S 1715 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAI, Pe TT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING.MECHANICAL J 1715
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICA)'ION SU13MI PDd.DAI
L ct
OWNERS NAME PHONE: CONTRACT'OR'S NAME: LIC NO'. NIC CONTROL k
v
�I ARCHI'IECT/ENGI HER LIC NO: ADDRESS: r% ❑
CONTACT':iiir, �7`V PHONE:ysf.d fj I' BUILDING PERMIT INFO
{��� ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MiCfl
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herehy afrtm that I in licensed under Provisions of Chapter 9 kammencing
WOO wh SecJOB DESCRIPTION
ittion7000)ofDivision 3 of the Business and Pride . PERMIT ISSUANCE -
des.... Code.andreylicensers RESIDENTIAL,
W
LWin full
❑SFDWL ❑KITCHEN RIM
O
DE
O Lia. YG J G QUU LcensAPPLIANCES-RLSIOENTIA. []ADDITION [I PLUMBING RE-PIPE
Z or
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
y-dZ Iunderstand mYplans shall be used ns public records PANELS MODIFICATION
NEY
_W UPT02WAMTS [I INTERIOR ❑ IMREPAIR Licensed Pndesai.nal 201-10NAMPS IMPROVEMENT E]SWIMMING POLLS
0.'W6 1 herehy u0inn h �lum lex In�ti Rolm the Contra�o
O r's License Law for the OVER IIXNIAMPS ❑OTHER[IBATH REMODEUREPAIR DEMOLITION
a.U fallowing reason.(Scalnn]1131.5,13rxincss and Profc.vion.Cada.Any city or county SIGNS ELECTRICAL.
when reyulrex a permit ra uhm,the neo,improve,demolish,or repdr any swment
h I I .. u 1 I N PPI or the
suchpe n is Law(Chapt eel SPCCIAL CIRCUIIIMISC
thath I' IP un 0 t Ilh C t t L Iw(Chapmr9
'00 (conm.ts'ty wth Su'Yon 7000)ufO vso 3 (lire Basics, rodP f bus Code)or TEMP MI..]ER OR 1'01.1 INST. COMM RCIAL:
tha he iv exempt Forcer'rnin am]the h:nls lriThu alleged cxctnptin i.Any viobuion of El NEW BLDGIADDITION ❑DEM01.1'f10N
I��m Secllnn]II11.5 by any applicant for e permit subjects the applicant wacivil penalty of PaAVER DEVICES ❑'TENANT ❑l'GGD SF:RVICIi
Om mote quo five hundred dollars 0500) IMPROVEMENT pl,mowner oft he property,army employees idt wages,nes buir,alc compensation, SWIMMING POOL.ELI:URIC
will do ilia work,and the structure is not intended or oncred for sure(Sm.9194,Busines, ❑OTHER
L m vnd Prof sim,Cole:floe Comorri Li,...e L+w docs not apply,,an owner of OUTLETS-SWITCHIii-FIX'I'UR17Sof
properly who build,ar improves dreram,unit who does such work himself or througM1
his own employees,provided that.such improvements arc nut intenJed or offered for NEW RESIDENT[A].ELECTk Pf.
sale.If,however,the building orimprovemenl i.s.sold within one ycaro f tompletion,Ne SQ.FE FLOOR AREA S/SQ.IT.
ownenhuiider will have the burden of proving that he did not build or improve for pur-
pose.(sets.),
❑ L as owner of the property,an exclusively connecting with IicensW contmmors to TOTAL:
construct the pro)ect(Sac.]044.Business vnd Pmfe,um,Cale:)Ina mrracmr,Li-
censeLaw dms not apply to mowner of property who build,m improves thereon.aid QTY. PLUMBING PERMIT FEE
whincontruna for such projects with u etmmenods)licensed pursu at io the Committees
License law. PERMIT ISSUANCE
❑1 am exempt under Sec. .B&P C far this reason
ALTER-DRAIN&VENT'-WATER(RA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury ane of the following declarations:
I have and will maintain a Certificate of Conxnuo self-insvm for Workeh Compaq- DRAINS-FLOOR.RO)RARU. STORIES TYPE CONSTRUCTION
sation,as providW for by Section 3700 of the labor Code,for the performance of the
work for which this permit in ism N, FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
]1NI of the LhorCole,for the N,fonnanceinfthe work for which this permit is issued. GAS-EA.SYS HIM-I INC.4 OUTLETS OCC.GROUP APN
My Worker' Cu ration lWurunee carrier and P.licyn roe: GAS-EA.SYSTEM OVER 4(EA)
Currier: over Policy ticYr.
CERTIPICA'1'Pl EXIiM1T10N FROM WORKERS' GREASEANDUSq'RI,WASTE IN'IERCL'ITOR
COMPENSATION INSURANCE. BUILDING DIVISION FEES
(Thowetiun need not Im,up hpod,ftheperot i,hoonohundraddolloo(SI00) GREASHTRAP
or lase) PLANCHECK FEE
(certify lhuGn dna perfnrm;mce aft aworkG which lhla permit i,ixsved,lehall SEWER-SANITARY-S'IORM ITA.2011 EL
nmemployuny pe mniany mmnne or Ol not to the Workers'Comped- ENERGY
FFJh
z saint Luw it a d� 'u. )
WATER HGAI'IiR W/VIiN"FIELIiCTR
z Applicant tBUILDING
p) NOTICE'1'O AI'I' CA 'I",ll;xl'Icr n t g ua n tlicaa of F,xemption,you should WATER SYSTIiMlI'RIiA'I'INC
f become subject I the WnrAcr's Camp nxl Tun proviniinn of Nc Labor Cada You most s
Lakl forthwith rustily with such provisions his permit nhdl be deemed revoked. WATER SERVICE
P Q
GDNSTkDGI'1DN[.ENDING AGENCY NEW RF.SIDEMI'IAL 1'LMB. SUPIL
L) OThereby affirm that mere iso cnnstmdian lending agency fonhe periormunee of uvV Receipt
(, the work for which this permit is issued(See.3097,Civ.C.)
OU Lenders Name TA
W Lender's Address TOTAL:
0. 1 caddy that I have read this application and xmte that the above information is
tF-t fA correct.l agree to comply with all city and county ordinances and state law's relaing to QTY. MFCHANICALPERMIT FEE SEISMIC FEF.
U Z building construction.and hereby authorize representatives ofthls city In enter upon the
Ij
above-mentioned property for inspection purposes. . PERMIT ISSUANCE ELECTRIC FE�-E
(We)agree m save,indemnify and keep heroics the City of Caperton.against e
liabllities.judgments.costs and expenses which may in any way accrue agmost said City ALTEk ORADDTOMECH. PLUMBING
in consequence of the griming of this permit.
APPLICANT UNDER STANDS AND WILI )h1 (WITH ALL NON-POINT AIR HANDLING UNITCTO IOJIOOCPM) MECHANIC
SOURCI 'GIILATI VS. e
AIR HANDLING UNIT(OVER 10.0X0 CFM) CONSTRUCSigndurc L pplicanl/Uon rEXHAUST HOOD(W/DUCf) HOUSING MEE
HAPARD(U, h1ATHR1AIS DISCLOSURE
illtheapplicamurfuture wilding occupant store or handle hazardous material HE UNIT O'D lfl(1,0NNI BTU) ( � 2(�
as defined by the Cupe Municipd Code,Chapter 9.IL and the Health and Safety
Colo,Section 25532Mi a HEATING UNI'I'(OVER 1X).000 H'1'U)
❑Yes �No VENTILATION PAN(SINGLE R&SID) PAID
Dace keceiptp
Will the air co Ira or future building by the B use.Air ant or devices which BOILER-COMP(JIIP OR I(X],IXX]BTU)
emit hvzallous air co mntlmm�s ux detinnl by the Bay Area Air Quality Matagcmem 'TOTAL:
District? BOILER-COMP(OVER Hp,000 BTU)
[:1 Ya, No
Ih,,e rad the barurdous materials requiroments under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
f Ia Health&Safety Calc.S,,Ii 255115,2551 l d 2,1534.1 undrmvnd that If the NEW RESIDENTIAL MUCH SQ.FT. '
huilAings our' buvcnlem hist ns Ililym no fy lha ecnpard ( O
ofth r2i IrteP t nodi hem Ari mi..mre'd Ansim .f0c
Owncrn IhnrircA vgcn ` ] ISSUED BY:
OFFICE