S 0418 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BDH,DIN'G-KLECTRICAL PogMIT NO. O
BUILDINGD VISION APPLICATION/PERMIT PLUMB NG-MECHANICAL S
BUILDING PRO(ECTIDEN'I'IF'ICA'1'[ON
BUILDINGAS�^< SAKI I'ARY NO. APPLICATION SUBMITTAL DATE
10L I
OWNER'S NAME: (w PHONE ACID NAME � EJC NO, 9;���
P SIC CONTROL
/ ARCM rECT/HNGINIiIiR: LICNO'. ADI PSS: ❑ 1
CONTACT: PHONE: BUILIJING PFRMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) hUG BIPLT PLUNIH MECH
` LICENSE[)CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT F E
1 hereby affirm that 1 am licensed under pnwi,ions of chapter v(cannmen arg JOB DESCRIPTION
vedir Sellinn 70k))of In
force mW,Ren)ivisianHn(Enc Buxinces unA Profuseiom'code. nyllccn,c iv RP I TI L
Iv O Q PERMIT ISSUANCE
Fu; tt t DW'1, ❑KI'fCHIiN REMODEL
aVV Liccnm Lica APPLIANCES-HESIDIiNTIA1. JADDI I]ON ❑PLUMBING RI 1'11'I,,
tF�ul Dam
Contractor
F,Oy III ECTS DECLARATION PANELS ❑h1Ul.l'1-UNIT' ❑STRUCTURAL
ZOu I understand my plans,ball Is,used ax public resort MODIFICATION
OZ-0 UP'IX)200AMPS [_1 INTERIOR ❑CHIMNEYREPAIR
rF=FW Licensed P,uhasinnal 201-I000AMPS IMPROVEMENT ElSWIMMING POOLS
j OR'NER-RUILDER DECI,ARAT ION OVER I(XM)AMPS ❑BATH RESIDUE JRHPAIR ❑DIih1OLITIGN
6 1 worthy ummr Thar 1 am exempt f, me Cod,arnas Lieclnec hose for the
sedx O i U follow'mg reaxm.(Section 9031.5,Business and Pmfution,Code:Any city art em my SIGNS ELECTRICAL ❑OTHER
W 3 i x Eich require,a permit It,conform,due.improve,demolish,or repair any'run urn
Oa prior to its mrance,also requires the applicant for such permit m file a,igned,tamnvon SPECIAL CIRCUIT/MISC.
,ESN mat be is licensed pursuant to the provisions oflhe Cotfavor'x License Law(Chapter 9
�O (commencing with Section]000)o(Division 3 ofthe Business and Professions Cade)or TEMP METER OR POLE INST. COMMERCIAL:
L p o a thin he i,cwmpt Ibercl'mm and the bask futile.11e,cd c cur,ina Any violation of ❑NFW BI,DG/AUDITION ❑DEMON I[ON
W Ira, Section 70315 by any applicant for a Writ subjects the applicant m a civil penalty of POWER DEVICES � ';NAN'f ❑1'OOD SERVICE mote than five hundred dollars($50(11.
PROVESIEN'T
6 7I,asowner of the propcny.or my employees with wago at their sale cvmnpensntion. SWIMMINGPOOLELECFRIC
will do the work,and the structure is not intended orol'lered for sale(See.9W4,Business ❑D'I'RER
W3. and Pmfcstiont Code The Contest Liceme Law does not apply to an owner of OUT[.E-SWITCHES-FIXTURES
property who builds or improven thereon,and wwu does such work himself or thnmgh
his own employee-,provided that such Innpmvemmats are not intended or odlered for NEW BESIDES]AL.17LECI'k SQ F1'.
sale w
IC h 'eves the building or improvement is wild wiminone Yearn(completion.the SQ.FTFL( RARIIA SISQ.14.
owner-milder will have the burden of proving that he did not build or impmvc for pun N. ^ O`2
pose of sidle.).
I,at owner of the property am exclusively contracting with licensed contractors to A
construct the pmjcet(Sec.9041.Husinosn and 1'm4conon,Code:)The Comractur',Li-
....
i- /t �St�
sc law does oul apply to inn owner of pmpeny who mAt14 or hnpnnes thereon,and QTY. PLUMBING PERMIT FEE N/L�.�a�� (,�(1
who contracts for such projects with a contmctort0 u
licensed pursuano the Cnmmm
er's
License Law. PERMIT'ISSUANCE
❑ I atm ucmpl nndcr See. .B A 1'C for Ihiv rwa
ALTER-DRAIN A VIiNT-WATER(F;AI VALUATION
Owner Dam '
WORKER:SCOMPENSATION DECLARATION BACK 17LOW PROTECT'.DEVICE
I hand willttrm under pewhy of e perjury one of the followimam for Workers
okerdeclarations Co
Qlbave and will maintain sCeniwcacof Conxcnor ,If-imam WriormaCnmpem DRAINS-I1,00k,ROOF,AREA.COND' STORIES 'TYPECONSTHl1Cl'ION
,mime,rte provided for hY Section H9W of the Luba G.fe,tar IM1e Icrl'ormuna of the
work fur which Thi:permit i,seated. FI%TURES-1'IiR TRA(' JJAI
❑ 1 hove and will maintain Worker,Compensation work
cc, h,his required!by Section
37N)(if the Latin Coale,Forthe perfimmnme nfthe work fur which,his permit is issued, GAS-PA.SYS'1'll (TNG 4PHIS OCC.CROUP AI'N
My Wnrkuv ampenmtionln,urance artier and Policy numheriere.
Cartier. Policy No.:�— GAS- � YSrEM11PI�i IEA)
CP.RFI•CA iOP E; 3MI'TION(ROM WORK.H.'
COMPHNSA'I'ION INSURANCE: 'AS: LWAST T'ERCEPFOR h///
(Ibis section need not Ise compleN ifthc permit is for one hundred dollars 15100) p BUILD(, DIVISION FEES
f
;A
or Less GR Q1 RAI' p PLANCHECK FEF,certify that in the performance of the work for which this permit iv issued.I'liall SEWER- HT-, 1A.21M1 FT
not employ any per`arn in any manner w o hmm ex it) subject the Workers Cummins- ENI2RGY FEE tait
z 'Z salon laws of CalifmAi,Date WNI HE IILAJ HR Yy 'F/EI,LCFk
Q Applicant GRADING IIiE
y NOTICE TO APPLICANT:If,after making this Ceroficam of Eumdism.you should WATER SYSTPM/fRF,A N G is
hecnmc subject an the Workers Compentmion provisions of the Labor Code,you most SOB, FI?II
forthwith comply with such priorities or pcnnit,M1vIlMAccmcJ revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW HESIDEN'GAL PhMB. SQ,Irl'. 1'MU
herby off res Ihnl there In n rnnsnnc.307.Cilending agency I'nr the perlinmmnce of
Du Iicaipll
Ne worki for which this pcnrt is issued(Sec.JOg9.Civ.CJ
OU Tcnde ,Name T(ylAl.:
Tender's Addrc,a
Fa 1 certify that 1 have real this application and sate that the above information is Bllll. NG PEE
rA emmn.I agree to comply with all city and county on innnces and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z holding eonamclion.and hereby tmtloriau rcprtsedulivev ul'Ihi city m corer upon the S.IS C ITH
ubwemenlioned pmpeny for inspection purpose,. PERMIT ISSUANCE
(We)agree to,ava,indemnify and keep hennlcss the City of Coliseum)against EL iCfRIC FL
qwj
Iiawilitiuv,judgmruus.eua,and expense,which may inony way,ecrocn'tull,and City ALTER OR ADDTOMECH.
in asequence of the granting of this permit. PLUMPING EE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CIO 10,000 CFM)
SOURCE REGULATIONS, MITCHANI AL FITE
0 AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRl T10N TAX
Ell—SV, uta of Ap dContmnnr Uulc L'%HAUST HOOD(W/DUCT) HOUSIN( h11'rIGATION FEE
HAZSRDOUS MATERIALS DISCLOSURE
Will lhcapplicamar futmelsaildingouOr,cm,orre nr handl,hosurdom material HEATING UNIT(TO 100,000 BTU)
u,defined by the Cupcnim Manic ipal Cuda Caine,9.12.; 1 the HeTilth:red Ssfmv
Cure.Section 25532(a)P HEA'L'ING USE F(OVER 100.000 BTU)
E)Ye C]No VEN'I'I LATION FAN IS I NGLE R PSID) PAID
\ Will the applicant or future building(ccupatn use equipment or device,which I Receipt b
t haivJnuv air contaminants as defined by the Bay Area Air Quality Management BOILER-COME CHIP OR 100.00,BTU)
�. striar T(ylAl.:
❑Yea MNo BOILER-COMP(;WIiR IIMLIMkI BTU( -
I have read the haeuNrus tnmerials rccmm ends under Chapter 6o5 of the Cull- AIR CONDITIONER ISSUANCE DAIS
Poria Health A Safety Gale.Scelion,25305,25533 and 25534.1 umkotand that if the NEW RESIDENTIAL MECH. SQ.IT
building does not currently have a tenant.twat it is my responsibility to notify the occupant
of mer;uirci wbieh mast Mme poor to issuance ata Cenine:ue or Occe,nq.
Owner to aulhrnocl agent Date st ISSUED BY:
OFFICE +