S 1809 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO.
BIVIIANG DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. 1809
BUILDING PROJECTIDEN'I'IFICATION
BUILDINOADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATEBUILDINOADDRESS
10-3 ,, Q.cJ 3 oSd p
OWNER'S NAME: PHONE: CO R CfOR'.' ME: .IC NO:
/ C�S' NIC CONTRODM
ARCHITE ENGINHIiR; LIC NO: / / ADDRESS ❑
CANT/� PlIpNF.: BUILDING PERMIT INFO
/JlL.._ 9 72/1 ❑ consultant Fees Paid by Applicant(Initial) Bu)G ELECT PLUM "MECfI
L , JJJ 444111/// ❑ ❑ ❑
LICENSED CONPRACfOR'S DECLARATION QTY- ELECTRIC PERMIT FEE 1 hereby affirm that I am licensed under provisions of chapter 9 Rnmme ring JOB DESCRIPTION
D a'2 with Seclnm Y000)ofD1v1 o3ofthe Bu:ilia:aw P +!,..ions odea Imylicemeis RESIDENTIAL
100 PERMIT ISSUANCE
C�� in full Run and ! n ms's D �� CSMWL ❑KITCHE REMODEL
¢UV License Cl s Liak APPLIANCES—RESIDENTIAL El ADDITION ❑1'LUMHING RE-PIPE
F Z W Dam ? Commcmr
'Do, E]MULTI-UNIT ❑STRUCTURAL
ARCHITECTS me DEC[. ION MODIFICATION
Z p N Z I under.unJ my plans shall be used ns public rennJs PANELS
OZ�O
Oil T021MIAMPS [I INTERIOR [I CHIMNEY REPAIR
F W Licensed Professiond 201-1011AMPS IMPROVEMENT CSWIMMING POOLS
�W 2; OWNER-BUILDER DECLARATION OVER IIXNIAMfS ❑BATH RIiMODF:L/RIiPAJ- QAX�IR�1 1.0 DEMQLITON
%=, 1 hereby affirm on 1 am exempt from the Contractors License Law for the COTTER bs��-- I s
W 3 es F fallowing reason.(Section 7031.5,Business and Professions Cote:Any city orcountySIGNS ELIiCTRICAL
y which requires a permit be construct,alcor,improve,demolish,lir repair ed mleme e
prior to it,issunncc.alw requiresthe applinm Entomb permit to file usigned smmmenn SPECIAL CIRCUI'1'7MISC.
t4 Ihw he is licenwd purseem m the pmvisionx of the Comracmrs Littnse law(CTapter9
w..00 (commencing with Section]000)of Dlv!OmJ ofthe Brionessand Professions Code)or 'CEMP.METER OR POLE INST. COMM RCIAL,
a a e but he ix exempt therefrom and Inc basis for the alleged exemption.Any violmloo of C NEW RLDGIADDITION C DEMOLITION
Xm, Section]031.5 by anyappliend fora permit subjeasthe appliromm.dart penalty of MOWER DEVICES CTENANT [I FOOD SERVICE
W^mSSnot more thin five hundred dollars($500f / IMPROVEMENT C ❑ I,us owner of Ne pnlpeny,nnny enlployms with wages us their sale aompmuanion, SWIMMIN .POOLELECTRIC COTHER
p. will Jnthe work.and the umewmis nil intended or oRered
finish, 7W4,Business
W m and Professions Ctdc:'IB,Contcacmrs License Law does not apply to an Owner of 01/TLti rS—SWITCHES—FI%T'URPS
� property who builds or improvice lhereon,and who does such work hhnsvlfor through
his own employees,provided!Ihm mch impmvemems are not intended lir offered for NEW RESIDEN'HAL F.LECTIt SQ Inn
sale.If.howler,the building or imptnvemern is sold within one yew ofcompletion,the SQ.FT.ILCI AREA VSQ.IT.
owner-huider will have the burden lir proving that he did not build lir improve for pur-
pose Of sole.).
F11,as owner of the propeny,ala exclusively contracting with licensed convectors to 'Tpl'AL:
comfort the prince[(Sec.71144,Business and Professions Cose:)The Contractor's To
ase Law does not apply to an Owner of pmpeny who builds Or improves commit,and QTY, PLUMBING PERMIT FEE
who contmets forsuch projects with o conlanclons)licensed pmsuanuo the Convectors
License Law. PERMIT ISSUANCE
❑
.,it exempt under Site ,B&P C for do,reason '
ALTER—DRAIN&VENT—WATER(FA) VALUATION
Owner Date
WOR KF.RX COMPENS At ION DECLARATION HACK FLOW PROTECT.DEVICE
1 hereby dlirm under penalty of perjury one of Ne following declarations:
❑Ibave and will muimninaCeniOcate of Consennoself-innme for Workers COmpem DRAINS—FLOOR,ROOF,AREA.COND. STORIP_S TYPE CONSTR UCTLON
sminn,as provided for by S,,hon 3]00 of the Ishnr Code,for the perf rmancr of the
work for which this permit is issued. FIXTURES—PER TRAP
gl�rhave and will maintain Workers Compensation Immance,as"fired by Section
37010 of the Labor Code,for the performance ur the work for which this Front is issued. GAS—EA.SYSTEM-I INC.4 oETLEI'S OCC.GROUP APN
My Workerx Inge swan Imo lice carrier olid Policy nun bl c f`r a ':�
Canner Policy No.: ONL_ �Vy O D GAS—fiA.SYSTEM-OV13N 4(FA)
CE TIFICATE OP EXEMI?ION IEOh1 WORK S' GREASIYINDUSTRL WAS'I'17.INTERCEPTOR
COMPENSM ION INSURANCE BUILDING DIVISION FEES
or less.)
(ITnsseenimins of hecmnplemd ifthe penitis for one hundreddollars(SI0() PIANCItECK FEE
GREASETRAP --- __—--
I nnil'y thin in the perfnrmmntent he work for which this permit is lWourl,l ehdl SEWER—SANIVARY—SFORM BA.200 FT.
not employ any person in any manner so as to become subject m the Workers'Camper- ENERGY FEE
smion Laws of Ca rtoo nes.Date WATER HEATER WIOERI'/ELEC R
z Q Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after conking Nis Certificate of Exemption,you should WATER SY$TEMinREA)ING i'►
F .OILS FEE,become subject m the Workers Compensation provisions of IIIc Uhrin Cole,you must V
Wbulhwith comply with such provisions lir this permit shall he deemed revoked. WATER SERVIC17
CONSTTI LENDING AGENCY NEW RESIDEM'IAL PLMIO, SQ.FT. PAID Y
p Ihereby aifanl thardsme is a coneuuction lending agency for the performance of
LJ
U the work for which this pemtit is issued(See 3097,Civ C.) .I.(YEAL:
U Lenders Name
LTJ Lender's Addmss TOTAL:
fyrl 6. I ready Nal l have read this appmlication man stale Ihthe above inlonnutinn is BUILUINC
it V) correct.l agree to comply with all city and county ordinances and state laws relining In QTY. MECHANICAL PERMIT FEE SEISMIC
U building convection,and hereby authorize representatives o this city to enter upon rhe
above-mentioned propcny for iuspeclion proposes. PERMIT'ISSUANCE ELECTRIC HE
(We)agree to save,indemnify and keep harmless the City of Copenino against
liabilities.judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECfI. P UMBINGM
in consequence of the scanting nT Nis Permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('TO IB,(gM)CI'M) MECHANICAL IEE
SOURCE REGULATIONS.
AIR HANDLING UNIT HOVER IO(M1 CFM) CONSTRUCTION TAX
Signator,of Ap,hpwoC7wu.cmr Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCI.OSURE
Will theapplirmt or fulurc building ouvpme score ur handle humNousnorcriul HEATING ON[I(TO 100,INN1 BTU)
a depots by the CoNdo o Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532(1)' HEATING UNIT(OVER 111000 B'rU)
L]Yes El No VEN I II.ATION I AN NGLE RESI D) PAID --
Date Reaipl R
Will the applicant or home building Occupant use equipment or devices Which ypILER—COMP(JHP OR 100,01(s)BTU)
chit hundons air contaminant ,
as defin.1 by the Bay Arca Air Quality Management TfttAL.
Domirla. BOILER—COMP(OVER 100,000 BTU)
❑Yes ❑No
I have readthe hamrdnusmaterials requimments under Chapter 6.95 of the Cali. AIR CONDITIONER ISSSUANCE.DATE
fnmie Neahh&Safer Code,Sections 25505.25544 atd 255]1.I unokrsmnJ slut if the NEW RI?SIDENTIAL MIiCN. SQ.FT. 2l7^
huildingJlcs nancu cmlyhavcumnann,nhmitis my respnnsihility al notify the recum / �^
nl'the ob,tr ni sn m'h etpfismR)issuance ol'u Cenilicatc of enpan
izcdagenl Da TOTAL: ISSUED BY.
OFFICE