S 3158 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELECTRICAL 1.17 11 NO
RUII,DING DIVISION APPLICNFION/PERMIT PLUMBING-%tEcunNIC.AL J 3158
BUILDING PROJE.CP IDF:NI'IFICATION
IfU1LDING AUDRIi55: SANITARY NO. APPLICATION SU13MI'I']AL DA]I
OWNS 'S M : PHONE CON'IRAC'IOR:SNAMB: LIC No
if NIC CON'IROLno
40 ARCHETECI'IENGINEER: LIC NO'. ADDRISS: ❑
COnTACT: ('HONE: BUII,UING PIiRMI'1'INFO
7.7 —q,5VO ❑ Consultant Ems Paid by Applicant(initial) IfI.DG n1.ECr 'Lu MOH
C•/ •/VLL[CF.NSED CONTRACTORS I))ECLARA'1'IONJ ' QTY ELECTRIC PERMIT FEE
I wmhy.Im.t mm Imo Eccnos nude,pmvmh...at Chapte,9(,rannoenuins JOB DESCRIPTION
M=Z with SeNon9000)of Division 3ofthe liusinc¢.nJ Pmfeaions Cdc.andmyliccn.als RESIDENTIAL:
W O O PERMIT ISSUANCE
tr+ In lull forccmW dlkct, ❑SFDWL ❑K[TCHENREMODEL
aUyV Licenw Class Lic'N APPLIANCES-RESIDENTIAL []ADDITION ❑I'LUMBING RE-PIPE
6 W Wm—Cammcmr
0. ARC]IITECGS DECLARATION
PANELS ❑MULTIUNIT ❑STRUCIVRAL
MODIFICATION ZZImadenaanl myptmxshal beused mpuhlc mcrnd. ❑ HIMNLY REPAIR
O = UP TO 2m)AMPS ❑INTERIOR
ka.`_F_-Wj Licensed Professional 201-IIXIDAMPS IMPROV17MINT ❑SWIMMINGPOOIS
OWNERBUILDIiIt DECLARATION OVER IIxNIAMI'S ❑ TH REMODEIIREPAIR ❑UEMOLII'ION
C W Q 1 hereby union then I..cxanpl from the Cnmrunor's License Law for the
XO W U following m:non.(Soon 7031 5,Business and Prufc,sion.Calc:Any city or county SIGN$ELIiGTRICAL OTHER
U 3 LL EFwhich requires a parr l to construct.alter,improve.demolish,or repair any Immure
.�.OG prior,,which
ionumca.ko caluires the applicant fornnch permit tome a signed statement SPECIAL CIRC JVIA SC,
C„yah
that he is limned pursuant to the gnviown,of the Commends License Law(Chapter 9 COMMERCIAL -
O (cannwiter,with Seaton71AN0of Division 3 of lbe Bmincss and Professions Crle)cr TEMR METER OR POLE INS)
d 6 C Thar he is cxanpl therefrom truth,busts lira the alleged exempamm.Any violation of ❑NIIW BLpG/AU ( ON
W ovi Section 703 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES pcna ❑TENANT ❑FOOD SERVICE
e than fisc hundred Jolla,,($500), IMPROVF.MIiNT
FSD FITas owner of the property,or my employees with wages as their sole comMnsution. SWIMMING POOL ELECTRIC ❑OTHER
It will Jothewod,unJ thcxWdurcixnolimendcd orulTercJ(or xaI'(Se'7094.Bmincsse77 10
3 W and profession.Cale:Doe Contractors Licese Law dues nal appy wan owner of LOU'II_Ers-SWI'rCllliS-FIxTUktts
pmpnrty It,,build-11 intprnwn,ummin,and who does such work h+maelf it,through
his own employees.provided that such impnwenwa s arc not intended or offered for NEW RESIDENTIAL EI ECI'R SU 14.
s:Jc.IL bowcer,the huilAing nrimprnvemcnt is sold within one year of conmpletion,the SQ.IT.I7IAOR AREA ISQ.Ir.I'.
cr-bullder will have the buNen of proving shut he did and
M1uilcior improve fur pur-
panc ed sele). TOTAL: O
❑ [,;is owner al the pwpeny.am exclusively contracting with licensed conuuc"'^m 8661 8 T AON
cnnxtmct the pmi Si law.Business and nnde
fession.Co :)The CentracmLi-
cense
r, - L a
c c Low does not apply.an owner of Conroy who hulldsormprovex lbua,n,tall QTY. PLUMBING PERMIT FEE
who cormactx for such projects with a rornewbo(s)licensed punuanun the Csmeremr's
Liam'.Low. Q
❑lam exempt er Sec. R&P C I this canon
ALT[R-UkAIN&VIiNT-WATIiR(I?A) ALl1ATION
Date $Oa
IN DECLARATION RACK ITAW I'ROfIiCT.DIiVICIi
1 hr cby ulEnn under penalty of q+rjury ane of the fnllowin6 s ceLvu tun
❑ I have and will maintain a Certificate o(Consenuo calf-insure for Workers Compen- DRAINS-FLOOR.ROOF,AREA.COND. STORIES 'I'YI'EC0NS'1'RUCI'1(1v
xado.,ax covidcd for by Scet'wn 371x)nl me Lthm Coda or the of ton
wTyt
d,for which this pernil is issued. FI%TV kl!S-I'liR t'kAl'
37 I have and will maintainc Wurerfor an a ofilicw rkfor cc, it nyuireA by Section
39fM)nf the LahorCale.motion performance of the work for whicM1 this Pcnnit is iseuon. GAS-IiA.SVS'IEM-I INC.40U'TI,II;S OCG GROUP AI'N
My Worker' Compenxtnlon lismancecncier and Pnheynumherurc GAS-IIA.SYSTEM OVER4(EA) � .� 2
Cartier. Policy No.: J
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASTANDUSTRI,WASTE I :RCE.ITOR
COMPENSAD
' ON INSURANCE BUILDING DIVISION FEES
(This welion need not he completed if the permit is Income hundred dollars(SIM) GREASETRAP
VLANCIIIiCK PIiE
or Ices.)
Iready that in the
mu cnmpiny any p.7x qan:ryfnnmmu. of workfor which this permit isaSEWER-SANITARY )ORM iA.3%Fr.
ENERGY IBE
nnu...as o bsa,cawsubject c he Wnet,C.....l ,-
nn in to
Z, satin.Lsws of California.Date WATER HEATER /VEN'T/ELE:CTR GRADING FEE.
zApllicvm
.N.
NOTICE 10 APPLICANT:IL after making this Ccnificam of Exemption.You should WATER SYS' :Mll'REAI'I NG SOILS FEL!
a > become xum,C w thc Worker's Corop le pion pro visiuns of the Labor Cole,you mot
IJ.I fanheah comply withsuch pm,i,im,o,this penmen.hall be deemed revoked. WAIEII TtVICE
y
= Z
CONS'1'RUC'r10N LENDING AGENCY NFRI?.SIDICNTIAI.PLMB. SQ.FT. PAID
,m R«eiptp
U O l hereby ammo thauhem is.cnnawction leadingagency forthe performance of
D. the work Iia which this ronin i.is.mcd(Scc.3w97.Civ.C.) 'TOTAL:
Q Lenders Name TOTAL:
C) IU Uudcrx Address BUILDING FEE
y 1 comfy that I have mad this application and ante that the above information c /.
F-t v) ....-c et ingreen+comply with all dry and conmyordianme,cad slate acv,olming In Q'I'Y. MECHANICAL PERMIT FEE SEISMIC IEE
U huilJin6 construction.unJ MmbY authnri'r<repmunntivez nl this cilY toemerugm the
rhove-amntioned p tTeny for ins,awtimm purpows, PERMIT ISSUANCE ELECTRIC FM 4�
(We)agree it, own.indemnity and keep baonless the Cay of Cupmmao agaimt
Iiaikucx.Rdgments.costs and expemes which may in any way acerae against said City ALTER OR ADD TO MECIL PLUMBING Ell
in nsyueaccof the F' +gel this Proud.
APPLICANT UNI .,AND .COMPLY WITH ALL -W NT AIR HANDLING UNIT(TO I8.Ix1(i MECHANICAL FEE
SO I . s iC - IONS
/y AIR HANDLING UNIT(OVER Iugg0CFM CONSTRUCT ION TAX
Si of,pp livoutfComtl
rnor D c EXHAUST 11001)(W/DUCT) HOUSING MHIGA'IION THE
HAZARDOUS MATERIALS DISCLOSURE
W the applicant or future budding occupant store or handle barardousmaterial I ILA'IINGUNI'f001(djudcur'
as J ed by the Cuperine Municipal Cale,Chapter 9.13,and the Health and Safety HEATING UNIT(OVER IM )BTU)
Calc.Section 25532(.)! 1
❑Ycs ON. VENTILATION FAN(S GLE BESIDE PAR
arc Receipt x `
Will the applicant or fawn building(occupant equipment or Jevitts which BOILER-COMP POR 1118.(x10 BTU)
unit h,radoux air ctmommion u,u,.)diced by the Btoy Arca Air Qwlity MManagementTOTAL:
s
District" BOILER-C( P(OVER Loddon BTU)
pros ❑Nu
I have rcadthe hwnnlB,neaccals a under Cha tar 695 ofthe Cali- AIR CO' 1'I'IONIiR ISSUANCE IJA'I'E
top 5533 a p
fending oesn SafetyCode,a.ea ou 25505,15533 mycesd25534.1 to actsun Ius, the yE ESIUEN'I'IAL MISCH,
M1uilding Ateu not cutmntly hmculcnant,Ihahis my rengmsihilitym ratify teoc lam
of them rnt nem Prinnoixmunmml it onifmamof cols
GerrlmauunpIn TOTAL: ISSUED BY:
or
OFFICE