S0001B0190 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 50001 '0 0190
BUILDING PROJECT]DENT'IFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT(
i o se, ►o-7w rn"Lo-\X_, 6uv� e 67_ ?
OWNP. 'S NAME: 1J I�x PHONE: CONTRACTOR'S NAM1 E: LIC NO: NIC CUNTROLp
-102) 4~I I 8u kp ' C14-
110
ARCIHrFCIIENGINEER: LIC NO: ADDR SV ❑
CDN'I'Af:'I': PHONE: ICY -J BUILDING I'fiRMl'I'(NPU
PIrp6`� 1 nam- ' 2 ��H-� ❑ Consultant Fees Paid by Applicant(Initial) BLDG El ECT I'LUNIR MEC
!M V �J oa��lf � d ❑
LICENSED CONTRACTOR DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby anion mar 1 am licensed ander provisions of chapter 9(commencing JOB DESCRIPTION
OoZ with$minn 9(Xp).f Division3.f the Huniness and Professions Code.and my li<enseis �--� RESIDENTIAL'
TD O O PERMIT ISSUANCE
K WF- L ane Class dcRcct. 0SFDW'L ❑KITCHEN REMODEL
QUU License Class Lica APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
N Z W Dan Contractor
vQy ❑MULTI-UNIT El STRUCTURAL
ARCHITECTS DECLARATION
F,lAz l understand my plana shall he used as public records PANELS MODIFICATION
ZO UP TO 200 AMPS
p ❑IN'I'IiR10R ❑CIIIMNEV REP.11R
Licunaal Phot'cnaiomd IDI-HVIOAMPti IMI'kOVEMF.N'I' SSW IMMI NO POOLS
OWNER-BUILDER DECLARATION OVER IB(N)AMPS Q PATH REMODEIJREI , t iMOLITION
q 1 hereby aBirm that 1 am enempT from the Cnnmuumds Liccnu Law let me
EX,
X 3 m U following reason.(Section]0315.Business and Professions Code Any City or county SIGNS ELECTRICAL Cl OTHER
ywhich requires a Permit to construct.Other,improve,demolish.or repair any onacare e
F•�Otn j prior to its issuance,also requires me applicum for such permit in file a signed 4atea¢ot SPECIAL CIRCUIT/M ISC. d(nl
� } thin he is llcemud pnnnammme provisions of The Commerce,License Law(Chapter 9 R .
(commencing with Section 3 oftbc Business and Professinne CWcl or TEMP.METER OR POLE INST.
a a e 2 that he is corrupt therefrom and the basis far he alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEn10LITION
; may Section 703$.5 by any applicamfor.schrolmbjeca he applicant To.civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
n more Than rive hundmd dollars($5110). IMPROVEMENT
,=0Q 1.as owner of the pmpcny,or my employees with wages as Their sole compensation, SWIMM ING POOL ELECTRIC
will do The work,and The suucere is not intended or offered for sale(Sec.I(H4,Business ❑OTHFiR
=Fm
G 3.. roil I'ndecsinns Code:The Commcurzx Liccnu Law Jces not apply In an avner of OUThETS-SWITCHES-PIXI'URLS
pngrcrty who builds or improves thenar,and who does such work himsdfa through
his own employees,provided that such Innpmvennnts are not intended or orferud lin NEW RESIDENTIAL ELHC'1'R 5Q PI'.
xale.lt.however,the M1uildingor ingnnvtment ivaold within ane ycarofcomd"on,me SQAI'.FLOORARHA $/SQ.Ff.
mbuildcr will have the$amen of proving rhm he did not build or improve iia nt- ',f^S
q% of'.1,O TOT V
m rmner of the popery,ran exclusively contracting with licensed contractors in
construct the pmicer(Sec.70,FL Business and Pr.fession%Code:)The Conwcturs Li-
cinve Law docs not apply m an owner of propeny who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a mmracmr(s)licensed paramnuo the Conractot
License Woe. ,. PERMIT ISSUANCE
❑Tam exempt on ,B&PC nthis awn
ec ALTER-DRAIN&VENT-WATER(EA) VALUN'ION
pw�n ° 7 /� / {'
• iY. S MPENSATION DECLARATION BACK PLOW PROTECT.DIiVICIi ...) I .3I herenr' ",alEw p, ran nfine followingdeduroeoncI hmu and wit rtefcmtofCn,,wmo elf-insure for Workcex Connpcn- DRAINS-FLOOR,ROOF.AREA.COND, TORIIiS 'I'VPI!CUNS'TItUCT10P
sutinn,as pnoided for by Section 391X1 of the Luton Code,for the performence of the
work far which This Proud,is is.cued FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Smtinn
3700of the tabor Cord..for Ne perfmarsureof the work for which this Tamm,is leaved, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compeneamm Insurance carrier.nd Policy number are:
Comer; Policy No.: GAS-FA.SYSTEMOVER 41CA)
CERTIFICATE OF EX12MIMON FRONTI WORKERS' GREASMNDUSTRL WASTE IM'ERCF.PfOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
IThisuctionneederabecomplered ifthepermit is for one hundreddollam($100) GREASETRAP
PLANCHF.CK FEE
or Ices.)
Hominy Thain me anylomnecofs t work for subject to Front Workers'
SEWER-SANITARY-STORM EA.21X1 Of.
not employ any pcnnn in any manner so as m M:unne subject m The Wmkeri COmptm ENERGY FEE
Z sutinn lavu,of Califomia.Dom WATER HEATER W/VENT/ELECfR GRADING FEE
Z Appllwm 1 .
NOTICE 10 APPLICANT:If,uuer nuking this Ctnifcale of Exemplum,you should WATER SYSTEMOREAd INC, f_
h SOILS FEE _J
hcona subject to the Wmh pro Colons on this provisions of the Labor Crain,you must
� r forthwith comply with such provisions or this perms shall be deemed rivalled. WATER SERVICE
PAID
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL('LMB, SQ.FT PAID Da¢ ccipT p
V 0 (hereby affirm That mere is a construction lending agency for me performance of
— the work for which oris permit is issued(Sce.3099.Civ,C.) TOTAL:
0 Lender's Name
U
Lenders Address TOTAL:
} G 1 cenify that 1 have read this application and%rate that The above information is I F
iF. N torten.I usres,to comply with all city and county ordinances and state laws renting to QTY. MECHANICAL PERMIT FEE SL15MIC PF,E
U Z building construction.and hereby anthoriec representatives ofthis city menter upon The (�
ahovu-mentioned property for inspection purposes, ! PERMIT ISSUANCE \ I H I:I.ECTRIC FEF. 31 / J lo
(Wel agree m save•inden r y and keep namless the City of Cupcnino against
liabilities.judgments,.,I,..d expenses whichone,a any way acemeagair,I,rud City ALTER OR ADD TO MECH PLUMPING FEE
in consequence of tlm grading of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS. 73
AIR HANDLING UNIT(OVER IOJNXI CFM) CONSTRUCTION TAX
Signature of ApplicanVCommctm Date EXHAUST DOUG(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the upplicam.rfuture building aculsom store.,handle hmadim,mmeri.l HEATING UNIT(TO]OBJET)BTU)
us drEard by the Cupcnino Municipal Cale.Chapter 9.12,and the Health send Safety HEATING UNI'('(OVER 00
(OVER q
Cole,Section 25532(x)?
❑Yes E]No VENTILATION PAN(SIN GLE RESID) PAID
nam Be
` Will Ile applicant or fmure,building occupant use equipment or devices which BOILER (31111 OR 100,g)(1 BTU)
1 mil levroh us air cnmaminnua as dclincd by the Bay Area Air Quality Manugcmum 'I OIAL:
District' BOILER-COMP(OVER Ikd,O(p BT LI)
E3 Yet ❑Nn
I have read me Maidesmaterials ragrom itis ander Chainer695 of me Colt- AIR CONDI'110NER ISSUANCE I 1E
Terms Ilcalth&Safety Code,Sections 25505.25533 and 25534.1 understand That if the NEW RESIDENTIAL MECIL SQ,pT.
building rocs ret currtntly have.mount,mat it is my responsibility V%naify the axupxnt .G O
of the requirement which must be met prior to issuance of a Cenifcme of Occupancy. �� _
Owner nrnmhomcd agent Dae TOTAL: I ISSUED BY `-' � '
OFFICE