S 1872 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUu,)ING-ELECTRICAL llll yIT NO.
BUILDING DIVISION APPLICATION/PERMIT PIAIMIIING.MHCHA,NICAL 1872
vl
BUILDING PROJECT IDENI IVICATION
BUILDINGADDRESS: l c SAN I'I'ARY NO, APPLICATION SU13MI'ITAL USE
Iik:SNAMEPHONE: CO Its NA 1L: LIC tyO,
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J e •/ NIC CON THill,p
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AS HE ECT INIIIiR F .ICNO. AtJURE.S: T ❑
Co PACT: PHONE: BUILDING PI7RMIT INFO
�V ❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLU❑MH MEC I
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 um licensed under pinsist is of Chapter 9(commencing JOB DESCRIPTION
M=z with Sec,ion70(moof Ommon 3o fine Hamnaa and Profashm.Codound my license isQ RESIDENTIAL
W 00 PERMIT'ISSUANCE El Ny�W in full termand effiro. SFDWI, ElKITC1117N REMODEL
<UULs'ene Class Lic# APPLIANCES-RESIDENTIAL CADDI'1'ION El PLUMBING RE-PIPB
1-Z W Dae Comntor
.<4 ❑AfU1TI-UNTf [I STRUCTURAL
ARCHITECTS DECLARATION
F m Z I undersand my plate shall rte n.ce l as public renrtJs PANEIS MODIFICATION
TO 200 AMPS
�Zr3G ❑IMPROVE ❑SWICHIMNEY REPAIR
F+13 g'W Uce,rscJ l'rofessinart Illi-❑MN)AMYS BATH RHMO B EISW 01.111 POOLS
�Y Oat I am exempt from Ce Conte ON OVER I(M OAMPS ❑BATH RHh10DE REPAIR ❑DEMDLTI'1QN
06'< 1 hereby affirm that 1 am exempt from me Contractors License Law for me
X4x(060 following reason.(Section 7031&Business and Professions Come:Any city or county SIGNS ELECTRICAL ❑OTHER
W G y which caluires a permit on construct,alter,improve,dentoli.sh,lir repair any snrcturc
a prions is isseunce,uNo...or. he applicant for such vamiuo filen signnitatemcat SPECIA1,CIRCtII'I')MISC.
`2 mut he is licensed puaunnt,o me provisions of she Cnntnmmr's License huw(Chapter'l
H00tn
foocerm'ng with Section 7(M)of Division 3 offiH E
e Business and Panooi,ars Code)or TEMP.M It OR POLE INST
C. mm he is escorts therefrom and Ibe basis for me alleged exemption,Any violmim of ❑NEW BI.UG/ADDDION ❑DEMOLITION
�N
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POW17R DEVICES
main or nun five hundred dollars($500). ❑TENANT ❑FOODSERVICE
7��ry+d p I,it vocrof the pntl,a,,or my employees with wages os Ilan,sole eompcma.lon, SW I M M I NO POOL I?UM RIC IEGMENT
R
^0o will do the work.and the swerve is nen intended or offered for wle(Sec.]IW4,Business ❑OTI TIIEB
6 3 ao and Professions Code The Comracmr's License Law does not apply w an owner of OUT LEI'S-SWITCHES-FIXTURES
prnpersy who builds nr improves durcon,and who d,.s such work hinnclf or through
his own employees,provided that such intpmvemecu arc not intended or offered for NEW RESIDENT[AL HLECTR SQ IT.
"Ar.ll;however the buadlngin,improvement is sold ,illnm one year nfcornpletier,he SQ.PC FLOOR AREA S/SQ.ET.
e>huimcr will have,hc hnnlen of proving that he did not huild or iinprnve for Pur-
puc Inat'.)
❑ 1.......of the property,am exclusively cramming with licensed contractors ro TOTAL:
Instruct the projcat(BUc.]BW,Business and protestors Caned The Contnce",Li.
se law does not apply ht an owner of proper,who bunds or improves thereon,unit QTY PLUM 3INGP MIT FEE
who cvnncta lin,mh pmjeen with a co bacto(s)hcnnsed pararama the Cmaactor'x
Liccnsc law. PERMIT ISSUAN H79,
l am esemps under See .R&1'C for Wis reason
ALTER-DRAIN&VENT-W (PAI VALUATION
Owner Dam
WORKER'SCOM PHNSAfION Dl the oliolim' BACK PLOW PROfIeCL DHVICI?
I lerehy icandmuter pcnnunyofperjuryoneofthe Bdlowlor Workeutions
❑Ihave and will malmalna Cetifie-um nl'Comenno Core,for for abatouce of h- DItA1NS-FLOOR.ItOOP,ARFA,G(1ND. STORES TYPI?CONSTRUCT]ON
workf as provided for by Sermon 3701 of she LnMtr Comes,for rhe perfnnnnnee of she
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will sale. on Waserfi n Cea a of th w n k to n hi h [is"'J by Senior
3700 MyW.'nba Labor Cancai 0 hupafnnuunierand work to Ibis Perrin is fissural. GAS-IiA.SYS'1'1?M-I INC.40UTLIffS OCC.GROUP ANN
Ca Workers Compen.valinn Innuranec courier and Policy number arc:
Cnrnior. policy No, GAS-13A.SYSTRMOVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS' GREASI%INUIISTRI.WASTE INTERCEPTORCOMPENSA'r ION INSURANCE; BUILDING DIVISION FEES
(This section rived nal be mntdiled if Ihepearit is for one humlral dooms($1 WI
of lac.) CI11iASli'I'RAP PLANCI IECK FEE
I cetify that in the performance of the work for which this permit is issued,Isued SEWER-SANITA BY-STORM F.A.200 FI'.
not employ my person in any manner so as to become subject to the Workers Compen. ENERGY FIJI
C) Z, saticn Lows of Califomin Date WA'TR IBiATF,R WNEND/F.LEMR
Applicant GRADING FEF.
O
Not 10E'TO APPLICAN'1:If,after nuking this Cunlficme of Even,,! you should WAIT 3R SYS'THM(I REAPING
abeenue xuh tO to the Worker's Compmsm,m provisions of the Luhne Come,yen rums, SOILS FEE
W forthwith comply will such proneiomonlis peomilehal be dcannicevoked. WAITR SERVICE
IL
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL 1'fA1R. SQ.P11 PAID
� 'z' Ihcrcb (firm thn,,here is cnnstmcrian rennin for the Entheses of Danes �cipt#
yr leading par
U O doe wok or which,Lie pcmit M issuuA IScc.3097,civ.C.)
fL F•' Lerida',Name TOTAL:
U�• LenJcrx Address 'TOTAL:W
1 certify that 1 have rev)this application and stone that the vintimidatingtvu inarion is BUILDING PER
tZt correct.I a'.to comply wimall cq dcounty ordinances andsmn laws reladngut Q'TY. MECHANICAL PERMIT FEE
7
U G handingeamn.alichand hereby omhnrizo retresenwlivcanrthiscity m ram,uporithc SHISMIC PEEi
abovcntcndnncl prnpeny foe inspection puHMne's' PERM[IISSUANCEIA,F.CfRIC IRili
O
(We)agree to save,indemnify and keep harmless the Cay of Cupetnin,agaie
Iiabiliries,judgonenrs,cost and expenses which may in any way accrue against said City ALIERORADD'IOMECIL
consequencein of the greening of this permit. PLUMBING Plil$
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING ONE I'(TO I0,000CFM)
SOURCE REGULAIONS. MECHANICAL FHB
T
AIR HANDLING UNI'I'IOVER 10,000 CFM) CONSTRUCTION TAX
Si,marenf Ap Immit/Cmdalcmr Dec EXHAUST HOOD(W❑>UCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the ap,Iii, ,,,Entire huddingcccupan,s1nrn nr handle wwridous Manorial HEAIINC,&IT('10100,010 BTU)
as d1durJ by he Cuponinn Municipal Code,Chapter 9.12,and the Ilet,h and Safety
@Mie,Small 25532(u)f 1 HHA'1'INC,UNIT(OVER 101.!10)HE
❑Yes E]No VLNI'l1A'OON PAN(SINGLE RESII31 PAID
eBORDate Rereeipt#
Will nheapplienntorfummhuilclingaceupunt uscequipmemordevoceswhich VEST IL-CON FAN(1'ORI E RUSH))
min lneudn is air mnli mans as refined by the Bay Are,Alf Quthy Managerial,0T-6f
El Yes ❑No BOILER-COMP(OV 1B1 100,00013'1 U)
I have read he),..Noes materials requirements under Chapter 6.9.5 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma health&Safety Code,Sections 25505,25533 and 25534.1 mmcmmnd that rthe NEW RESIDEN'I'I AL MBCA. SQ.ET. �-
hudding docs rat eun<n.ly have ("our.hat i,is my nal"omni fity to nodty the oecupam 1
of the requirements which must be mot poor o issuance of a Certificate of Occupancy.
Ownenrr amhoriam!agent Dam TOTAL: ISSUED BY
OFFICE