S 3161 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
AL
BUILDING DIVISION APPLICATION/PERMIT PINGPRNGCTIDEN IT FIC S 3161
BUILDING PROJECT IIJEN'TIFIL'ATI(IN
BUILIIINGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
OWNER'SNAME: PHONE: CON'FRACTORSNAME: LIC NO.
MELSv� L, / Z/ / gy>•�v/^/J� J�/ SEC CONTROL#
• ARCHITECT/ENGWEER: V LIC NO: ADDRESS:
-a'G�La-V'1 1. ❑
C 77
CON'T'ACT: PHONE: BUILDING PER INFO
--512,7 ❑ consultant Paid by Applicant(Initial) BLDG ELECT' PLUMB MF.CH
❑ ❑ ❑ ❑
LICENSED CON FRAC'I'OWS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby anent that Sam licensed made,pmof stoor chapter m(commencing JOB DESCRIPTION
nogZ with Section 7NX))afDivision3af Oa Businessand ProfessioasCde.andmy license is RESIDENTIAL:
WOE in lull force and gifted. PERMIT ISSUANCE
ul" �� ❑SFDWL ❑KITCHEN REMODEL.
�UU licence Lic.p APPLIANCE ti-RESIDEN'HAS, ❑ADDI'T'ION [I PLUMBING RE-PIPIT
F Z W bate TS DECL
Naa' ANCIIITF.CTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
PANELS MODIFICATION
z IunJcwanJ my plans shallhuuJ az public recnNz
UI'T02(M)AMPS El INTERIOR [I CHIMNEY REPAIR
Q oft b. LlwmnJ Prafe"000d 201-IOWAMPS IMPROVEMENT C]SWIMMING POOLS
a' J OWNIiR-BUILDER DECLARATION OVER IW)AMPS ❑BATH REMODEIIREPNR ODEMOLI DON
C Q 1 hereby aRrm that 1 am exempt from the Contracmr's License Law for She fixx' .U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
F µ0 y which requires a permit to construct,alter,improve,demolish,or repair any structure
#Tato its lsmamce,chm reclaims thcnpplicunt fur.vuchpermit to flan signcdatamncnl SPECIAL CIRCUFUMISC. fy
that he isliccmed pursuant to the provisions ofthe Contractor's License La (Chapters
1IyOC, (commercing with Section 7000)ofDlvision3mfac Businessand ProlessionsCde)or TI!MI'.METIiR OR POLE INST. COMMERCIAL
ti a c tY that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^'u' Section 70315 by any applicant for ap mout%objects the applicant a civil penaltyol' POWER DEVICES ❑TF,NANTb. ❑FOODSERVICE
^ n t mom thin five hundred dollam($500).
iZN 0THE IMPROVEMENT
a l]Lone wornflhc de,rusumenyotime badtfrhwmgn as tha(See mmpen>iness SWIMMING POOLELECTRIC�Swill Professions
wons Code
The Coreia tori Licameoraw ed does rot apply to an owner of ❑OTIJIiR
%L2 and Professions Cole:The Contractor's License Law does not apply m an owner of OUTLET'S-SWITCHES-FIXTURES
pngtedy who hould nr improves therea r.and who Jocs ouch work himself or through
his own employees,providd in,,,such intpmvencents am not intended or.1mo d Tor NEW RESIDENTIAL BLkL'!'N SQ I .
sale.If.however,the building or imparcomat is%old within one year of completion,the SQ.FT FLOOR AREA $ISQ.PI'.
owner-builder will have the burden of proving that he did not build or improve for pur-
onic of sale.).
0 I.......cr of the pra,icly,nm ex6movely cammaing with Iicen%nI commetnry I,, 'f(YTAL:
mstrmctthe prajed(Sec.904,Busier,and Pmfesians Crab HireContractor%Li-
censeLawdoennotapplytounownerofmoemy who build.%or improves thereon,and QTY. PLUMBING PF.RMIT FE
who mntmcts for such pmjects with a Commands)licensed pursuant to the Conamber'x
License Law. PI7RMIT ISSUANCE
❑ tum exampluoAer See ,B&PCliathurernon �,
pwne Da¢ ALTFR-DRAIN&VF WA'TEA7(I!A) VALUATION
WORKER'S COMPENSATION DECLARATION PACK WI'ROTECT.�OBVICE
I hereby affirm under penalty of Penury one of the following declarations: ( %J
I have Intl will maintain a Cendicare of ConsennnndGlnsurefor WnrkersCOnrlvm GRAINPI': R
OO .ROOF,AREA,COND. S'fOR RS tVPF.CONSTRUCT SON
sal ion,es provide)for by Section 3200 of the labor Cade,for the perfam
rnnce of the _ 9
work for which this#droit is issued. FIXTA-. -PERNTRAP'
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 ofne Lobar Cde,for lire pc,foormateof the work for which this Amon is is%ocd, GAS-EiSYSTEM-I INC.4 OUTLETS LICE.GROUP AI'N
My Workers Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: GAS-EA SYS)TEM-OVER4(FA) _
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFII IlUSTRL-WpS'1`EIMERCIiI'TOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
nal
(Thisse,foa need heeona,leed ifthe pconil i%tar atm hunlmdal htrs S 100) GRF.ASL'rTRAP ^�or less.) PI, fljX FEE ! .73 a 4�
Icenify tharsom to pa,aedfitm.else s week far which thispermitW i%iss,Cmapen. SIiWER-SANITARY-STIR, .200 FT.
nm employ any person in any manner so us��e ysst �ef the Workcri Compcm Et(3/171313
0 Z xmion Tat %'C�lihrtnia,D G WA'I'IiR HLAfHR WNENT .1 A NG FEB
z 0 Appllcanl
N NOTICE TO APPLICANT: making Nis entp lS{R,'yOY should WATER SYSI'i!M/iREATI NO
h ; became wbjed m the Workers o pen%ation en s sN IM1e - r Cade,you matt -S.11 S Flil!
Wfnnhwirh comply whir such pnrvi minion thi%perm to land revokul. WATER SERVICE
COtthemRUCTION LENDING lending
agency
NEW RESIDI!N'1'IAf.PLMH SQ.FT. PAID
V 0 Thereby off lm Oat isaconswdion lending agency fonhe performance of Date Receipt#
Pthe work for which this armil is issued(See.3092.Civ.CJ
Lender's Name Al
W Lender's Addee, TOTAL'.
')+ W i BUILDING FEE
1 certify that 1 have read This application and slmc Ihm the above information is
W correct l agree to comply with all city and counly ordinances and state laws alluding to QTY. MECHANICAL PERMIT FEE SEISMIC FEE /
U %Z buildingcommaaion,and hereby refomat represeatativesofthis city tocnterurym the
aMwe-mentioned property for inspection purposes. 11I7RMU ISSUANCE
(Wr)ngmc m save,indemnify and keep harml,,the City of Copanam against P.IF. R FBF,
liabilities,judgments,cssartudexpenses which may in anywayeceme againstsen City ALTER OR ADDTO MECII.
inconccquenceaflhegrelningafthis'refit. PL GING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT ATR HANDLING UNIT(TO UT00d CFM)
ANICAL Fit
SOURCE REGIA, pp �Q !
�/ 1 5516 AIR HANDLING UNIT(OVER 10,000 CPM) CO S'UtUCTION'TAX
Signature ofA,1 mmior Date IU(HAUST HOLD OVIDUCT) SING MITIGATION FEE
HAZAR SMA'I iuU SDISCLOSURE
Will the applicanfulamn 'cupant store or handle harallons material I STATING UNI'T(TO 100,000 BTU)
as Jenard by She Caliendo Municipal Code,Chapter 212,and the Ihealth and Salcey
Code,Settle.255320)P 1 HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No p
VLNTILAD(>N PAN(SINGLE RESID) -Dam Rea'eipt#
Will lbe applicant or future building occupant use equipment or devices which
enol hazardous air commournls as defined by the Buy Area Air Quality Manugmnenl BOILER-COMP(3HP OR I00,000111 US
> Dismicl:' BOILER-COMP(OVER I00,00i
❑Yes FIN.
I have rend lire hamNnno na cmd,rcgnircmans under Chapter 695 of the Cali.. AIR CONDITIONER ISSUANCE DATE
hours Health&Safety Cade.Sections 25505,25533 and 25534.I undcmtand that if the NEW RHID17NTIAL MECII. SQ.FT
Wilding does not currently have a tenant,that it is my responsibility la notify the occupant
of the requirermms which must be met poor to issuance of a Cenificau i f Occepaocy.
Gumma auhorimd agent Date TOTAL: ISSUES)BY: �
OFFICE