B 0157APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING -ELE(7fRICAL
BUB.DINGDIVI810N APPLICATION/PERMIT PLUmmNG-MECHANICAL
BUILDING PROJECT IDEN-n F'ICATION
PERMITS �O 15 7
50001
BUILDING AUDRESg:
SANITARY NO.
APPLI 'PION SUBM1ff RALDATE
2oysS
OWNER NAME / PHONE %j'
(f W/NME
OF
CO. TRACOpTOR'S NAS1E: LIC NO:
IE C q-97
NIC
❑
CONT OLp
ARCHITECT/ENGINEER: LIC NO:
ADDRISS:
? iv c. u
CONTACT : PHONE:
BUILDING PERMIT INFO
�eC� � b - �O
❑ Consultant Fees Paid by Applicant (Initial)
HI.DG ELECT/ PLU:W1 MECH
❑ kX ❑ ❑
WOO
WOO
ad
yUV
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Thal I am licensed under previsions of Chapter 9 (commencing
with Set oloaun)ivi oa 3ofine Monessm l Prefesairm, Code, and my Eeen.e is
�7
in full force and cff t. �w�^�f7
LiccnscC ss Lic.N
Uma Comma �+ EQ.Ti.-, CGSG
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL;
OSFDWL [I KITCHEN RIiN10OF.1.
[I ADDITION [I PLUMBING RE -PIPE
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
[I INTERIOR El CHIMNEY REPAIR
IMPROVEMENT [3 SWIMMING POOLS
BATH REMODE1JREPAIR 0DEMOLITION
❑ OTHER
C/
PERMIT ISSUANCE
O
APPLIANCES -RESIDENTIAL ^
V
�<i ARCHITECTS DECLARATION
D N
Z- Z 1 understand my plan• shall be used us public records
-EW Licensmt Premssional201-1000AMPS
Y � OWNER -BUILDER DECLARATION
a W 6 I herchy of Ian roam 1 am exempt from the Comment', License Law for the
O d U following reannt. (Section ]1131.5. Business and Pro[essinns Cak: Any city ar county
LLO y which marires a permil to ttm mur: alcor, improve demolish, ur repair any'aucwre
pnurmitsissuome,korequlras the npplicum fursnch permin, life signed natemenn
PANELS
DPT02MAMPS
OVER ]"AMPS
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC.
�} mat he is licensed pursuant to the provisions apart, Contractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 ofthe Business and Profcaxionn Code)«
D. c that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects me applicant to a civil Penalty of
E+ZY mmare (ban live hundred dnllars($500). 1
�0 ❑Las mvrmr of me prnperY•or my employees with wages as thcirmlc compemation,
N will do the work. and the swcmm is not Intended or uBered lot sale (Sec. 9144, 11 els
tail w and Prise,dmns Code: 'rhe Contractor's License law does not apply to mi menet mf
63 property who huilds or improves thereon, and who does such is ork Himself or through
TEMP MBTER OR POLE INST.
COMMERCIAL:
0 NEW BLDG/ADDITION 0 DEMOLITION
[I TENANT 0FOOD SERVICE
IMPROVEMENT
❑OTHI7R
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES _ FIXTURES
bis own employees, provided that such improvemenw arc not intended or offered for
NEW RI-SID17NTIAL CLEC'rR SQ 14.
SQ. FT FLOOR AREA
$/SQ. Fn
sale. If. however, the building or improvement is sold within one yvarofcorepletion.the
v v -
co -budder will have the burden of moving that he did not build or improve for put
rysse i f sale.).
❑ L ax owner of the protary, am exclusively contracting with licensed contractors m
TO D O
construct the project (Sec. 7044, Business and Professions Cock) The Contractor's Li-
wdoex mota,ply to im ow.c,.fp-,.y wno builds or imprevcsflnem..and
elm contracts liar such pmjab with a collusions) licensed pursuant to the Commemu's
QTY. PI RING MIT FEE
PERMIT ISSUANCE
it
License law. �
❑ I am exempt tinder See . B& 1' C for this reason
ALTER -DRAIN&VENT-WATER(
)e
Owner Dat
VALUATION
WORKER'S COMPENSATION DECLARATION
I hereby eRrm under peruly of perjury ane of the following declarations:
BACK FLOW PROTECT. DEVICE
DRAINS -FLOOR, ROOF, AREA, COND.
lbavcmndwillmainmina Cerificmtcof''Cnnsen(IOsell-inwrefnr Worker's Cmmpe-
Mian, as provided for by Section 37M of the labor Calc, for the performance of theers
STORIES
TYPE CONSTRUCTION
k far which this permit is issued.
have and will maintain WorkCompensatina Insurance, as required by Section
FIXTURES - ITR TRAP
ofthe labor Curb. far he perfnmmnre of the work for whichthis permit is issued
My Work ICyyd�co,inim y ..qy.. ^�• d Policy Mr ore:
GAS - EA. SYSTEM -I INC. 4OUT LED S
OCC GROUT'
AI'N
Carrier: JC4HAn/ fa r4L dicy No.:
GAS- F.A. SYSTEM OVER 4 MA)
0 O
=
+
�G
CERTIFICATE OF 1?Kl:ml'TION FROM WORKERS
COMPENSATION INSURANCE
CITis section rend not be completed it'the permit is forome hundred dollmis SI(X11
or let,,)
I cemfy that in the performance ofthe work for which this permit is issued.I shall
num employ coy person ma. mamwmer'u ij m e Workers' Ca i,n-
tan as nm neamm sun'an: th
^IiolrrLa1 sof C.Iifam
Applicant
'
GREASUINDUSTRI. WASTE: INTERCEPTOR
BUILDING DIVISION FEES
GRF,ASE'TRN'
PLANCHECK FEE
S17WER-SAN]JARY-STORM F.A.200 IT
ENLRGY FEE
WATER HEATER W/VENT/ELECfR
GRADING FEE
NOTICE TO APPLICANT: IE after nuking this Certificate of Exemption, you should
becomesubjecuo the WmkersComlwmation Provisions of the lahor Code. you must
buthwith comply with such provisions or this permit shall he damned revoked
WATER SYSTEM?REATING
SOILS FEE
WATER SERVICE:
yq
.ti. z
CJ
u"
CONSTRUCTION LENDING AGENCYagency
l for white thi that there isacomSee, 31 lending agency fm the Performance of
the work for which this permit is issued (Sea 3699, Civ. C.) I
tenders Name t
PAID
Uate ceipnX
NCW RP_ti1DEN9'IAL PLMN. SQ. PI'.
TOTAL:
U
WLendds
Address I
TOTAL:
H III
f.) Z
I certify (mat 1 have rand this application and sante that the above information is
conal lag. mcomply with all cityond counryorainanas amt zlale laws relaingm
hnlldingcnnstmninn. and also, umhnrim rcpresenim we's nfthis ciiy,, emcr upon the
BUILDING FE
QTY. MECHANICAL PERMIT FEE
SEISMICFFEV fill,
alcove -mentioned property for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of Copeman ugamra
ladilities.judgmcnts. costs and expenses which may In any way accrue against said City
in cmnscmom of the grouting of ohne permit.
AI'I'LICANT IJNDERSTANUS AND WILL COMPI,Y WITH AI,I, NON.I'OIN'I'
SOURCE. REGULATIONS.
PERMIT ISSUANCE A
ELECTRIC FEL O
ALTER OR ADD TO MECH.
PLUMBINGFEE A
AIR HANDLING UNIT (T J0n(;
MECHANICAL FEE
AIR HANDLING UNI'I'fOVERtO){�Y)O CPM)
I
CONSTRUCTION TAX
Signature of Applican/Contractor I Date
MATERIALS DISCLOSURE
EXHAUS'THOOD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO I plants) BTU)
Willmcapplicam or fumrc building cecupantemsm handle nvardous mmen.1
as deBntd by the CaNdime Municipal Coda. Chapter 9.12, and the Huallh and Safety
Code. Nation 255320)?
HEATING UNIT (OVER 100,010 B'HH
❑Vex [-I No
VENT HA'r10NFANISINGLERESID)
Wil the applicant m (more building «aPam use equipment or devices which
emit H,oenl us ulr ennanmi tim, as daMcd by me Bay Arta Air Quality Management
PAID
Dec Receipt p
B(ILER - COMP SHP OR 100.00( B rU)
District'
Yev No
❑
TOTAL:
BOILER - COMP (OVER I UP000 BTU)
AIR CONDITIONER
Ilmve maJmena/allou mmcrials mynimmem.a under Chapmr b95 of the Cali-
forma Health &Safety Code eaten t. that , is my and 25534.1 understand Out if me
building ly havettewnt. that it is my mspon' lity to notify the «cupant
of arm mswhichmmst t dpsim ei issuoncat n enificmeal r
U// s
ISSUANCE: DATE
/rs.' N ��TT /�
ISSUED BY, , A -r J
NEW RESIDENTIAL MECH. SQ. FT.
Owns ramM1orised agcm _Date
TOTAL:
OFFICE