S 1817 (2) APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL Pel�lrr NO.
BUILDINGDIVISION APPLICATION/PERMIT1817
PLUMBING.MECHANICAL lV
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SAMI'ARY NO. APPLICAI'I ON SUBMITTAL DATE
�a o S'aN i-ow NAME. �� lit"
CONTE:
RACTOR'S NAM ,�QNPy.3�
f 14t
WACA,
Poe
ARCHITECT/ENGINEER. LIC NO'. D ESS:
❑
CONTACT: PHONE: IUILUING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PL;-HMyg/ MEc-H i
❑ ❑ 1�II��7J Ir1tl✓
LICENSED CONTRACTOR'S DECLARATION QTY. � � ELECTRIC PERMIT FEE
hShereby afrnm(list 1 am licensed ander provafors am of fouchning - .LOB DESCRIPTION
��o witcud,7 d))of Division 3of the Business and Profession,Code i Imyllanmis PLRMI'I'ISSIIANCE RESIDENTIAL'
F�py� to full foacuand rat , eK L44 :74
❑SFDWL ❑KITCHEN REMODEL
dVV I.icervse Cl. s \\ 0 Idea la L APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMBING RE-PIPE
In 7 a Dme ^ ` C<antrar we
ARCUI'I'F.CFS DECLARATION ❑MULTI-UNIT [:]STRUCTURAL PANELS
oza4Z lmnaer,larm any purr,shall he used r<rnmir rmemm, MODIFICATION
UP R)Zan AMPS El INTERIOR C1 CHIMNEY REPAIR
Licemed Professional 201-IIMAMPS IMPROVEMENT E]SWIMMING POOLS
(1WNIim R-BUILDER DECLARATION OVER IIIOOAMPS ❑BATH REMOD'IJ Jjl'/111{ Q3WA�0_LI�NN_
0.'{y�a 1 hereby a0h'm that I aesho,a four the Contracte
's License Low for the
V following baser.(Section]031.5,Bu,mess and Profussmns Cade:Any city or county SIGNS ELECTRICAL ER
��y
oy which requiresp It I I II 1 d P Ystructure 6-
ym< prior to itsis me,,l .hasuch,croutl file.si,rualsourearad SPECIAL CIRCUIT/MISC. -
0 mala licensedpursuant 0 nh Contractors L 1 (Chawae COMMERCIAL'
0 (ct e lhhere ]W(d rU' '. I fA B .' adP t Cdoof fP.MP METER OR DOLE INST.
t1 c Ihrt he s exempt therefrom and Lha bee's for the alleged exempt n Any 'eni on of ❑NEW BLDGIADDITION ❑DEMOLITION
^+� fieclinn]0315 by any applicant for a permit subjects the applicant m n civil penally of POWER DEVICES ❑ ❑FOOD SERVICE
nm mem than five hundred Jnllrrs(551)0).
IMPROV
F Z Y I IMPROVEMIiNT
'W�Ad El Lnsbe vorof mepn.thee be smot mendesw0hwagesnstheirsolo 044,Bteimmt, SWIMMING POOL ELECI'RIC
will dolhewons rod thm stnCtc Isomi Livens Lawdtls hot apply to
owner
❑OTHER
W"i m and Professions Code:The Contaemds License how Aces nm apply m un owner of WI'hF:I'S-SWITCHES-FIXTURES
3.. propery who builds a improves di,con,and who does such work himself or through
his own enarloyms,Provided hat such improvements arc not imendW men for NEW RESIDENTIAL.HLPAI'R SQ FT.
sale.If,IimVvegthe buildir,orimprounabre is sold within one year el completion,tire g0,.Pf. LOO A h S/SQ FI'.
wneuddar will have the bunlen of proving that be did not build or improve for pu,-
pa-h
oaemf,e
❑ 1,as owvenene pmJUL 10 ANr or mo penm
g am exclusively enmcdncontractors with licensed TOTAL,
consumer the project(Sec.7044,Bashers and Profession,Code:)The Contractor's Li- .
re Law does not apply to an ownmaofpropedy who build,or improves menton,and QTY. PLUMBING PERMIT FEE My / If
whrcommins holsuchpngea,with a comaramo accused pcomand u,t heC orwar's S+ UUrttillNu
Lints,,Law. PERMIT ISSUANCE
I am exempt under See ,B&P C for this reason
Owner ALTER-DRAIN&VENT-WAIERGIA) VALUATION
(� WORKER:S COMPENSAHON DECLARATION BACK FLOW PROTECT.DEVICE
ll had
will maintain
ai under penaltyof pc Cemordefcaf-ho lnwiar Walker,Cr.
�Ihave and will mrinhainaCeniriwlenfCmnsam memlf-insure for Workers Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONS'I'RUCfION
morn,a, Each h'for by Section d. of Ibe Lul.rt Castes fonhc pcdmmance of the
work for rairm ,Il a mi is issued, FIXNIttlS-PBIt TRAP
1 nave and a oft.fir Worker's Gaulufl ion Insurance,as requirul by Swoon
3700of the"be Craft.Ponhe perform soros wntl:to which Ibis permit lx issued, �� GAS-HA.SYSTP.M-I INC,4OUTLETS Nv OCG GROUP APN
My WU Co r tiI�on�lfftsu;,yyyy� aundPnlic ryp�p.� p
Can nicr �0s[lel'l�atric Palley No.� l l /1.d/�QZ CAS-EA,SYSTEM-OVER 4(CA)
CERUMCA'1'd OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASHIUMUSTRI.WASTE INTERCEPTOR
(This section nod not he completed i f the ,,are t is human,hwWmddellm00)s($I - BUILDING DIVISION
m less)(This TRAP PLANCHBCK PEE
I certify than in the performance ofthe work forwhich this permit is issued,l shall SEWER-SANITARY-S ORM F.A.200 FT
col aurpley any persm any ma so as Ir Ke bjce to the oaken CnnaFear ENERGY FEE
Z ration Lr -r f n in co��`O` ,W WNI ER I(HATER WNEN ULECTR
nnu d
� Appllemn � ^. n GRADING PBR
r.t h NOTICP.T LICANT:If,alae making this Cni Orula of Exemption,yon should WATER SYS'I'ENVI'REATING
aiheeome subject In the Walker's Compansmien prcv war,of the Lubar Code,you must I SOILS FEE
W fnnhwhh comply with such Provisions or this permit shall he deemed revoked. WATER SERVICE
a0,
CONSTRUCTION LENDING,AGENCY NEW RESIDENTIAL PLMB. SQ PI'. PAID
z Ihervby rlBnn that mere isrconstmdion leading agency loathe performance of Dyle Receipt
V
'he work far which this permit is isarml(Suit 3097,Civ.C.)
w F Lenders Name TOTAh
Lenders Address TOTAL: -
1 cenify that I have read this application and state that the above informntfon is BUILDING PEE
.rm emit,i agree louamply wimml enyand coumy ntdftumee,animate law,mdming m QTY. MECHANICAL PERMIT FEE
V building um,loclum,rod hereby curb cc occumr,esof mismry to enter mpumic SEISMIC FEE
ohovcmemioned pm,,Iy rot inspection purposes- PERMIT ISSUANCE
(We)agree to we,hadenhafy and keep harmless she City of Cuperine ogrinst 61,IiC'I'RIC FBG
liabilides.judgmen4,cossund expenseswhich may In any wayareme ugstn,tssid Cay ALTER OR ADD'IO MECH,
in sequence.1 he gdanim,of this permit PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WI'PH ALL NON-POP,HP AIR HANDLING UNIT(TO 10,kU CFM)
SOURCE REGULATIONS. MECHANICAL EEE
AIR HANDLING UNIT(OVER I U000 CFM) CONSTRUCTION TAX
Signature o'Applicanl/Cntraor Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the rMicunt or future building occupant pore or handle hamrdousmmedul HEATING UNIT(TO 100,000 BTU)
as defined by the Cupeninn Municipal Coda,Chapter 9.12,and the I Iumh roil Safely
Code,Section 25532(0)/ HEATING EST(OVER 100,000 BTU)
❑Yewptvo PAID
VENTILATION PAN(SINGLE RGSID) Doe Rcecipt#
Will the applicant or future building ocwp id use equipment or devices which
emit hoarrdim,air contaminant,us defined bymc Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
District, TOTAL: /
�Yav � BOILER-COME(OVER 100,003 RTU) �
1 have read the hocardoes materials requirenren is under Channel 695 of the Cali- AIR CON DI'I'DONEE , a ISSUANCE ATE
fomta Health&Safety Code,Sections 255115,25533 and 25534.1 understand that if the NEW kF.SI DENTIAL MPRH. SQ.FT,
hap�gou?
Aoes nota areoyhaveatutant,maI yresponsfbility to assaylhe,eciurm,
Ym
n .,, Is Sl' til `be mol print is e efe Cenificate�offt, �,e
mhonmd,gem+`S L )me 'roTAl.: 30, rssueD u@
OFFICE