S 1545 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIU11,DING-ELECTRICAL Pli IT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB ING.MECHANICAL 1545
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICAI'IHNSUBMIIIAL DATE
{0 510 �J- 22- ?9
OWNER' NAME: 1 (1N:. ONTRACIOR'S NAM H: LIC NO N/C WNIR(B.p
1 � rti p
ARCHITEC!/ENGINHER: LIC NO: ADDRESS: ❑
WH V
CON'T'ACT: PHONE: HUILDING PERMIT IN.,-0
�` &_7 ❑ Consultant Fees Paid by Applicant(Initial) BLOC ELECT PLUMB MECCH
Y^ \V.�UWIo-S 5 >OM
LIC17NSED CONTRACTOR:S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby spank.1 am hanged under pranvis;ona..r Chapter lanmmenain, JOB DESCRIPTION
Da'Z with Satinn 7gq)n(DivisinnJofthc Business rod Rafcainns Ctwlu,unJ mylicense is RESIDENTIAL:
W O p �! PERMIT ISSUANCE
x-i- in full internal t. O ❑SFDWL ❑KI'fCHIiN Rf:MOUfiI.
aUV License Iss X APPLIANCES-REMDENTIAL ❑AUDITION ❑PLUMBING RE-PIPE
�zW nam Cnmmctn
ARCHITECT'S DECLARATION ❑MULThUNIT ❑STRUCTURAL
F�. PANIBS
ZOZ=Z I understand my plaresshuli be used aspublic Atriums MODIFICATION
UPT02W AMPS El INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 201-1000AMPS IMPROVEMENT [3SWIMMING TOOLS
CYC; OWNS&BUILDER DECLARATION OVER 1(XX)AMPS LJBATH REMODEURITAIR ❑DEMOLITION
CC
W4 1 berchy offinn that I am exempt from the Contractor,License Law(or the
X31 U following reason.(Section 703 1.5,Business and Professions CAR:Any city or county SIGNS ELECTRICAL OTIiER
W a y which requires a permit to command.alter,improve,demolish,or repair any structure
FOa pdonoini....e,also mqoices the applicant boximh permiuo Hleasignedd.trimmd SPECIAL CIRCUIT/MISC. T
fwV1 that he is licensed pursuant to the pmvicions of the Contractors License Law(Chapter J
EI� O (connnencing with Section LXNO of UivieinnJnl the Basinexe vnd l'rofaesiun.a GXklm 'IF.MP.METEROR POLEINST. COMMERCIAL:
d E:.'C that M1c is exempt therefrom and the basis for Om alleged exemption.Any violation of ❑NEW RLUG/ADDITION ❑DEMOLITION
K'^ta• Section 70315 by any applicant for a permit subjects the applicanto u civil penalty of POWER DEVICES yt
W^y El TENANT [I FOOD SERVICE
not more men five handout Jot Tun y 500)
cinud.
E.
wiLo the work,the procenyof myot intended or h wages almost foslale(Se.urEBusiorsa SWIMMING POOL ELECTRIC OTHERIMPROVEMENT
�Oo will Jo the and the he Con is not intended s or almost doe ire of apply to an, weer sx ❑OTHER
�3m and Professions Cnde:The iresI mr's License Law doss not apply s an owner m tIIl'TLLTS-SWITCHES-FIXTURES
hpropertyis own why builds or sided that such and who done mch wand himself or through
his own employees,provided dint such impnn")It w um or Iota''or offered for NEW RESIDENTIAL ELEC:R SQ IT.
sate If.however.thnbuiltling nrimpnrvenmm is solA within enc ycnrafcolnpldinn,the / 'Q.ITC PI-DOR AREA EISQ.171'.
twner-laidder will Imve the burden of,owing Iha he did not bnlld nr improve Ar cur
pose.1 sale.).
❑ I.as owner of the prtiNriEu exclusively contracting with licensed conreencs In TOTAL:
ennxtnsl the prgieet(Sec.7044,I1minesn trod EndeVions Caul,)l'he Cournetnrx Li.
ase Law does not apply m un owarrot properly who builds m immArs Ihcmnn,and QTY. PLUMBING PERMIT FEE
who contracts for such,rats witha ennvamnrW licensed pursumr mthe Conwcto4
Lirenea law. PERIOD ISSUANCE S O
❑ Ilan exempl under Ser. ,It&1'C bar this numott
Owner Date AUI'ER-GRAIN&VENT-WATER(HA) VALUATION
. WORKHR'S COMPHNSAI4ON DECLARATION BACK FLOW PROTECT.DEVICE
I herebyoffirm under penalty of pe Jnr,orrof the followingdeeit ons'.
I have and will maintain a Certificate at Consent to sell-insma for Worker's Cumpen DRAINS-FLOOR,ROOF,AREA,COND. STORIES T
YPE CNS'TRUCI'1ON
inner,uv provided for by Semlan 37(X1 of the Lnhor Cnde,to,the performance of the
Werk for which Im,permit is ixsood FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compen,ation Insnrnnce,as rnprted by Section
37W ofthe Labor Coda.for the darmance of the work tot which Thio it lsstmd, GAS-FA.SYSTEM-I INC.4OUTLETS
pc panel OCG NO
My Worlare ,vnsrlitytiln.wrance comer and Policy 6Meq,Ck�O "
Cartier !r•I br, Palk Nn,: Cl1 l 1 GAS-EA.SYSTEM OVER 4(EA)
C13kTIPIC O OF SATION INS FROM WOR KERS'
COMPENSATION 1NSUkANCI? GNCASUINOUSTNI.WASTE INTERCEPTOR
Il IL TNG
(This section need h
J not cnmplcmd if penr
the nh is for hundred dollars($I
or less.) GREASETRAP PLA DIVISION ITES
I: K
I certify MNm
at in e perfoutnce ofthe work far which this permit is issued,Ishtdl &E v
SEWER-SANITARY-STORM EA.2W pT.
not employ any person m hm in any manner rn as econsubject Workera'Cnmpcn. ENERGY FEE
Z scion Laws of California.Dore WATER HEATER WNENT/ELECfR
z 0 Applicata GRADING ME ZA
ti y NOTICE TO APPLICANT.Ih altar making this Ccnificam of Exemption,yea ehuulJ WATER SYSTEMffREATING
a 7 become subjecuo the Worker's Compensation pmvicions of the Labor Cole,You Must SOUS FEE
XXL
GL) forthwith comply withsnchprovisions orthis goictshall hedimmed raveled, WATER SERVICE it
3 V
CONS"fRUCGUN LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.mPAID
L) Ql hereby affirm that is a construction lending agency for the perhmnancc of Dae 'pIR
he work for which Wis permit is issued(Sec.30'17.Civ.C.)
F' Lxoder's Name TOTAL:
G Lehi Address TOA I BUILDING FEF:
1 certify that I have mad this application and state that the above information is
F rn correct.l agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL PERMIT FEE
U z building comwctinn.and hereby authonze representatives of this city m enter upon the SEISMIC FEE
above mentioned property for inspection pu pitws. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmins the City of Capeninn ligaiao ELECTRIC ITE
Iiabi1dia,jmfinemx,rnstsand expenses which may irony ulatermengmiel,iid City ALGE ON ADDT0 MECH. O
in nnwNtum a of the gmming of th' PLUMBING FEE
APPLICANT UNDERSTA AND WIT. COMPLY W I'!H ALL NO -I'OIN'T AIR HANDLING UNIT f1"O 10,00s)CPM)
' MECHANICAL PEE
SOURCE EGUL 10
AIR HANDLING UNIT(OVER 10,II11)CFM) CONSTRUCTION TAX
na fAppli%ln nlmmn Dat EXHAUST HOOD ONMUCT) HOUSING MITIGATION PER
HAZARDOUS MATERIALS DISCLOSURE
WoUlic applicanl or fair.building's,.....Istem ar handle lineation's lnamrial IAHA'1'INC,ON]'T(TO I W,000 BTU)
is JefnW by the Coconino Municipal Cade,Chapter 11J2 trod the Ileahh and Safely
Code,SmI n 255320)7 BEATING UNIT(OVER 1X0,000 BTU)
❑Yrs [:J No VENTILATION PAN(SINGLE RESID) PAID
Date Neceipt p
1 Will the in cotta m future bonding by tiro[i one equipment 0T Management which -
unithaznmouxairconmminnmsnsJdinedbythelioyArcoAirQnrliryMtmngemenl ROI1-IiR-COMP(3HPOR I100,000 PTU) q/ 0
Own,,[ TOTAL: J
❑Yrs E]No I)OILEIt-COM P(OV Hk IW,fNX)BTU)
Ihave rcaddae hm- .mama, eptircntmns under Chancre,(m5 nl the Odl- AIR CONDIIONER ISSUANC17 DATti
fmmlu Hrahb&Sid talm S ons 2550.25599 and 25554.1 ondectmN mol If the NEW RESIDIiN'1'I AL MECH. SQ.ET. ^
buildned - ncntlyhu ammmu,d- itixmylmepnnxibilitymnddy c e< "1 Z2 =K
gnlrcn is whle arm issuance fife Cvnilir a f cnlpnnl. i
rmNor . D TOTAL: 15SUIiU It v r"rT / _•�' O
OFFICE