S 1295 ---APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PRISI'r N(l. �w
BUILDING DIVISION APPLICATION/PERMIT PLUM-HUNG•MECHANICAL V` 2 9
IN
RU11.DG I'R01ECT IDEN1'IFICSFION
BUILDING ADDRESS: - SANI'T'ARYNI N'PLICAHONSUBMITTALUA'I'E
V &t
NERS NAME: - PHONE: CONI' ACTOR'S NAME: LIC NO,
yg^ 0� - SEC CON TROL#
�-
ARCHITECT/ENGINEER: LIC NO, ADDRESS: ❑
CONTACT: PHONE: HUILDING PERMI'P INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PFRVHT FEL
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O�Z with gectionu]atlnln_fDivisipn3 ofmyyu'in�s and Pylfeasions Cude,and mylicenu is ❑SFUWLNTIAL• [I KITCHEN REMODEL.
X00 `1'+) CD G/`{7 G/ PERMI'1'ISSUANCP.
i-U Li
UU Ltce Co.N APPLIANCES-RESIDENTIAL. []ADDITION [I PLUMBING RE-PIPE.
N Q L Dale CntDEC '��
ARCHITECTS UEC,AL�I�ION ❑MULT6UNIT ❑STRUCfURAI.
[0 5 H PANELS
Z O r-Z 1 understand my plans shall W used as public record. MODIFICATION
p z..O UP TO 200 AMPS [I INTERIOR El CHIMNEY REPAIR
Licensed Professional 2814000AMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-exempt fr m DECLARATION OVER I000AMPS ❑HATH REMODFyRFP IR D' OLITION
Q - I hereby affirm that 1
OWNER-BUILDER
from the RATIOt)rs License Law for the
x 3�F following reawn.(Section 1031.5.Business unit Professinna Code:Any city or cnumY SIGNS ELECTRICAL E)OTHER
which requires a permit to consbaa,alter,improve,demolish,or repair any structure
priorlo its issuance.also requires the applicant forsuch permit in Cite a signed statementSPECIAL CIRCUIT/MISC. or
.� that he is licensed pursuannorhepmvisionsofthe Contractor's Licenac Low(ChapmrY
0 (commencing with Section That)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INS'll COMMERCIAL:
a y o ty' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES [:]TENANT ❑FOOD SERVICE
not more than five hundred dollars($500).
W Z] IMPROVEMENT
pFQ
E]1.as owner of the property,or my employees with wages as their sole compensation, SWIMMING fOGI.ELECTRIC 0 HER
jd will Jo thework.and Nc suunure is notimended or altered for sale(See.]Ot4,Husineas
6 3 and Professions Code:The Contractor's License Law does not apply to an owner a( OUTLETS-S W ITCHES-FIXTURES
property who builds or improves Limon.and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDFMIAL ELECTR SQ IT. 1101,
sale.If,however the building or improvement is sold within one yearofcompletion.,he SQ.FT.FLOOR ARG $/SQ.FT.
owner-broader will have the taNen of proving firm he did not Wild or improve for put
PAID
Bose a!aaleJ. N K
❑I,as owner of fine property,am exclusively contracting with licensed eomramms to FEB
construct the project(Sec.1044,Business and Profession Code:)The Contractor's Li. • J`IJ
cerise Law dresnor apply man owner of progeny who builds orimpwves thereon,and QTY PLUMBING PERMIT FIiE AlfDrytt
who coutmets for such projects with a contrncmrts)Licensed pursuant to the Contractor's �IYtI Y
License law. PERMIT ISSUANCE CITY Ur tar
❑Iamexemptunder5a. ,B&PCfortismawn
ALTER-DRAIN&VENT-WATER U:A) VALUATI
Owner Doc
WORKER'S COMPENSATION DECLARATION BACK FLOW PH(1IICCT.UEVICIi
I hereby illTmi under penalty of
to perjury one of the following for dalaWaker's Ca
❑Ihave and will lforby Se Certificate ofCe Labor selfcmotthe Performance
scempem DRAINS-MOOR,RUDE AREA.COND. y-yOBIFs EAPN
STRUCTION
cation,us provided for mi Section 1]W of the tabor Code,for the performance of the
work far which this permit is issued. FIXTURES PER'lRAP
❑I have arta will maintain Workers Compensation of the Insurance,h res peva by Section
3]glaf jhe laWr Code.fnnhe pertonnence of the work for which this permit is issued. GAS-F.A.SYSTEM-I INCA OUTLETS OCC.GROUP I.
My We o fiir(ln5y�scc crMllr,?�o[icy n
Cartier dr�l� �iY7I' No.: GAS-EA.SYSTP.M-OVERAIG)
CERTIFICATE OFL'AF�.TPIR)N FROM WORKERS' GRG54%INUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING In I$IUN PT:L•S _
(Drissmii..necdno,Wcompleted doe perun
mit is h)..chdmddollms($IW) ORGSII TRAY
or less) - PLANCHECK IEE
I certify ora,in the pedimmnciAde work farwhich this permit is issued,I shall SIEWIER-SANITARY-MRM HA.200 PT.
not employ any person in any manner so as to become subject to the Worluan Cmnpen- ENERGY FEE
ZZ sarion Laws of California.Dam WATER IIGTER WNENTELECTR
O Applicant GRADING FEE
r y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTIEM/TREATING
a ; become subject to the Worker's Co n,mottinn provisions cut LaWr Code,you must SOILS FEE
{Ta forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
R Q PAID
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'hMB. SQ.ET. D' tN
LJ l for which
tri thin ni i is a mn(Sce.3097.on Cing agency haute perfnrmunre of
the wad for which this permit is issued(Sas.1019].Clv.CJ oel
Lenders Name TOTAL:
lenders Address TO'1'A I.:
1*4
0. 1 certify that I have read this application and suite that the above infnreal iair is Br . G
(A correct.I agree to comply with all city and county ordinances and state laws rclmlng to QTY. MECHANICAL PERMIT FEF
building construction,nalmau
cbymorim represenmm tivcs ofthis city inerupon the S
U ?J :SM :IT:
r above-mentioned property for inspection purposes.
(We) ,o save,indemnify and keep harmless the City of Copettina against PEkMI'I'ISSUANCIi ..T FEE
liabilities,' it mems,cosy and expenses which may In any way acerve ugainm sail City AITER OR ADD TO MIECH.
in conse of the granting of this permit. PLUM GFEIE
APPLI , UNDERSNDS AND WILL OMPLY WITH ALL NON-POINT AIN HANDLING UNIT LTO 10.00ICInD
SGUR('Rr ' LAT IO MEC NICALI
AIR HANDLING UNIT(OVER 111,070 CFM) CON. RUCTION TAX
Sign.m of ApplicanU nrractor I Dun EXHAUST HOOD OV/DUC'T) BOILING MITIGATION IEC
HAZARDOUS MATERIALS DISCLOSURE
Will the...]at..,or future bui Wing occ.pantamrear handle memo us mueriul HEATING ON]'1'(0100.000 If I'ID
as defined by the Cupedinn Municipal Code,Chapter 9.12,unit,he Health and Safety
Gxle,Section 255320)! HEAPING UNIT'(OVER 100.00011170)
❑Yes E]No VENTILATION IRAN(SINGLE NI!SID) PAI) Dut Recti.,k
. irolthe air coamarfuturemasa building by the myA use�ea ipmeelar Uev Mana Which BOILER-COMP(3HPOR-I OIIamIBTU)
emit hazanlous air wntuminums as defined by the Bay Area Air Quality Management TOTAL,:
District?
❑Yes [I No 80111:11-COM I'(OV h!It IIX),IX)I)Im'U)
I have read the hamrdom materials rc is under Chapter 6-95 of Call. A I R CON DI'I'ION HE ISSUANCE DATE
quire p
Iomiu bHealthuilding
&Safety ly a,eamou 2&505,2551)and 25534.1 u radify li thin if 8r° NEW NHSIUHN'1'IAI.MICCH. SQ.HI'.
.it mcng dote nor b which have a,onN F that it is my responsibilityofaumilm notify the pacy..ml
of the reyuiremens which most W mu prior to Issuance of a CerUllurm nl Occupancy.
Owner ormMoriztdagent Date - 'I'OI'Ne ISSUED BY:
OFFICE