S 1343 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL ANG.ELECT'RIC'AL Pia YTNG.
BUILDING DIVISION APPLICATION/PERMIT PLUMRmG—MECHANICAL 1343
BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
'S NAME• Q PHON CO '1'ok:5 NAMIi: LIC NO:
NIC C(INTROLM
ARCHITECT/NGINEER: IAC NO ADDRESS: F 1-1
Tic
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) {LDG HLECr vLG R MECH
,vvr�z a ,-e 3Lu
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of chapter 9 hommencing JON DESCRIPTION
OCy cairn sermon 71X))0 nfDiviaion Jonhailaainas and Prafe,sian,coca,and ley),.ecru is RESIDENTIAL,
u 1_ PERMITISSUANCE
F U F- In full force and rYectJ ❑SFDWI. ❑KITCHEN REMODEL.
�UU License las ll�� Licb APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING Rit:-PIPE
N�W6 Dam ISDE
F onz ARCIIIT. Pre DECLARATION I'ANEIS ❑MULThUNIT ❑MODH STRUCTURAL
CArIO
p ZyZ mm nY�`.shat tsW us nlic rccnNx MODIFICATION
., epe! •ss..w pu UPTO200AMPS ❑INTERIOR HIMNEY REPAIR
1-,N, W Lensed Prnfe,x.....I 2014000AMP5 IMPROVEMENT MMING POOL-9
C{�s,,....11 OWNER-RIIILDER DECLARATION OVER 1600AMPS ❑BATH REMODEUREI'AI ❑DEMOLITION
a`
q I hereby.lair,.on 1 1. exempt from Inc Commis Co e:An l Law O for the
x 3 6 U )allowing lie,a (Semina 7031.5,Business addimprove,
Professions h,or Any city or county SIGNS ELECTRICAL ❑OTHGR
W which mynires n Permit m cnnstrum,ager,improve,Jemnlish,or repair say xtmcmm
1pp'LL'0� prior,.its kotanclodkoregnirex the aPPlicam for suh P
cnrmm
tit to file asignedsuneem SPECIALCIRCUIT/MISC.
A o') that heis licenud pmeuam to the Booki.mraffm Comreears).keno Law(Charier 9
�
�p� (commencing with Section]00d)ofDivision J ufthe Business and Professions Code)or 'IFMP.METER OR POLE INST. COMMERCIAL
W :
p� r� that he is exempt therefrom and the mesas tiro the alleged eoaroqu ce.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
PomH. Section]031.5 by mry applicant fors normal saMa:b thanPPliam to a civil penalty of POWER DEVICES
WWImola than llvc hundred dollars 1551%)7. ❑TENANT ❑FOOD SERVICH
F Z> IMPROVEMENT
6O ❑I,asowncnslthe Fm.eny,ar my anployces with wages us their sale compensation, SWIMMING POOL ELECTRIC
and Aothework,andtheswaurci.noty Liled nrnl do finor apply 91 N4.Business ❑OTFiHR
Lid
-" and Professions Code:She ConwamLs Lirensa Law does sol apply in nn owner of lU'ILIG S—SWITCHES—FIX'I'Uk
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such imponxmems arc but intended or offered for NEW RESIDENTIAL ELF.C!R S
,ole.If,Imwaver,the building nrimpmventem isold villimore yearol'completion,the SQ.Fr.BOOR AREA $/SQ.Fr.
ownerbuiiderwill have the burden of Proving thou Ate did not build or improve for Pur-
qsu of sale.) P A f1 I D
I,m r of the property am exclusively contracting with licensed virtue n at 1'
eensvuct tba projem(Sac.7044.11.6arss and Professions Cnde:)'lbe Contravene,Li-
censeLive does net apply toanownerofpmpvnywho haildsorimproves thereon,tied QTY. PLUMBING PERMIT FEIi (yn^^ p I(I n
who contracts for such projects with a cummemr(s)licensed museum m the Cormanoes MAR C7 ANS-0
License Luw. PERMIT ISSUANCE
E]Into exempt trader Sec. ,11&P C Immi,reamn
ALTER—GRAIN&VENT—WRIER LEA)
Owner Date '1)N
WOR KERS COMPENS A PION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under pcnalryofpvrjuryi cof the followingdedifirtions:
❑ I have and will maintain a Certificate of Commafso wIl-insure for Worker's Common- DRAINS—PI.00R,ROOV,,AREA.COND, STORIES TYPE CONSTRUCTION
sation,as provided far by Section 3700 of the Wiwr Cale,far the perfamana of the
work for which this permit is issued. Fix rokES—PER TRAP
I have Ind will msinmin Wm9vrs Cnnmcnwlinn Insoance,a,required by Station
3700of the Lather C�aree,,Iffarrl he yPeeformance afthe work for which this plaitisissued. GAS—EA.SYSTEM-I INC.JOIPI'I.17S OCC.GROUP APN
My Wor"xA�Cory/2 �roel'oliey Noeyli ���(1 GAS—BA.SYSTEM-0VER 4(RAI
Carrier.
CHR')'IFICATH OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE CRI{ASEINDUS1'RL WASTE INTERCEPTOR
BUILDING DIVISION PEES
(This xrtinn need no,he cmm�lemJifthe permit is Throne hundred dalton(Elnb GRIZASE'I'RAI'
or less.( PIANCHECK THE '214 ,-
Ioyanyuerromino its,aerfonnanccoastoberk for wNchthto the ail is Workers'
Compnh SEWER—SANI'fAkY—STORM EA. FI'.
natemploy any pemnn in any manner so anmhecome wM1jan,.the Workers Cmm�en- ENERGY PF.Iitoy %5--
zZ Salam Lowsof California.Date WATER BEATER W/VEMIAiLECTR
O Appliemt GRADING Prf.Vj
LiorI NOTICE TO APPLICANT.If,oder making this Cmificnue of Exemption,you should WATER SYS]EM/rREATING
abear,..subject m the W'orkees Compensation Provisions of the Labor Cale,you must SOILS Fii
[Ja forthwith comply with such provisions or this pamtit shallM deemed revoked. WATER SERVICE
4 Q
Z) z CONSTRU(TI(1NLENDING AGENCY NfiW RESIDBN'I'IAL PLMB. SQ,IT. PAID Date Receipt4
U Q l Lintelmishauhem iseco (See.iun len ding agency fur 0e perfnnnanee of
the work for which this permit is issued flee.3097,Civ.L'J
[t, I-s Lenders Nune, TOTAL
U Lenders Address TOTAL:
>s 0. 1lenity that I have read this aPPlicadnn and state that the abase information is BUILDING FE
rA correct.l agree to comply with all city and county ordinances and state laws relining to QTY. MFCI{ANICAL.PERMIT FEE
U Z bung onusamdion,nnJ hervM1y amhnriu mpmsenmtivev nf0lis eiry to ether upon tM SEISMIC IT
odbove mentioned propcmy far inspection purposes. PERMIT ISSUANCE
(We)agree,.save,indemnify and keep harmless the City of Cupenino against ELECTRIC F.li
liabilities.judgments.costs and expenses which may in any way accrue egainq said City AMERORADDTOMECH.
nseyuence of the gmming of tllis pemtit. PLUMBING TE
APPLICANT UNDERSTANDS AND WILL.COMPLY WITH ALL NON;lKN`T AIR HANDLING UNI'L GR 10,000 CFM)
50UR! CRE ✓tATI(sNS. �� F I CONSIR I ALFEE.
VS/L � � y�/I AIR I{ANULINGIINIT(0VER 111,1%10 CPM)
111 / CON59'NU TI(3N'TA%
/ Si ammof Applicam/Contmvtor c' Dam HXHAUSTIIOOD(W/DUCT) HOUSING ITIGATION TLE
'I)
HAZARDOUS MATERIALS DISCLOSURE
Will the uppliatmor I'mure building occupant store orhandle hazardous materialHEAfING ON]T(TO 100.010 BTU)
as defined by the Cul aninn Municipal Code,Chupler 9.12,and the Health and Solely
Calc,Sarno.25532(a)7 / HEATING UNI'T(OVER 100,110011TU)
❑Ycs }R1
VENfIIATI(3N PAN(SINGLE RF.SID) PAID
Dmc R ceipt
Will the applicant or future building by the B use a Air cut or devices which
emit hazardous air contaminants as definer)by the Nay Area Air Quality Managemmal BOILER—COMP(31{p OR II%IAgI PI'U)
District!
❑Ycs [j'ICsl BOILER—COM 11(OVER 100,000 BTU)
1 hall mad the hazardous materials mquiretnums under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505.2.5533 end 25534.1 i ndersmud Ihm if the NEW RESIDENI'LAL.MECH. SQ.FI'.
boildimgda no,currently baveaterutn,that it is my msponsibllity as ready the oeeupam
of the reyulmmams which,.hist In rant prier n)issuance of it Cenifieme of 0,eirs ncy.
'1 Owner or authorized agent Uam 'FO'1'N.: ISSUED BY:
\ OFFICE Ire