S 1552 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING-MECH MICA reryylT N°. 1552
RVILDINC DIVISION APPLICATION/PERMIT rINGPIN0-bI IDENTIFICATION
/
BUILDING PRO,IEC'f IDENTIFICATION
UILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
NNRB NAME: PHONE CONTRACT'OR'S NAM C' LIC NO
NEC CONTROL#
C I .CT/E GIN'F,R: hIC - ADDRESS: El
V
' N'TACT � PHON� ���yyy BUILDING PERMIT INFO
p-C IgD Consultant Fees Paid by Applicant(Initial) �,-ah+_ IDAG ELECT PLDn4e MECH
R�ZPa o 7z' U _ X
LICENSED CONTRACTOR DICLAFUTTION QTY ELECTRIC PERMIT, FEE
1 hereby aura urn I am licensed order pnwisiens sef Chapter 9(carmaro ng _ .JOB DESCRIPTION
C W Z with Section 700P at Division ufiheBasln...and Professions Code,and my license is
RESIDENTIAL;
w o 0 PERMY]ISSUANCE
F Ia full Inrbe andeffee, ❑SFDWL ❑KE CHEN REMODEL
Q,UV License Claes—Li,.# APPLIANCES-RESIDENTIAL DITION ❑PLUMBING RE-PITH
F Z W Datc Gmtrac,nr
0Q0. MUL'fl-UNIT El STRUCTURAL
rn ARCHITECPS DECLARATION
Z FO m Z I undarsmnd my hers,bill Ix used as pnhlie mcords PANELS MODIFICATION
024Q UP 3'0 2110 AMPS E:1 INTERIOR El CHIMNEY REPAIR
Fr�.F.til Licenool Pmfe,,enarl 201-100MAMPSNIX
IMPROVHMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION 5 OVER 000 AMPS [I BATH REMODT:IJREPAIR El DEMOLITION
a
Q I hereby affirm that I ant ceampi from the Contractor's[,fee...Law for the
iy� 6 U followingaim,a(Swoon]031.5,c u..Im.s andProfession,
improve,
de io demolish,
CodmAny city ar county SIGNS P,LECfRICA ❑OFF!PH
Yl3 4.y widen rite sm It recoil rr column.ahec improve,deermit I or mpmr ,ed our con
ti.F".OQ trio t t ':. I 1 ' papplicantf Permit r, .L dsmmie,9 SPECIAL CIRCUITI '
999��"� that lie licensed p tt 0 p fth C t m I Lw(Chap,er9
q0 (corn rtes tgw th$exnnn]Ogq of D'�ir n3 ❑h B rex JI I :!on,Code)nr 'FEMP.METERORPOLEINST OM F.
0. c that he is exempt IhemaNd and the basis for the alleged exemption.Any violation of ,W BLDG/ADDITION ❑DEMOLITION
W m�i Section 7031,5 by any applicant fora permit subjects the applicant loo civil penally of POWER DP.VICES TENANT ❑FOOD SERVICE
FZT not norm than Five hundred dollars($500) IMPROVEMENT
El 1,as owmr of the-property,or my tnployces with wages as their sole comprialion, SWIMMING POOL ELECTRIC
L�+.I+ will do the wort and thestn cos Bu
ondimendedurned for cre(Sce.9044,Business L1 OTHER
W 3 m and Professions Coda.Ilia Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who but ILp . I hi and w ho does sh work hinuselfor th gh
his own employees,provided th t such impownincon,am not J d or officiall for NEW BESIDES UAL ELECTR SQ FT.
arm BE however,the haildingorimpareverrical IJ lh' y f pl i the SQ.FF.F1OORARE $/SQ.Er
bld will have,h burden fp bdial l did th ld P f pts 7 4 O
pia r 1 ) �1a1/!
El
INepre.octan sines ly t l act :In
construct the project(Sec o an wnsme. 1 rt C 1 :)is C tea urs Li-
cense I : muchapply taan with
om property n bonds p thcon andora QTY. PLUMBING PERMIT PEE
woo contracts far such projects won v mmmemrts)licnmad pursuant e.ma connote-x
License Law. PERMIT ISSUANCE 1
❑ 1 am exempt under Sce. .B&P C for this rots...
A I:fP.R-DRAIN&VENT'-WATFRHEAL VALU TION
fares Doe
WORKER'S COMPENSATION DECLARATION NI OW PROTECT.DEVICE 7rz.
I heathy afFlnn under penalty of pcpnryoneof the following decbnanons: IiW, w
LJ Ilwve and will maintain nCcnlfentenf CnnsconmsdCin am for Worker's Con tas 1 .00R.ROOF,AREA,COND. S'fOftIPS TYPE CONST RUCTION
ration,as provided for by Sectio 3700 of the Labor Code,for the fondant the
workfmwhich,hispermitislasaed. AP
❑1 have and will mainmin Wnticcr's Cumpansminn Insurancea. "mord by Sectio
3900ofthe Labor Come,far the oloournaol the work Car wlie thisper'mhisieml 'A.. TEM-1 '3 -'FS OCC.OItOUI' AYN
My Worker's Compensation Insurance comer and Policy numberarc:
Carden Policy No: .AS-L 'I'6 P.R Avg3`C�QZ�aL
CERTIFICATE OF EXEMPFION FROM WORKERS'
COMPENSATION INSURANCE GRI. NUL. L�4ICuoft IIDU 'BUIL'DING DIVISION FEES' `
(Tharection need nm be complemold(h,and .,for one hundred dollars($Its)) R r
or less.) PhANCHECK FEE I
I cemify that in the performance of,ho work for which this tomtit is issued,I sholl SEWER RV-S'TOR .200FE.
not cidpley any tomo in any manner so ax to become subject Ira the Wn Im,'Compeam ENERGY FEE
at ion laws of Califomin.Dale WATER HEATER ENT/ELEC'B
Z Q Applicant t GRADING FEE
NUITCE TO APPLICANT:If.axe,making this Cenlfcnle of Exemption,you should WATER SYSTEMITRFATI
become subject to the Workers Compensation provisions of the LaborCn Id you nmst SOILS PEE
aQ fonhwi,h comply with such pmvisinnx nr this permit'MJ1 be decided revoked. WATER SERVICE PAID �_ �y0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLIAB. SO.PC Z
U'0 Ihereby alYnm thouhem is It cummetion lending agency for the performance of Data Recoup# /i 7�2
the work for which this pcmut is issued(Sec,3099,Civ.C.)
W lander',Name TOTAL'.
a Lendce,Address lO BUILDING FF.F.
1 comity th
at 1 have mail this ai pplart and sum that noc above information is
m correct.I agree to comply with a0.city and enmity onllmncea and state laws miming to QTY. MECHANICAL PERMIT FEE'
building um.rection,and herchy out wdze rctrosemmivesnf this city manmrupon the SEISMIC FEE
above-nmmioned
property it,,inspection purpo.c., -
(We)agree to nave,Indemnify and keep hnrmo le.,the City of Cupeminagainst PERMIT ISSUANCE BLBC'fRIC FEE
Iiabiliticsjudgments,costs and expanses which may in any way acture against said City ALTER OR ADD TO MECH.
consequencein of the granting of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITGO 10,000CF1,A)
MSCI IANICAL hEE
SOURCE REGULATIONS.
- AIR HANDLING UNIT(OVER III,fN1)CfM) CONSRUCfION TAX
Signature or Applicant/Contraclor Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant or future building oaupantstm'e dr handle hazardous at II HEATING UNII'(FO 00,000 BTU)
as defined by the Cupertino Municipal Com,Chapter 9.12,and the Health and Safety
Cade Section 25532(x)^ HEATING UNIT(OVER 103,000 BTU)
❑Yes El VENTILATION PAN(SINGLE RES]Do PAID S'/�V
Date Rnccltt#
Will the applicant m furore haulier,xenpum use eymipoicur or devi«s which
at hazardous air contaminants as defined by Ilia Bay Area Air Quality Monagement BOILER-COMP(31 IF OR I(X),(HN)B'PU) TOTAL:
District' BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
Ihave read the hnzenlous ora,ectal—ppdremmn,under Chapter 6 95o lie Cali- AIRCONDI'TIONER ISSUANCE DATE
I ...a Hro10&Safery Code Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SO.HE
butldmg docs not can'catly haven tenant,Thal it is nryrespnn,ibihty m notify the rxzupum
of the mondem.....which must be me,Prior m issuance of a Ck"am of Occupancy.
Owner or authotizai agre, Date ISSUED BY:
OFFICE