S 2024 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-E.LECI'RIC], PEI`II No.
IIl1I1.lIINO I1 VISION APPLICATION/PERMIT PLUMBING-MECHANICAL. V 2024
BUILDING PROJECT IDPIN"1'IF'ICA'I'ION
BUILDING ADDRESS: SANITARY NO. APPIJCA DON SUBMITl'AL DATE
OWN' SN ME PHONE: CO TRACroN:SN E: / LIC NU'.
<�r' 51.
NIC CONTROL"
•ARCHI'I'13G'WIT GINIdz R: IJC N(l:it 4 kA 6itilill 1257+ All1lRESN: Vl• 9J ❑
CONTACT: PHONE: UILDINU PERT, INFO
x.377-9693 ❑ Consultant Fees Paid by Applicant(Initial) BL1 ELECT PLUMB MECII
TyL W
/� ens ❑ ❑
LICENSED CONTRACTOR'S DECLARATION CITY. ELECTRIC PERMIT FEE
MIZI harchy:Irrnn mut I air remncf offer posrionx of Chapter 9 teammeneing JOB DESCRIPTION
F=a (Alla un1/and affdll ARCIII'I IiCII:S IDITLA?112lNm.cr,vcO.and my licennc ix
RESIDENTIAL
Z IhSI' tvnum 3afthc l{uk
n1 Q PERMIT ISSUANCI?
mull tome and cB ❑SFDWI. ❑KITCIi KITCHEN REM(lUlil.
Q,ZO LiccnscC Con# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE PIPE
PANELS ❑MUI.Tt-UNIT ❑STRUCTURAL.
z 0 of z I undem:mJ fry plan.shall ha teed as puhlic rem.J.s M(1DII KATION
OZ4O OF TO 21X!AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Fd.41tmLiccmW Pmfcxional 201-IfKK1AMPS IMPROVEMENT OSWIMMINGPOOLS
LCY � OWNER-BUILDER DECLARATION 1
C) )VER INXIAMPS RATA RI?MODIiiJREPAIR ❑DEMQLITIGN
Q I hereby affirm ),I'I nmxa
anpl fruit the Cnnm con,License haw fill the
XdX O a U fallowing reaum.(Section]0315,Business and Professions Coda.Any city or county SIGNS ELI CIRICAL ❑OTIIIiR
W 3 u.T- which mwim,a perms bI con.umet,:amr,improve,demolish,nr 2pair ,any sauatere SII
of
t Q pro, II 11iraIwr,dV1 11,1111c,ffidarflhican,I li,annott fill it,'cost"rearra SPECIAL.CIRCUITIMISC. ,
der he d parsurmu 'he p l the C I I Licran I '(Chapter! COMMERCIAL.
m�p0 (commencing withSection?(IOB) fD J fps BusinessdProfessions Card of TEMP MMER OR POLE IN'ST.
d 6 e C Ihm M1c s aumpl therefrom ane the Iasi r th II gcd ax pt A Y viola on of - ❑NIiW'NLDG/ADDITION ❑DEMOLITION
Xmas Sec,ion]031.5 ny any applicxm hr a perroa...two,rheand...... a civil penally of POWER DEVICES ❑TENANT FOOT)SERVICE
o
0ow
nth
ot more an live hundred dollars(1500).
1.asoa of the pmen
py,or my employdes with wages as their sole compensation, SWIMMING PDOL ELECTRIC IMI'It(IVEMIiN'1'
FSO will AU lM work.and the snunurc is nm inrenrlaJ onsRercJ Et sale(Stt.]IN4.Business El OTHER
CF
3^ and Poy who nx Code:The Comm...ri License I Law las not apply , an,caner or ON'hFI'S-SWITCHES-FI%'TURES
property who hails.m inmmvek thereon,and who dues ouch work deed o r ter through
his own uppinytts,pmvideJ that such improvcmemv me not intended ter offered faaQTY. PLUMBINC1,PERMlT
1?IJdCrR SQ ITP.
.ale.If,however,the building or improvement is.suld wiNitnne year orcampletion,the SQ.FT.PL(H)R AREA $ISQ.IrP.
,,act huil ier will have the harden of proving that he did fol build or Improve for$o r-
,,,a ter sale.) 'I GIAL.
I,a fawner of the property,am exclusively contracting with licensed contractors lir
construct the project(Sec.Tl4A.Business and Pretc,,ions Coact the Commemr's I.i-
nseLaw doesnot apply to ow net of properly who builds or impm,es theram,anJ INOPERMIT FEEhoa moons li suu11Ptnjcc.wffi a eofa:¢mIp)reamed pu nand m the Contmemre3License Law.I am exempt under Sec. .B&P C for Nis rcawn
ENT-WATER(EA) VALUATION
•
ilia
Uwfcr,
WOR KIiR'S C(IMtI'IiNSAI'IDN IJECLARAf10N RACE FLOW PROI'T:GI'.IIIiVICIi p CJ
1 hereby anion under penalty of Perjury one of the follrawmg dedauons
I Sseund will ifurron afenilicnm of Consent modbinmre for Workces Camper- DRAINS-FLUOR.ROOC ARCA,COND. STORIES TYPE CONSTRUCION
.Ilona,Its pmvdad for by Semon 301X1 able LabarCa le,for he pci f rmarce of
by
work din which this pcntil is issued. FIXTURES-PER'I'RAI'
I�(1 I have and will maintain Worker',Compammicn]a....na,as rammarJ by Section
W of the Labor Cale,It the lcdirtmance nl the worA for wbich Ibis permit i.issue). GAS-P.A.SYSTEMpI INC.i OUTLETS --UCC GROUP TPN
IT Worker's Cat 'u,nou lox lit' wnicr unll Polic, 'r �'
Carrier res, I'oh" .w1Nn JI GAS-Eh SY5T1iM OVER4fl?Al
CER'f11lCATGOFf:%EMYI'I(IN FRA IWURKERS'ylm�7 GREASI%INDU.S'IRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION 11F
IIhh.mtionfcednutheconnplamd iHha pcnniis 6nlnc hundred dole,($100) GREASETRAP
PLANCIIIiCK PEIi
d
Loy anylhalinl in any
as the
for which It io Enrit Wokirs'Coper- SIiWER_SANITARY-STORM EA.21X1 t1'.
i not employ any person in any munntt so m to become subject m the Workers'Camper- ENERGY FEE
Z xallon Laws nI C.11hanin.Dawe WATER HEATER WNFNT/F;LECrR GRA MING FEE
ZO Applicant
y NOTICE TO APPLICANT:If,flue,making This Cetipicme of Exemption,you should WATER SYSTEMVrR17ATING SOILS PEE
[••' Wevere subject to the Workers Compensation previdav of the Labor Cfde,you must
ai H ronhwith comply w ith such provisions or this permit%hall he deemed mvoked. WATER SERVICE N
aa.. Q
CONST'RUCT'ION LENDING AGENCY NEW RESIDEN'i'[A],I'LMIL SQ.Fr. PAID
z Doc Itmcipt a
U O 1 hereby which
thi that these is s construction ending agency for the performance of
[gs F•' the work for which this permit is owe)(Sec 1119].Civ.C.) TOTAL:
Lcndeh Nnn'e
Land,-Address _ ( BUILDING HE
0. 1 certify that 1 have read This application and state that the aMwe information Is
.F".I 0 k raft.I agree Io comply with all city and county ordinances and suite laws mining to QTY. MECI IANICAL PERMIT FEE SEISMIC F i Q
Uz ordingu'mlmetion.umWerchy nmhunic representative,al this city to enter upon the
abave mentioned property for inspection puGascs,
I'IiRMI'1'ISSUANCIi EhliCl'ItILP li
1Welagive s.save,indemnify and keep haeme..the City of CupanidCity
Iiahilnias,juJgmcros,rnaam
s and axpvnses which may in any way se againstt vis City ALTER OR ADD TO MECH. )LNG E
nagacnm of rbc 8nmtinSol his pannus - '
APPLIC RNT I GUI UNDERSTANDS ANI WILT.COMPLY Will]ALL NON-POINT AIR HANDLING UNIT(10 I - a'CHANI .IF,
URCEAIR HANDLING UNIT(OVER ILDWCPM) CONS'IRU IONTI
Signature ter plicanbcoutrac # WWIIGN/(,0�[�Irr C.l� Il c V HXHAU.S"THOODIWIDUCI) l� 1(18:1 "M O 'pili
HAZARDOUS MATERIAIS DISCLOSURE
Will the applicant or future building occupant store or handle hwardous material HF-Al'ING UNIT CIRI 101001111"U)
as def red by the Conti no Municipal Cale.Chapter 9,12,and the IIcahn and Safety HEA'L'ING UNIT(OVER 100,000BTU)) Y
Code,Seen 25532110!
0 Yea E]No VENTILATION FAN(SINGLE RESID) Receipt#
Will the applicant or future building:acupant use equipment or devices which UOII ER-COMP( IIP OR 100.000 RTU)
mit hmxrdous air amnmdmmrs its de roof by the Ral,Arco Air Qualhy Mfnr erreat AI
District? BOILER-COMP(OVER 100jaN)R u)
Wes ❑No
I an,mar the h:¢anlous mumrials Ir Lv under Cl lar 6.95 at Ira Cali- AIR CONDITIONER ISSUANCE DXI E
25533"
fair livau,,fres&Surely Gide,have
tins tenant.
i 2553]and 8534. undeoumd Ihm if rota NI?W ItEllDi?N'rl Al.MI?Cil. SV.FI'.
of the rgdnee at encs rmallyuhich est the
p pion r is mace of
Car ry it) the ecular upant
of the requirements which mot M:met prior m Iswance of a Ceniluca¢of Occupatey.
f�
Owner or aulhnrind ugenl Da¢ TOTAL: ISSUED BY:
OFFICE