S 3174 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIT II,DUM;-ELEC'I'RICA I, PEItS I]'NoI 3174
BUILDING DIVISION APPLICATION ITERMPP PLUMBING.MECHANICAL
IIIIILUING PROJECT IDRN'1'IF'ICA'1'ION
BUILDINGAUDklis% SANITARY NO. APPIJCAI]ON SIIBMI MAL ONE(
D � 0 Oz- � - �l 23-?Y
OW ' AM' / r'F. I'110N1i'. CI)I'If 'I'Oy:ti M I,IC NO:
/ V - N/C CONTROL#
JA HI'I';LTR.NGINI!IIR: 1.1 NO'. , URLSti: 902 3 /eY l
(;� - 875 b o .✓LS L 1� uC4Fz N v
CONTACT. PHONE. BUILDING PERMIT INFO
S �� ❑ Consultant Fces Paid by Applicant(Initial) HI❑DC ELECT� PI MB MI CCH
LICENSED CONTRACTOR'S DECLARATION Q'ry ELEC'I'R IC PERM 11' FEE JOB DESCRIPTION
I hereby aero Thal 1 am licensed under gmvisinnn of Cooper,9(commmecing
GCOwith Sncdmn 7NX)JmfDisision 3olme Boniness and Prefte,ions Cdde.� my license is
RESIDENTIALW p PURMI T ISSUANCI:
CLLF nfull force moil eRem^ /1. D ❑SFDWL ElKITCHGN REMODEL
aVLmeme Class G Lica APITIANCCS-RESIDENTIAL ❑ADDITION El PLUMBING RIi-PIPE
FZr,W Dae ContraOur
may
ARCIIIICTS DICLAHAION El MULTI-UNIT ❑STRUCTURAL
'Dco AI
mZ lundcntand my plans shall ht used as garlic rnmrdd MODIFICATIONOZ4 UPTO1(OAMPS [I INTERIOR ❑CHIMNEY REPAIR
Licensed pontoon...I 201-IGX)AMPS IMPROVEMENT (]SWIMMING POOLS
OWNER-HUILDER DECLARATION OVIiR I1XXIAMPS ❑BATH REMODEUREPAIR El DEMOLITION
a 1 hereby affirm that 1 am exempt from the Comracor's Licence Law lir The
X O a U following mason.(Section 7031.5.Business and Professions Coda Any only or countySIGNS IiLECI'HICAL ❑OTHER lqj?ZA
LL 3 LL towhich requires a permit to cmnvuct,area,improve,demolish,or repair any Immortal
E'u'pa paiur m its issuance,also reyuims the applicant!errant pennlno fleasignedsmmment SPECIAL CIRCUIT/MISC.
that he is licensed pursuant the previsions ofthe Contrai License Law(Chapter 9 C(5MNjFRIffIAL,
LL�pO Irommencingwim Section 7IX01 of Diviaionlnf the Buxincss send lMdnasinn Cldelor TEMP.h1ETIiR OR Pool INST.
a 10If that he is exempt therefrom and the basin for the alleged exemption.Any solution of El NEW BLDG/ADDITION [I DEMOLITION
^y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of IX)WER DEVICIS (3TENANT ❑FOOD SERVICE
not more man five hundred dollars($500). IMPROVEMENT
=O ❑Las owner-oflhe progeny.or my employees with wages inflonzole compensation. iik36T
F. will do the work.and the swcture is put intended urmffemd berserk(See 7141.Business ❑OTHER
W 3 m and Ponfien on Cade:The Comracmrx Licensc law does not apply o an owner of a ES (•Z�
ei. progeny who hands or improve%thereon.and who does such work himself or through
his own employees,provided her such improvements are our intended nr offered fill Sp 1T.
sale.If,however,the building or improvement is sold within one year ofrompletion,the SQ.FT.Fl.00R AREA SISQ.I.-I.
ownwebuilder will have the harden of proving that he did not build or improve for pur-
pnseofaala). �7
❑I,as owner name property,am emm.ivey contracting with rants conies m C
consumer the project(Seo.70N4,Business and Professions C do:)The Contractors l.i
w Law does not apply to an owner of progeny who builds ompnan menton.and QTY PI,U BI sP MIT FEE
who contracts for such pwajccts w'nt a comracmrtI)licensed pursuant o the Cmemetor's e
License Ww. PERMI T ISSUANCE
I am exempt under Se I 'I .H&PC burns reason
AEF17R-DRAIN&VENT-WATER TEA) � VALUATION
Owner Date /'-�
WORKER'S COM PENSATION DECLARATION BACK FLOW PROTECT.DEVICE OFA CO
1 hereby ulGml under pem:hy of perjury ono of the rollnwing decluconsto
❑I have and will maintain o CnnificmeofCim,em tosvlf-insme tin Worker's Compen- DRAINS-IIAOR ROOF.AREA.COND. STORIES TYIIT:CONSTRUCTION
saimn,as provided lir by Section TREE of the Lalxm CWc,fur the genbmnana of the
work fn which this permit is issued FI%'I Il "
NC
vad will maintain Walker',Compenntion In<urxncc,m rcyuimal by Seamon
.9 IM1c LoMr Cadc,for the perbannmcno(Ihc wok far.1fl hmis permit k eoued, MS-I' .S STEM- I 4 VILE' OCC.GROUP AI'N
My%;�My Wuk ' Con 'tioyl� m sand Policyn (IAS-II "(ICM.OVI',R 4 TEAT
T ` (�1( Yoliey No.: r rc
CEKTIIICA'rE 017 EXEMPTION 17ROM WORKERS' /
COMI'ENSSFION INSURANCE GRE S1 Us MST 'R . BUILDING DIVISION FEES
(Thi.escra—need not bccvmplctcd mime permit is fur nnchundmddollam(811X)) GREASE AP
nr less.) 1'LANCfIECK 'EE
I cerfly dell infhe permrnaanceofthewnrk for which ihislmnnil is lmnod,le hull SHWER S I'IAHY-STOItMI: 201117. O
not cntploy any pent in any inunncr no a,to bucnno xubjmt m the Wnrk�+x'
...... ENERGY
z sal nn Laws of Cal i lot ma.Datn WATHR I(EAT.B'Sv/VENT'/BT..T OItnI IcA.
ZO Appremd
iNOTICE TO APPLICANT'',11,nlor making mid Cenifcum til Exemption,you should WA'IY,R SYSTEM/I'IXI'ATW('
we I aI,bjc,,1n the Wn a,I,Cninpcnsnitun provisions of the Later Codu,you timet
Ihnhwim cmnply with.such prnvisions or this Straw shall be demucd revoked. WAIF IR SERVICE
❑ 1
CONS'I'RUCI'ION I.UNDING AGENCY NEW RP_SIUEN'I'IAL('LMB. Sp.I'I'. Dan RI'clpl sAh
UZ Iheehyaffinn lam Time is a cnnewction lending alien,,for the Perfimnuncu of
the work I,which this gcmtit Is mooed(See.3097.Civ.C.) TAI.
Q ULenders Nano TO' I
Lender's Addrusv
I anify dint I have read this application and a:ne feel Tire above mot..n onion is I 11. INC,PEE
(~ p] comet 1 n"ne to remmly wild all city and county nnllnunmx anA.vlum laws relating na QTY. MF,CI IANICAL PERMIT FEE ENMIC FEE
U building unswction,..,it herebYumbon,rcprestnolives til this lily'I'soar else Tom
Bene-menlionedpaopeny For inspectionpurrynsa'v1.1iRMII"ISSUANCE L ;''I'RICITCE 3 O
(We)agree In Hove,indenmafy and kap bmnale,the City of Cuptnino against e
Eabilidesjudgmman,c sant expenses whiehnmy in any way name againlsald City ALYER OR ADD'IO MECH. PLO INC,FEL'
in ncmence of the granting mf this Ixrntit.
APPLICANT ON DER STANDS AND WILL COMPLY WI'FTI ALL NON-POINT' AIR IIANDIJ NG ON]'I'(TO 10.1XX)CPM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING LINT r(OVER 111.001)CFM) CONSTRUCTION TAX
Signature of Applicant/Cuntracle, Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEB
HAZARDOUS MATERIA(S DISCI-
0111--Will the applicant or future building occupant some or handle h inside s maeinl IIEA1'INC,ON 11('TO I(M.000Ii I OI
as defined by he Cognomen Municipal Code.Chapter 9.12,and thn Ilcallh and Safety
Cadc,Section 25532(a)'! ,,, / HEATING ON]Y(OVER 100,000 BTU)
p acs XVII VENETTLAI'ION FAN(SINGLE RESID) PAID Use¢ RcceiplN
Will the applicant or future building occupant sew,equipment or devices which OOILL'R-COMP(1111'OR 11XLU0 RTU)
emit hazardous air contaminants as asi�by the Bay Arca Air Quality Management
Donict? BOILER-COMP(OVER I(X),IXXI BTU)
❑Yes
1 have read the Incurred.,nennuls iment,oder Chapter(x95 of the Coli. AIR CONDI'1'ION1eH ISSUANCE UATI�s
noise Health&Safety Gde,Section,25505,2.S nd 25531.I ler, et It the NEW RESIDENTIAL MECH. SQ.1T.
building dace net cumaid haveam at, Yaespen' ren thcaccupant
!
tithe rryuio I ch mil In tin isw Ove.
Owners nzeJ agent Data TOTAL: ISSUED BY:
OFFICE