S 1507 (2) -- APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.RLPICTRICAL PEgffNO. 1507
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL, lV
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATI
OWNER'SN E: } P ONE' CO R OR' AMG: LIC NO:
¢h1. �Qst 57��7 r NIC CONTROL#
•• ARC]II TEC'I'IENGINHER: LIC NO AODRII �_/ ❑
I�J�b 4i•/gJIY �:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
❑ ❑ lot ❑
LICfiNS[D CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
Inmeby IE of Ina1 terieceadanderund Pme,s of,Coder9(mmnense I, JOB DESCRIPTION
�OZ wire Seorcesu100)of Divisian3 aflhe 0asinexa and Professions Cede,and my license is RESIDENTIAL
�Fy� in ensc force and eliee PERM]IF ISSUANCE
QF.UU License Class Lic.# f ❑SFUWL LI KITCHEN REMODEL
NQ1 Dam Contmdnr T . APPLIANCES-RESIDENTIAL ❑ADDITION QSPLUMBING RE-PIPE
F. oilz all ammd.t,blic ATIQN ❑MULTI-UNIT ❑STRUCTURAL
ZO Z and J hull M used as puNic records PANELS MODIFICATION
UP DO 2N)AMPS [I INTERIOR ❑CHIMNEY REPAIR
F•4!:Y:I IACCnxd Prnresstonal 201-I0IOAMPS IMPROVEMENT E]SWIMMING POOLS
Oat lam exempt
fir nt the DECLARATION OVER IIXXIAMPS
��y
Q I heresy affirm IM1a 1 um eaempl from the Commmur's License Law for the El BATH RIiMODF.UREPAIR (]DIiMOLU'ION
X 0 IO following reason(Sectino 7031.5.Business and Professions Code:Any city or county ❑OTHER
47 LL.y which requires a permit m cnnsomr,idler,ire SIGNS ELECTRICAL
F..W.O prove,Demolish, fi repair any Nmaurc
priortoiliceuancPuNuantlo'bsthe
rovisiicunll'oesuch Cont=milmfiense ne(chaplaem SPECIAL CIRCUIT/MISC.
� mat lie is Reensea parxaantmme provismna none cantmclors Lieenae Dow(chaplain
GAO (emnmencingwilb Sedinn 7lNXBof lliviaian tat the Nuxiness:nW Pmfesaiwns C,,d.)nr 'I'TiME METER OR POLE INS T. COMMERCIAL:
d y o,Y ded he is exempt tbercfrom olid the basis for the alleged exemption.Any vialaion of ❑NEW BLDG/ADDITION ❑DEMOLITION
DXI INi Svaum7031.5byunyvpplicant fora pfrmitmbjaithe.pplicanuoacivil penally of POWER DEVICES ❑TIiNANT ❑FOODSERVICE
=0nI mem than five hundred dollLra($il NR.
❑1,asawacr of theprnpeny,or my employees with wager as theirsole dtmpensmion, SWIMMING POOL ELECTRIC IMPROVEMENT'
f..o willduthe work,xnd thestzuctumisnot imendedoroffared for sale(Sec.]6N,Business ❑OTHER
3 m and ProfeW I,Cale:The Contmcmrs License Law Aces not apply et as owner of OUTLETS-SWI'I'CIIHS-FI%'TURES
pmpeny who builds or improves Thereon,and who does such work himself lir through
his own employees,provided that such impmvemenb are not intended or offered for NEW RESIDENTIAL ELECTS SQ FT.
sale If,however.The huilding m improvement issold withinoneywr of completion the SQ.FT,FLOOR AREA $/SQ,FT.
ser builder will hove the burden of proving that he did not build lir improve ror put.
"a ofsnle.).
❑ I,as owner of the property,am exclusively curtrading with licensed contraetnrs it, TOTAL: `®
construct the project(Sec,7041,Business and Professions CNR:)The Contractors Li- A
euLawdtesnotupplymanownerofpropenywhobaildsorimproveslherenn,and QTY, PLUMBING PERMIT FF. i
who contracts for such projects with v contractor(s)licensed p irsvent it)the Comvictors
Liccnae law. PERMIT ISSUANCE
❑Ivmexemptander See. ,B&PCforthia mmr \SVVV
ALTER-DRAIN&VENT-WATER(PLA) 09,
OwnerDate ALUATIOI$ja
WORKER'S COMPENSATION DECLARATION RACK PLOW PROTECT DEVICE „1 �� v
1 hereby affirm under penalty of perjury One of the following dcdaations: \�`
El have and will maintain a Certificate of Consenuur
o self for Workers Camper- DRAINS-FLUOR.RUDE,AREA.GOND'
N STORIES TYPE CONSTHULTION
fl on,as Provided for by Section 371X1 of thb
e labor pe
r Code,for the rform ume of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insumnee,as required by Section
3710of the Labor Core,for t no perfonnvnce it the work for which 11o, —it isl mad. GAS-PA.SYSTEM-I INC.40UTLETS FCC GROUT' APN
My Workers Compensation Insurance carrier and Policy numhcr are:
Carrie,. Policy Has: GAS-FA.SYSTEM OVER 4(EA)
CERJ IFICAl E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRRASUINUUSTRL WASTE.INTERCEPTOR yU1LU1NG DIVISION FECS
This section need not he completed if the Permit for one hundred dollars(5100) GREASE TRAP' - - ---
or la's.) PLANCIIECK 1138
IayI that in]heperformance ofthe work!orwhicvv per W.Nis i,'Croshall SEWER-SANITARY-STORM EA.2IU FT.
eta employ nny pe t nncr set gyp, t m the N'nrkeri Campem ENERGY FEE
Z satin..Lawsaf Ca — Tec
WATER HEATER W/VENT/GLECTR
NOTICE
1 a
GRADING FEE
rsti NOTICE TOct the WortIf,hier,
afarmaking Isis Certificate h Exempting yon mama WATER SYS'I'FINUTREATING
FKi , femme scoop ut tic Workers Cnmpeor this previsions'of he deemed
Code,you must SOILS PEG
Lk)
forthwith comply with such provisions or this permit shall be domed revoked. WATER SERVICE
CONS IRUM ION LENDING AGENCY NEW RESIDENTIAL PLMH. Q.17L PAID
U IM1ercby arfmm the there isudmswdinn lending agency f«the Performance of Date Receipt#
LTsP the work for which this permit is Issued(Sr 3091,Civ.CJ
0 U Lendc's Name TAU:
Lander',Address T,
F y I certify that I have .it this applle is and sate that the above information is
BUILDING FT:C
V) cogen.l agree to comply with all city and county ordinances and state laws relming to QTY. MECHANICAL PERMIT FEE
U building cummonion,and hereby authorize repraetnaives ofthis city to enter upon the SEISMIC FEE
ahovo-meetin red progeny for impact Ipm,aw, PERMIT ISSUANCE,
(We)agree to save.indemnify and keep henalcss the City of Cupcnin0 against ELECTRIC :1'
habili]ies,judgmenu.costs and expenses which may in anyway accrue against said City ALTER OR AIIII TO MECH.
in OamaNuenee mile granting fill Permit. PLUMBING FEE
APPLICANT N ERSTANDS TWILL.COMPLY Wl1'13 ALL NON-POINT AIR HANDLING UNIT(TO 10,000CI M)
SOURCE RF J ADO MECHANIC .FEE
AIR HANDLING ON[['(OVER 1I,000 CFM) CONS'FRI ''ION TAX
Signature fAppli,, i)Cont ter Date EXHAUST HOOD(W/DUCT) HOUSIN MITIGATION FEF,
HAZARDOUS MAI ERIALS DISCLOSURE
Will the apPlicanmrfuwre huilding cecupunl store lir handle hazallouz material HEATING UNIT(TO 100k000 BITO
as defined by the Cupcnino Municipal Cale,Chapter 9.12,and the Health unit Safety
Code,Semon 25532(v)'f HEATING UNIT(OVER IMI,Mp BTU)
E3 yes WN.
VENTILATION FAN(SINGLE RESID) PAID Date ceipl#
Will(he farOrpcontaminants
ca M1uiWing by the ay Area
Air
mlityor Managemena,i.s whicht
BOILER-COMP OHP OR 100,000 BTU)
mit District?
ux aft comaminunks M JefinW by the flay Area Air Quality Alanagemem
Uisviet4 T(YfAL:
El Yea No BOILER-COMP(OVHR IMI,(NN)BTU)
1 have read the hazardous/s materials r AIR CONDITIONER ISSUANCE DATE
cyviremcna under Chvpld fi.95 of the Cali.
fomia Health&Safety Cade,Sections 25505,25533 and 25531 I undersand nor if the NEW RESIDENTIAL MECH. SQ.ET.
buildingd«s t rte I hvv aRoad,that it is my responsibility to notify the occupant
of Ibc rqui yt I M rod prior te Ixxuenca of n CmtiOrae ti f flan
Owner.oImaho .e est /7�[)am TOTAL:
ISSUED BY.
OFFICE