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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - EL4.CTFUCA '
BUILDING DIVISIONPLUMBING-MECHAN'C"
APPLICATIONIPERNIrr
BUILDING PROJECT IDENTIFIcnrlory
PrISIT NO 1473 .
L\7
BUILDINGADDRESS:
SANITARY NO.
APPLICATIONSUBMIlTA1, DATE
8SD S fa e5I✓
�_�,�t8
OWNITR2 NAVH: 1 PllO
u —, �e as3- o 0
CONUTACTOR'I NAME: LIC NO:
NIC
❑
CONIROLp
ARCHITEC'EfFNGINIiER: LIC NO:
ADDRISS:
CONTACT: PHONE:
BUIIAING PERMIT' INFO
❑ Consultant Fecs Paid by Applicant (Initial)
BLDG ELECTPLUMB MECTI
LICENSED CONTRACTORS DECLARATION
I heresy affirm that I an, ucenxed miner pram...., of Chapm, v (contmaneirg
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
with Section 0000)of Division 3ofthc Bnsines., and Prore,siae, Code. and my license is
in full force and affect.
RESIDENTIAL:
❑SFDWL [I KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
License Class Liep
Date Cnmmanr
El ADDITION [I PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
ARCHI'rHCTS DECL.ARA'I'(ON
1 understand my plansshall buried as public t... ds
PANHI-S
UP'102(X) AMPS
El INTERIOR ❑CHIMNEYREPAIR
PROVEMENT SWIMMING POOLS
TH ODIiIIRIiPA1R ❑F17 IOLITION
Licensed Professional
OWNER-BUILDHR DECLARATION
1 hereby affirm that 1 am exempt From the Commences himnse Law for the
281-1000AMPS
OVER IWt1AN1I :S
SIGNS EL.HCPRICAI.
fnllnwin, rcoon. (Section 0031.5. Bnsinuw and Professions Ccale: Any city or county
OTIIE�
which menaces a permit to construct. inter, improve, demolish, or repair any %waure
SPECIAL CIRCUIT/MISC.
franc In I,iunle, also rcyrim, We npVlicnm forsuch pcnnil to He ti A,redrtutemmitt
that he is liammd pars ant to the pmry m
s of the Comcra, Lime, Low Chapmr 9
�
TEM, SEE, MET ER OR POLE INST.
g with Sen]t1IXRofP,uio..3nrmeN..ire... and Pride,.ions Code) or
(Cmnencinilo
m
COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWI"R DHVICLS
Sect on 7031.5 by ashy tyaplicunt for u pcnnil "Eirsa the applicant ,, a chit Vcnalty of
not mare than five hundred dallmn 015001.
Ql, un owner afhhe pmpertY, err my employee. with wage. ue mcir sale Compensation,
will do the work. and the structure is not intended unaffected for sale(See 70,t4, Business❑OTHER
❑'TENANT ❑ FOOD SERVICE
IMPROV
�1
SWIMMINGPOOLELCCT C
and Professions Code: *Me Cn orecons 1 icense Law does not apply In nn owner nr
OUTLETS -SW PTCI-IIXTURES
property who builds or improves thereon, and whereas such work himself or through
his awn employees, provided that such improvements am sat intended or offered fur
NEW RESIDEN NA , ;LF, SQ FT.
SQ. FL FLOOR AREA
S/SQ. IT
sale. If. howerm, the building or improvement i%%old within one yearofeompletion.the
owner will M1me the burden of proving that he did not build or improve for per-
p rvc of sale).
C31, as owner of the property, am exclusively contracting with licensed c mmamn ph
P1
I�
TOT
vn,l u l In, pmJai (See. 7844, Bnsines and Pnde,xion, Code:) ]be Contractors Li-
censelawdoesnotapplymanownerofpropenywhobuildsorlmprovesthereon,and
QTY, PLUMBIN FEE
/i
who connot'sPalmer protea, with a contractors) licensed pursuant it) the Contractor
License law.
❑Ism axena uuma Sec. , B A4 P C for Nip rcas)a
APR ANSV
/
PERMIT ISSUANCE,
V
ALTIiR-DRAIN &VENT-WAIIIH (L'
Owner Dom Fe
VQ:
BACK FLOW PROTECT. DEVICE
WORKER'S COMPENSATION DECLARATIONEE I
1 hereby affirm tinder penalty of perjury one of the fnllou ing decltimtian.:
—N1L.GON
DRAINS- FLOOR. ROOF. AREA, COND.
F) I have and will maintain a cenufcote arComenl lowif-insure for Workers Comms
.noon, n, nr,,,d d for by Sedan 37000 the Labor Cade for the Permrnanae of the
511mar, IF'I'YPFCONS'HRUCHON
1XTURF_S - PFR TRAP
stock far which this permit r issued.
❑ I have and will maintain Worker's Compensation Insurance, its required by Secnan
3700of the Labor Cole, or the perl'onnance of the work for which this permit is issued
My Worker's Comfaminiun Insurance canis, and Policy numb, are:
GAS -HA. SYSTEM- I INC. 4 OU' 1' LETS
(KC. GROUP
APN
Carrico Policy Na.:
GAS - LA. SYST17M-OVER 4 (EA)
C13RTIPICATE OF BXEMI'TLON FROM WORKERS'
('ARHASFJINDUSTRL WASTE; IN'IIiRCI:PTOH
COMPFNSAI ION INSURANCE.
Ohix section need not he completed ifthe pcnnil is for one hundred dollar, S1001
or le".)
ofine work for which this permitis,ir, Coo shall
1certify O in the any amour
semploy any pershn in any mmmncr,o av to become sato{ons m he Workers Cooper.
mion Laws of California. Date
Apptie:mt
BUILDING DIVISION FEES
- -
GRHASE "I RAP
PLANCHECK PEE
SEW(?R- SAN] 'ITRY-STORM EA. 211111x1'.
ENHRGY FEE
WATER HHATER W/VI:NT/IiLEC'IR
GRADING FEE
SOLI 4 FEL?
NOTICE TO APPLICANT: If, after making this Cenifcme of Excmyo
ptimn, u should
become subjectw the Work,,, Compcnsminn provkiun, of the Lobar Code ,, , you nm
WATER SYSTEMcFREATING
lorthe, h comply with such provisions or permit shall be deemed re,oked.
WATER SERVICE
CONSTRUCT ION LHNDING AGENCY
l herthY affirm mut mere isarnngmmion lending ugencY For the permrhhr:na of
PAID
Die He iplN
NEW RESIDENTIAL PLMR, SQ. IT
the work for which this pvreat is ismcd (See.3 W), Co, C.)
'1 OTAL:
lenders Name
lender'. Address
I certify hist 1 base rcaA this application and vain Item the aMnre infomhminn i,
,
BUILDING THE,
QTY. MECHANICAL PERMIT FEE
sect. l agree nh comply with all city and county ordinances and vme laws relating tit
building construction, and hereby amborare representatives of oris city matter main the
SRISMIC FhE
aboveenentioned property rot inspection purposes.
(We) agree to save, indemnify and keep la tmleas me City of Catarina.,air,,
Iimbilirmn.judgmenae.cosuand expamm whichnd, in any wnyncwengainasaid City
in consequence of the granting of His permit.
1'ERMG' ISSUANCE
EI.HCIRIC FEF
ALTER OR pDD'I)M11[CH.
PLUM BINE
AIR HANDLING UNI'1'('TO IILIXO CFAD
APPLICANT' UNUHRS'I'ANDS AND WILL COMPLY WITH ALL NON -POINT
SOU,RCCEE'�/y GUTANONS. �J
�J_/�
/1 {D
MECIIANICAI. -E
CONSTRGCr10N TA.'
AIR HANDLING UNIT (OVER Io.Up CFM)
FtXHAUS'I H0N)U(W/DUCT)
Signature of Appltcat,Cammoor k—Utast
HALIRDOUS MATERIALS DISCLOSURE
HOUSING MITIGATION I -'i
I (EATING UNIT ('10 I0M1.(XN) LITUI
Will the applicant or future M1uilding...capons store or Fondle harardom Twcnul
ax defined by the Cupertino Municipal Cole, Chapter 9.12 and the Health and Safety
Cole. Section 25532(0?
HEATING UNIT (OVER 100,SX)11'1 U)
❑Yes Fl No
VIENILATION FA N IS INGLH R RSI U)
PAID
Will the applicant or furore bailding occupant use escarpment or devices which
emit hmardoux air contnminenu as defined by the Bay Area Air Qnulily Management
Data Raeciph p
HOILER- COMP OFF OR 100,00 BTU)
Dr, riefl
'TOMNI.:
BOILER- COMP (OVER 100,000 BTU)
[]Ye, [:j No
AIR CONDITIONER
litres read the M1mardous mamtiols myvirements under Chnpmr 695 aRM1C CnIi-
1'nmin 1lcaltb noSafetyt Coda, ea tion. 25585. 25531 end 25534. i mhderstmd that if IM
tai gdne,nmcurrently M1aveanmanl, thing ismyre.1. Glary Innmifytheoccupant
ISSUANCE IJATF,
NIiW HISIDRNfIAI. T1ECH. SQ. FT.
of
of abu tequimn¢no which must be met prions issunnm of u Certifcam ofOnuponcy
ISSUI3D BY:
Owner err authorized again Dae
TOTAL'
OFFICE