfhrthauhere is.mhdnm;mr lendiagagency for the perfoneance of
the work for which this pens.is issued(Sec.3199.Civ.C.)
V.
U lender,Name 'IDEAL:
Lender's Address TOTAL:
aI vanity that I have read.his application and state that the nerve information is BUILDING ITE
fro V2 corer,l agree to comply with all city and county onlarric,and state laws relating In QTY. MECHANICAL PERMIT FEE
U Z building consmetion.and hereby uethrriac representatives of this city to enter upnn,he SEISMIC FEE
uMwcineationed mr,s rty nor inspection purposes. PERMIT ISSUANCIi
(We)agree rob save,indemnify and keep harmless Ibe City of C,Vrino vgainq ELECTRIC PFE O
Iiabilllies,juJgmcnls.costs and expenses which may in any wayaccmeageim,said City AI.TERORADDTOMECH.
in nw,n mce of the granting ofthie peril. PLUMBING PE6
APPLICANT UNDERS'ANDS AND WILE COMPLY WITH ALL NON-POIN"I AIR HANDLING UNIT(1010.0X10 CFM) MGCHANICAI.IIHi
C O
SOU 'E RE GUI AT] at e L
r _/�/ " / AIR HANDLING UNIT(OVER IQ(XX)CFM) CONS'URUCT'ION'I'AX
nmreo Contractor 1 P.i "1� One'1 EXHAUST HOOD(W/DUCT) HOUSING MI I'IGA'I'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
W the apphnm or future building accupam stem of bundle hamNous material 1 IEATINGUNIT(TOi010MB'TU)
an defined by the nn Municipal Codc.Chapter H.12,nnA die IIeuIIM1 wW Safety
Code,Section 25532m)?
I! HEATING UNIT(OVER 101M)BTU)
OyTry7
Yes _ vENFILATION FAN(SINGLE BESIDE PAID
Will the u,limon or term mildne t use equipment or devices which Dac Street,,a
IP dbythen altoir Qu BOILER-COMP(3HP OR dDY"B'IU)
mit M1aeallous air contaminants us defined by me Bay Area Air Quality Management yf I Q
t iisvinl
11 ye, [IN BOILER-COMP(OVER IBD.000131TH
o (n�
I have read the hvardims mammas mquimmctas under Chapter 6.95 of the Cali- AIR CONDITIONER C/ ISSUANCE I1 DATE
foram llcullh ffi Safety Codc,Sano..,25505.25533 and 25534.1 un serdand That if the NEW RESIDENTIAL MECH. SQ.Fn
builJin not currently hav t,that it is my re,ansihility to nntifythe sternum ( C \ GJ
o1't a1 clno -.y ptmat ap{uunofu Ccnifi�m
T w
A
uthnrin gc f'V 4 )4c L: I ISS jEUBY � "Q5>
OFFICE