S 0550 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL pp ITND
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANIC L 0 5 5 0
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS.. SANHARYNO. APPLICATIONSUBVar AI.DA'D
21 eLS CA S V r} Y Qr�1 IAl 5 �
` Il _PIIONF.: — CO T( l'OR1 %NA :: �NLr LI�OyS3
VrW. 1 NIC CON'[ROLp
• ARCHITECUF.NGINEF.R: LIC NO: A DRF,SS: ❑
�v1 V ' e �.� L
CONTACT: PHONE: BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ El
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I Hereby Err not Thai Ear licensed aaher pmixmnv'.r Clarifier 9 mmenemg JOB DESCRIPTION
WOO won secuon llKKllofDivision3onhe Baseness and Dofessimnx Code.and my lkensein RESIDENTIAL:
FW. in full force and effect. PERMIT ISSUANCE
R W F ❑SIUWL ❑KITCHEN REMODEI,
aZW Date cc Class Centr APPLIANCES-RF_SIDENfIAL ❑ADDITION [I PLUMBING RE-PIPE
yQan Date—TSDECf
ARCHI'TECT'S DECLARATION ❑MULTI-0NIT ❑SODIFICTIO
F�y PANELS
Z p v�Z, I understand my plane shall rte nxul uc public recnr0.a MODIFICATION
Cz-M UPT0200AMPS El INTERIOR El CHIMNEY REPAIR
F4LM Licensed Professional 201-1000AMPS IMPROVEMENT'
Q -'I OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
C 9�6 1 hereby affirm that 1 am cxemp from the Contmmoh License Law for the OVER 1000AMPS ❑OATH RRMODELIREPAIR ❑DEMOLI'I')ON
WIigla
owing ream.(Section 703)5Mess
.Businessand Priam CWe:Any city or county SIGNS ELECTRICAL El EITHER
LLpti which requires alos r It,cloobion. ll p va.dainolikh, ,,repair.,,ImsturcArf*A�M!�/
prior to ts issuance.alsoq s the applicantfor such pc it to file a signed,tatement SPECIAL CIRCUIT/MISC.
Eby''
'hat he is I mersedpursuant tthe proviomm,ofth C t t r License La (Chapter9
uISpO (commencing with Section 7100)of Divismn 3 of the laud mss and Pmlessions Code)or TEMP.MET ER OR POLE I NST. COMMERCIAL'
QL 0.a M 'hat he is exempt Iherefmm and the basis for The alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOI.ITION
u' Section 7031.5 by any applicant for a Permit xubjecs the applicant to a civil penally of POWER DEVICES
F-ZY not more than five Imndrol dollars($50UL ❑TIiNANT ❑FOOD SERVICE.
f=a ❑has owner of the property.or my employees with wages as their sole compensation. SWIMMINGPOOLELECfRIC IMPROVIiMF,NT
ce F.0 will du the work,and the xtmewmlx mol lmmoJed nnsf[ered for role[See.9(W3.Pu incl ❑OTHER
,kidd ilr ac and Rofcscione Care:The Contractor's License Law docs not apply'o an owner of OU'I HIS-SWITCHES-FIXI ORES
LL property who builds or improves thereon.and who d'ws>uch work himselfor(^rough
hie own employee,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTS SQ FE
sale.If,M1nwneq the huilJing orimpmvcmem is udA within on eyemofcotnplelionthe SQ.Fn FLOOR AREA S/SQ.FT.
mer-builder will have the burden of proving that he did not build or improve for pur-
,oc aLsalc).
❑ 1,as owner of the impiety,am exclmivcly contracting with licensed contractors in TOTAL:
ons0um the project(Sec.9043.Business and Professions Cade:)The Contractor Li-
cewLay,does not apply it,an owner of property who builds or imprimis Thereon.and QTY. PLUMBING PERMIT FEE A
who commas for.smmh pmjceu with a enntrecmge)licensed ptnsuanl to the Contmctods
License law. PERMIT ISSUANCE 'A
I am exnupl under Sec. ,B&P C far da reason4 11 V
Owner Date ALTER-DRAIN&VENT-(PATER RA) All
9 VAA�LUATION
• UN ERS 'OMPBNSATICN DECLARATION BACK FLOW PROTECT,DEVICE 'Q,I- M /.Beya
(hereby liffim under penalty ,f,,j.,oncoflhe following declnoinar,: Lr 9CG-
]I have and will maintain a Certificate of Consent to self-insure for Workers Camper- DRAWS-FLOOR,ROOF,AREA.COND. - a��.��
salma,as anviJcd far h Social 3900 of the Labor Code.fav the -,Tri Z, TYPE CONSTkUCfIOn
I Y• pnformaone of the l
work have
this maintain
in is.cued. I'IX'IURES-PER TRA(' h��/V�
i]1 hail and will maintain Workers he ante of the w rkfor which
h his per by Section ,
My0orker ofils,Labor C'defor n Insurance
er and work for athispermitisissued. GAS-fiA.SYSTEM-1 INCYOIfTLITS
OCC GROUP MIN
My Wnrter's Crmpensmion Insumncc carrier and Policy number vie:
Cumcc Policy No GAS-EA.SYSTEM OVER 3(EA)
CGNTIIgCCO OF COMPENSATION
INS FROM WORKERS'
COMPENSATION INSURANCE GRFASIJINDUSTkI.WASTE INTERCEPTOR
(This section need not be completed if the permit is Gxonchundred dollars(510) BUILDING DIVISION FEES
orless) GREASE TRAP
PLANCIIECK PEE,
toy any thatmthe perfornmer oOnewaryfor whichthis permit is Issucd,lsn:Jl
oil employ an SEWER-SANI'T'ARY-STORM EA.200 ll'.
Y Y Pelson in any manner m as m huome subject m the Wnrken'Cnmpen- ENERGY FEE
Z Z satins lawn o(Calilinnia.Uwo WATER HEATER WNENT?LECTR
Z Applicant GRADING FEE
y NOTICE TOAPPLICANT.If.alter making
nIt C ikioloc of Emulator,dyoushould WATER SVS'ILM/fREAI'IN(i
? become subject y the Wnrkere Comlwn. iis provisions of'rte Labor Cole,you mux' SOUS FEF.
W forthwith comply with wch pmvizions...his penniLcnall Ti,Jamal revoked. WA'1'FiR SERVICE
a �
D CONSTRUCTION LENDINGAGENCV NEW RISIDC:NTIAI.PIMB. SQ,Fi. PAID
V (far by ami hdii, vnere issued( ofconstructionB lending agency for performance of Dam Receipt
V. f~-I Inc work for which this permit is issued(See 1090.Civ.CJ
OLender's Name TOTAL
:
U Lenders AJdrea TOTAL:
1 rarity that 1 have it his application and late Thai the abrve information is BUILDING TE
to .,act.1 agrre m comply with all city cad county ordinances and.vae law.mlming to QTY. MECHANICAL PERMIT FEE
L.l Z building con4runion.and hereby authoriac eprezcntatives ofthis city menarulem the SEISMIC FEE
.move mentioned property liar inspection purgsses. PERMIT ISSUANCE
(We)agree to,cave,indenatify:nd keep nanmlens the City of Cu,sw iso against ELECTRIC ME
Iianilities,jmIgni coxa and expeves which may in any waYacente against said City ALTER nceORADD'IOMECH.
in quence of the Brumm,of his permit. PLUMBING PEI?
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(IQ 111."CFM)
SOU .E REGULATIONS. MECHANICAL PEE
L
AIR HANDLING UNIT(OVER 111,000 CPM) CONSTRUCTION TAX
Si Enure ofApplicanaComme D' e EXHAUS'THOOD(WIDUCT) HOUSING MITIGATION PF.Ii
HA' UDIP ATERIAIS DISCLOSURIi
Willtheapplieamrnfame uildmg necupannmro or noodle h:nznrdous mammal HFAI'INGUNIFEMBIBDITIB'IU)
as define:l mum Cupeninn Municipal Cale,Chapter 9.12,initial 11.11h and Safety
Code,Section 25532m)? HEATING UNIT(OVER 100.000 BTU)
❑Yen DNo
• Vr,"LA'1lON PA N IS INGLE RES I D) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt N
emit hvardou.c air connotations as delincd by the Bay Arca Air Quality Management BOILER-COMP(3HP OR I W,IIW BTU)
Distrin! TOTAL:
Cl Yes Fl Nil BOILER-COAIP(OVER 100,000 BTU)
I have cad the hazardws mamdak mquiremcnls under Chopin 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
filaria Ilmllh&Safety Calc.Satinns 255(15,25533 and 255,0,I mvkalnid That if 0c NEW Rli$IDENTIAI.MSCI I. SQ.1'f
huilding date nomurten0y hmw¢n:mtnhunlis my exlmmihl Goy lanotifyineseupvm
of the rgainer ems which blow be met prior to issuance of a CeniOcne of(kcuplan,
Owner m avlhnriice again Date TOTAL
ISSUIiU 14Y
OFFICE