S0001 B 0356 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
I CH'Y OF CUPERTINO BUILDING-ELECTRICAL PRRM�O. O 3 5 6
APPLICATION/PERMIT PLUMRINf.-MECHANICAL L. 1
BUILDING DIVISION BUILDING PROJECT'IDENTIFICATION `0001
BUILDING ADDRESS. /' SANITARY NO. APPLICATION SUBMITTAL.DATE
'9S�
aWNER'SNi: `jFMNE CONTRAL'Ok'S NAME: LIC NO:
NIC CONTROL
e -
CHITECUENGINEER: PJC NO: ADDRESS: ❑
CONTAAGCT: PHONE: BUILDING PERMIT INFO _
M t Ne -Vetivell A) 22y 03 ❑ Consultant Fees Paid by Applicant(Initial) BLDG M
LEC( u0 MECH
LICENSED CONIRACTOR:S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
{O{s�0Z with Section 7")of Division 3 ofthe Business and Professions Code,and my license is 3 e"'- RESIDENTIAL:
F�� in full fofceand effect. PliliMll'ISSUANCIi O 0SFDWL ❑KITCHEN REMODEL
GVzt.J IJceme Class Lice APPLIANCES-RESIDENTIAL
F Q W Dale Contractor ❑ADDITION [I PLUMBING RE-PIPE
rn a ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION
F 7 m PANELS MODIFICATION
Z, Z l undcrmnnd my plain shall M used as public records UPTO 200AMPS m
OZ-0 ❑INTLRIOk 11 CHIMNEY REPAIR
r;/r,t."W Licensed Professional 201-I0II0AMPS IMPROVEMENT [3SWIMMING POOLS
S g 7-1 OWNHR-BUILDER DECLARATION OVER IINNIAMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
R�C U 1 hereby uffnn that 1 vin exempt from the Cessions o License city
o for the C.
xox. G V following mama(Section]moan Rosiness and Professions Code:Any city or county SIGNS 131.EC1'RICAI. ❑OTHER
W WO y¢ which fcquims a permit to ro.the aper,improve,h mad' or repair any soucturc
-fn va.i 'hot hes lsamncaen oto he tro,ki far , ,Licensefile- -neJ statement SI'13CIA1.CIRCUIT/MISC.
Yl> nornmrem,with
pursuknt 70th)of Disidr.tithe Commarrts License Law(Chaphrr9
AGO (et he n,eslatoa Seeinsto and the
Car oftheeged e.conlion,Any
vi Cadet or TEMP.METER OR I'OLC INS3',
6 y p n COMMFtICI
Shut he is esempl therefrom and Ne apeim t We alleged exemption.Any violation of El NEW BLDG/ADDITION ❑FOOD SERV(
trX] 4yy
Section]O3 LS by any applicant for n permit subjects the applicant mecivil penalty of POWER DEVICES ❑'fIiNAMf ❑1'000 SERVICE
FZY not ane than five hundoeddellers(S5(0). IMPROVEMENT
21 [JJ�as ownerofthe xvperty,ormyempinses with wages as their vale compensation, SWIMMING POOL ELECTRIC
wdl do the worhe k,and the trmor eis nm intended oroffemd Imsalu(Sce.9014,Business ❑OTHER
W�3 and Professinns Code:TCotham
mors License Law docs tot apply an owner of '3 OIfILEfs-s W ITCIIFS Ty,
.. properly who builds or improves thereon,and who does such work himself or through
his own employees,prm'idcd that such improvements are not intended or offend for NEW RESIDENT ILW41f SQ Fn
sole,If,however the building aro improvement is sold W WHO one year of completion.the SQ.FT,FLOOR ARIA S/, 1•T.
owner-builder will have the FuNen Of proving that he did not build or impmve for par-
accfl
po1,as e.). in,pmp)ny,nm exclusively contracting with licensed cantremrs to
cmtstruct tho project(Sec.7044,Business and Professions L.:1 I'He Canoucto, Li-
ceeWawdoesnotapply70anowncf Of foppery who builds or ne rooesthercam.and QTV, PLOMBINGPERM FEE
commasD
who forsuch prts ojecwith a mmfac r(a)licensed pursunat m the Comractmrs
License Law,. PERMIT ISSUANCE
I am exempt under S .B&P C for this moron
ALTER-DRAIN&VENT-WATER(EA)
wner Dam 1
WOR KERS C MPENSATION DECLARATION BACK FLOW PROG!Cf DEVICE 4
[hereby union under penalty of perjury one of the fallowing declarations:
❑I have and will maintain aCenibcmeof Cansemmmlhinsumfor Workers Compen- DRAINS-Fl.00R,ROOF,AREA.GOND, Ip G)NS'IRUCPION
kation,as pnwlded far by Section 39110 of She Labor Code,far the performance or he -
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will mmntuim Wnrker'x Compensation Insurance as inquired by Section
rw
er
3900 Of the labor Cade,for the pemorsmme of the work for which this permit is issued. GAS-FA.SYSTFh1d INCA OUTLETS OCC.GROUP APN
My Workers Compensation IrWOmWc caner and Policy number are:
Comer: Policy Na: GAS-FA.SYSTEM OVER 4(EA) Y
CERTIFICATE OF EXEMPTION FROM WORKERS' GNIiASFJINDIISTRI.WASTF.INTF.RCEPI'OR
COMPENSATION INSURANCE - BUILDING DIVISION FEES _
(Thi....an.need not be completed POpermit is for one handled dollars($10(h GREASETRAI'
or less.) PLANCHF.CK FIEF -
Imnilythatinthepoffunnunecofileworkforwhicht his permit is issued,l sholl SEWER-SANITARY-STORM P.A.200 FT.
not employ any penon in any manner so as mecu
bome subject the Wnderi Compen- IiNERGY FEE
Z sotion laws of Cclifnmin Data WA'I ER HEATER W/VENT/EIECR
Applicant ( GRADING IEE
ti
NOTICE TO APPLICANtt IL seller making this Cenific.m of Exemption,you zhnuld WATER SYSTEMl1REA1'ING
a beeome subject to the Workei s ComperSsmion provisions of the labor Code,you must 5011 S FEE
forthwith comply with such provisions or Shis permitshall W deemedrevnked. WATER SERVICE
a
� Z CON51'kUCt'PON LENDING AGENCY NEW RESIDENTIAL.PLMI1. SQ.PT. LAID ale Receipt#
L) thereby from 11nonaem iso conslatemn lendingage.ey fm the performance of
the work for which this permit is issued(See.30)9,Civ.CJ
0 L) Lenders Name TOTAL.:
LSI Lenders Address 'TOTAL:
C6 1 certify that 1 have mad this application and state rant the above information is D L 'FEE
W correct.I.gree tt comply wish all city and county ordinances and soon,laws relating m QTY. MECHANICAL PERMIT FSE
V Z Wildingconsuuction,and hembyanhome rtpreweramwes.f.hiv ciytoenba.pon the SEI a1 FEI3
.lame-mentioned property for inspemion purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hardens the City of Cupcnino against EL RIC PER
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
I.consequence of the groaning M this H. PLUM NG FEE
APPLICANT UNDIIR.' '/DO DS VI LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 1(kIXp CFM)
I MECHAN AL FEE
j1.URCI:R, UTATI( AIR HANDLING UNITVER IO,OINICFM)
`O� 9p (DCONSTRUCTION TAX
Signature rfApplicanUCnntractnr � Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FTSE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant(it fwum building Occupant sorraor handlehamrlous momrial HEMI ING ON['P(TO 10009)BTU)
as defined by the Caperton)Municipal Cade,Chapter 9.12,tad the Health and Safety
Code,Suction 25532(0)7 ,/ IDEATING UNIT(OVER 11X1,(00 BTU)
FI Yes UNo VENTILATION PAN(SINGLE I2ESID1 PAID
Late Receipt
1�1 #
Will the applicant or future building occupant use equipment of devices which
enlS hazardous air ronmminanu as Jefnul by the Bay Area Air Quality Management BOILER-COMP f3HP OR 100,0110BTU) T 1
District? #
❑Yos BOILER-COMP(OVER 100,000 BTU)
I havered the hazeNoux matmialerequifanenm under Chapter 6.95 or the C.HAIR CONDITIONER. ISSUANCE DATE
It Health&Safety Cade,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH, SQ.FT.
WildingdtmsualC roc ly Invent .that it is my responsibility to notify the occupant
ofthere viinme 'h must prior m issuance Of a CeniOcme of pancy.
Af
\ wneema rzedagent ate TOTAL: ISSUED BY:
OFFICE