S 1383 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF(�CUPERTINO BUILDING-ELECTRICAL PEg ITNO
BUILDIPG DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. V - 1383
BUILDING PROJECT IDEN'TIFICA'TION
BUILDING AC RPSS: SANITARY NO. APPLICATION SUBMITTAL DATE
�Z1t� $
'S NAME: PHONE: - f A TON' NAME: /f, IAC NO: N/C C N'IROLp
IAC IITECTIENGINEF.R: LIC NO: lJ RESS ❑
llyhplloi
CONTACT: PHONE: - - BUILDING PI7RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BCI) ELECT PLUMB MECH
X X, i "
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE
I hereby affirm Ihm I atm IicensW under pmvixiona of Chapter 9(commencing JOB DESCRIPTION
,aZ Ih Section70"bol D!sisio li.fthe Businessood Professiom Code,amd my license is RESIDENTIAL:
1W+00 wtl'u 11 force and efl cc(. P17RMIT ISSUANCIi
n'U� LicenseC ss Lia# q OSFDWL ITCHEN REMODEL.
Q U __ 'I /. APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RIi.PIPE
yz L Date c f+ Cnmractor
ARCIIITF.(.TS DIiCLARATION YI ❑MULTI-UNIT ❑STRUCTURAL
p.Om /^ / PANELS MODIFICATION
Z O I understand my pian.,doll be used ac Public records
Oz O UPT0201)AMPS ❑INTERIOR ❑CHIMNEY REPAIR
w Lmemed Professional - 201-1000AMPS IMPROVEMENT 0SWIM M ING POOLS
�yf� OWNER-BUILDER HECLARA'f10N OVER 10MAMPS O BATH RF.MODEIIRHPAIR 0DEMOLITION
CC 6 I hereby affrtm that 1 not exempt routine Conoucmrs License Law for the
ip5,O 0.U following reason,ISedion 91131.5,Business and Professions Cale:Any city or enm;ly SIGNS ELECTRICAL ❑OTHER
x+a 2Iv"1 which reyuites a permit m,rename,alter,improve,demolish,or repair any swrem,
��•f0fnn¢ prior to its issuance,also enquires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MISC.
9 p0 um
that he is licensed pursuant the provisions of the Comrecfs License Low(Chapter9(commencing with Section90gB of Div!eioa3ofthe Business and Pml'awions Code)or 'JUMP.MM fit OR 1101,17 INS'L COMMERCIAL'
that he is exempt therefrom and the had,I'or the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iLLl7 4• Section 9031.5 by any applicant for a pennitsubjecs the applicant to a civil Penalty of POWER DEVICES 7 ❑TENANT ❑FOODSERVICE
toort o'.Ihan five hundred dollars($500).
F z i IMPROVEMENT
qsQ ❑ I,o the work.the pestructrmyemployees oroffth e dfrs as lali(ee (94,11 messn. SWIMMING MCI,ELECTRIC
2 0 and(to the work,and the he Contractors
tors License L w du f,net apply 91H4,Boniness ❑OTHER
CW � and Professions Code:The Cnntmmor's License Law Anes urn apply to an owner n( OUTLETS-SWITCHES-PIXTURps
Ina,my who build.,or improves thereon,and who dens such work himself or Ihrotgh
his own employees,provided doer such improvements are not intended or offered for NEW RESIDENTIAL ELEL.R SQ Ff.
aide.IL howewx,line hadding nr iopmvcmcm lS sold within one year ofcompletion,the SQ.FT.FLOOR Alt.A ' $/SQ.IT,
owner-builder will have the harden of proving that he did not build or improve for pur-
,,a of sale.). dunn
Fl 1.m owner of the property,sin exclusively contracting with licensed contractors m TOTAL: AR 1 9 ANS(.
construct the project(Sec.7H4,Business and Profc Sion.Code:)The Contractor's I.i. ys'T y ANS.
mise Luer ducame apply to..owner of property who hui ldsor improv..Ihmmad"iI QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commica0s)licensed pursuant o the Contractor's Uf;Urktu Uvu
License law. PERMIT ISSUANCE - V
❑I ant exempt under Sec. .B&P C for this rcasun
ALTER-DRAIN&VENT-WATBR(I!A) VALUATION
Owner Dene
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTI!CI'.DEVICE.
1 hereby allot under penalty teperjury one of the following declamations:kau �JJ��JJ
❑Ihove and will maintain aCenifcare of Cooenno aelGinsurefor Workers Compen- TRAINS-FLOOR.ROOF.AREA,COND. S'D)NII!S TY 1117.CONSTRUCTION
dation,us provided far by Section 3710 of ado Labor Coda Por the perforn t nee of the
work for which this pernth is issued. rUcTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
390Oof the Labor Code.fat the prommunce of the work for which this permit is issued GAS-EA.SYSTEM-I INC.40UTLETS OCG GROUP APN
My W nVprJ,Cs;�rt yve,artier and Policy qy�V atrl
Carrie d Policy No:O *'r�L—�T� GAS-EA.SYSTEM-(lVER4(EA)
gmpen
CERTIFICATE OF EXEMI'T'ION FROM WORKERS' GREASPIINDU$TRL WA$'ITiIMI'ERCF.1'NR
COMPENSATION INSURANCE BUILDING ;ION[lips
(This section need not be completed if the Permit is for one hundred dollars($100) GREASETRAP
in Ices) PLANCHBCK P88
I certify that in the performance of the work for which this permit is issued,lshall SIMER-SANITARY-STORM EA.21X)IT.
rs
not employ any peon in any manner so as to become subject to the Workers'Compen- ENERGY FEE
O Z sttion Laws of California.Date WATER HHA'1P.R W/VEN'f/ELECTR GRADING PET!
O Applicant
ti
NOTICE 10 APPLICANT If,ahe,making ads Cenifcateof Exemption,you should WATER SYS'IENVTREA'JING
became subject m Ice Workers Compensation provisions of the Labor Gale,you must SOILS FEE
Wforthwith comply with such previsions or this pemtit shall he deemed revoked. WATER SERVICE
Q PAID
CONSTRUCTION LENDING AGENCY NE RES11lEN'I IAL PLM L SQ.FT.
LJ O IherehyaRrrrms,there is.construction lending agency for the ps'mrramerof Date Ne til#
E-' the work for which this permit i,issued(Sec.3099,Co,C.)
Lenders Name TOTAL.:
LULcav,'d Addend, TOTAL:
gy 1 certify that 1 have read Ibis application and stale that the have in mnandion is BUILDING PEE
N correct.l agree to comply with all city and county ordinances and state laws relating In QTY. MECHANICAL PERMIT FEE
L)Z building construction.and hereby aaburire represcroadvesafthis city Incineration the SEISMIC4E
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agreo on,ave,indemnify and keep homeless the Clty of Cms,rdso.,am,, - ELECENIC PEI:
liabillues.judgmems,costs and expenses which may in anyway accrue against said City AITF.RORADDTO MECIL
inea quence flhegmmingofahisperand. PLUMBING FEE
APPLIC NDENSTANDSANDW .COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(11)10.000 CPM)
SOUR,'. MULATIONS. - MECHANICAL :Le
AIR HANDLING UNIT(OVER 10,01X1 CPM) CONS"fRUCfION'f
St am ofApplicanU eacmr V Dare EXHAUST HOOD(W/DUCD HOUSING MITIGATION
H BOGUS MATERIALS DISCLOSURE
III the applicant or labor building oceupme slam or handle somlous m ldanal BEAT UNIT(TO 100.shl BTU)
as d lined by the Cupenino Municipal Calc,Chapter 9.12,and the Health and Safety
Cade,Section 25532(e)? HEATING UNIT(OVER UM000 B'CLI
❑Yea ONO V17NTILAI PON PAN(SINGLE RF.SIII) PAID
Will the applicant or future building ocal...at use ca,mpmenl ser devices whidt Onre Receipt#
emit hazardous air cummnameatsas defined by the Bay Area Air Quality Management BOILER-COMP QHP OR 100,070 OTU) TOTAL:
District?
❑Yu 0 N BOILER-COMP(OVER I0L.00(i RTU)
I have most the h.zardous materials noitumments under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fool.Health&Safety Code,Saban.25505,25533 and 25534.1 understand Out if the NEW RESIDENTIAL MECH. SQ.FT.
building dues a.,count have u¢nom,that it is my responsibility mouthy the.,.,an,
of tine raryiremer s which must homed prion.issu...c of a C.mficam of Occupancy.
Owner or authorired agent Date TOTAL ISSUED BY:
OFFICE"