S 1219 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PEB ftp NO. 1219
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL `V
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICAI ION SUBMITI'AI,DATE
2C
'S NAME ' PHONE � C(INTRACTOR'$IAMB: LIC NO:
O azcz N/C CONTROL#
( ❑
ARCHITECT/ENGINEER: LIC NO: ADDRESS:
/ ,6 X D e? e
CONIAC': PHONE: - BUILDING PERMITINFO
❑
Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB ]"i
❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT PEE
1 hereby union that 1 am licensed under pmvrdons or Chapter 9(commencing _ _ JOB-DESCRIPTION
COZO with v000)orDivlsion3ofineBusinm%and Pmfcssiom eone,anc myhemn%cis RESIDENTIAL
F PERMIT ISSUANCE
in full 1,111,and effect. Q SFDWL ❑KITCHEN REMODEL
�UF License Cl. Lin.#
U APPLIANCES-kBSIDHNT1At. ❑ADDITION ]PL11M61NG RE-PIPIT
F'yg W Dam Cmnrfmlor
m Q ❑MULTI-l1NIT ❑MODIFI URN.
Caml be 'oi DE,mIia TION PANELS
Z y7� lsSunaarsmnd mY Plum sM1nll he used ns public records CHIMNEY
DZi,,,p UPTO 2110AMP5 ❑IN'T'ERIOR ❑CHIMNEY REPAIR
F Cued Licnmed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
QQ'' OWNERBUILDERDECLARATION J(��
CL"� se OVER Hand AMPS ❑BATH REM II E �ITION
CCLL W¢' 1 hereby,Nee tial 1 1 exempt from ado Carou'rus License Law for the
O M V following reuena($ectiun]0315,Bu.viness and Prolcssium Code Any city or manly SIGNS ELECT REAL
❑OTHER
W 3-'0 col M1 I P u t t 'It p d M1 pl Y:uucture /^
Fiery pri t I I q 'm 'ppl' II hp a II 'g (Chaps tet SPECIAL CIkCU1TIMISC.
�¢1y matt licensed 11 the Provisions 0th L t Ir L L (Chepdcr9
C4'os,d� (commencing w'th beunn]IHNY fD'vix ot3 nfmc Bu% mss and Podwsinns Cody or TEMP.METER OR POLEINS'f. COMMERCIAL:
d poi o C
deaths i.exempt I...ofmm and the 1,....for the alleged axemp0nn.Any ram ma of El NEW BLDGIADDITION ❑DEMOLITION
W.m.0.N Section 91131.5 by any applicanl for a permit subjects the applicantto.civil penally of POWER DEVICES ❑TENAN'T ❑FOOD SERVICE
I-. nom'lre than llvc hundred dollar.155111). IMPROVEMENT
C.iQ I] I,as owner of We propeny,or it,employees with wagesas their sole compensation, SWIMMING POOL ELECTRIC
f.� oil dome wouvana thostrucmre is nm intended or offered fursale(Sar.9044.Business El OTHER
a.rand Profevsionx Code:Lie Contractors ll Law does not apply to an owner of WThHP$-SWITCHES-PIXTUHHS
property who hu'dds or improves diatonic and who docs such work hansalf ar through
his own employees,provided that such improvements me not intends(]or offered for NEW RESIDENTIAL ELECfR SQ FT.
sde.ILaw,wegthebuildingm improvomcm issnld within onoycar ofmmplutinn,the SQ.PT.FLOOR AREA S/SQ.PI'.
ownsolaulder will have the burden of proving that he did not build or improve for pur-
i polo of sale). P
❑I,as owner of the propady,am exclusively contracting with licensed contractors to AL. A
acoun the project(Sec.704 4,Basin....and Pro(%ions Cade:)The Contractor's LJ-
censeLowdoes aolapply teanownerof)napery who builds or impmvesmnccn.and QTY. PLU INC PERMIT 'FEE
who contracts for such projects with a cantmlicensed par to the Connector's - ES
License Law. PERMIT IS. 1 ANS
lamexempdander .Ser. ,B&PCfo tasrca.nn
Owner Data AurER-DIM019N'1'-WATER(EA) UUP,VALUATION
WORKER'S COMEENSA'HON DF.CLARA'1'ION BACK FLO PROTEC ICE CnI1/pV
Ilinewaffirm under peachy ufperjury oncaf Iha following reel Jinn
D I have and will maintain a Certificate of Consent to self-insure rot Worker's Compen- DRAINS-FL k ',A OND. S'IOItIES TYPE CONS'fRI1CPION
sadism as provided rot by Section 37M at the Labor Cole,for the performance of the
work far which this permit is issued, FIX'I ORES-PE TR
❑I he,, d diner coin Wrukaex Corona -fan,Insurea's,as ne"aideal by Section CAS P.A.SYSTEM I IN L
39110 fah Labor Cod 1 thepef cause of the work far which this mid is'.med. OCC.GROUP APN
yW k / I I : dPfyn� GAS EASYSTFM-OVER4(RA)
Ca ' PI yN
is
L k' MCAT OF COMPENSATION
FROM WORKERS'
LOMI PNSATION INSURANCE CRGASBIINDfJSTRL WASTE IN'IHRCP, OR
s - ='f BO_ILIJINO.DIVISION FET"
(Thissr,am,necdood be armpleted i r the pramid is fmnne hundred dollarx(5100) w —
or lase.) GRBASE'BAP PLANCHECK FEE
I certify that in the peA'oomenceofthe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM F.A.200 FT.
nm employ any person in any manner stn as m hceomc auhjoo m ue Workers'Compcn_ ENERGY FEE
Q Z san i Laws of Cchfurnia.Date WATER HEATER W/VEN'TIELECTR GRADING FEE
y Applicant
F7 NOI'ICH TO APPLICANT:If,after making thi%Cenifcale of Exemption,you should WATER SYS'FHM(I'RP.ATING
F hccnmesuhjeo In the Worker's Cumpan%adon provisions of the Luber Cade,you Tull SOILS FEE
�y forthwith comply with suchpmvixiarror(bit permit shall be deemedmvokcd. WATER SERVICE
7sz CONSTRUCTION LENDING AGENCY NEW RESIDEN TIAL PLM. SQ.IT fPLUMBIFEE
e eceipt#
1 hereby affirm that them is a comtmc0on Iending ngency forme performance of
U � the work l'orwhich this pemrit is issued(Sou.3099,CIv.CJ
W Lenders Name TOTAL'
U Lender's Address TOTAL:
I cenify that 1 have mad this application and slam that the aMwe mous inion is -
mania 1 agree to comply with all city and county ordinances and sure lawn relating to QTY. -MECHANICAL PERMIT FEE
Uzi building construction,and hereby authorize representatives of(his city to enter tout We
shove-nientioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep Imrmleas the City of Cuperlinn against E
Iiabllilies,judgments,costs and expenses which may in any way acme against said City ALTER OR ADD'TO MECH,
F.Ein SCANT ofme grantingof this permit.APPLICANT U :RSTAND9 ANO WILL COMPLY WITH AhL NON-POINT pll<HANDLING UNI'1'ffO 10,000 CPM)SOURG'E REGIA 4'IONS, - EAIR HANDLING UNIT(OVER 10,0001 CFM) ION'rSignature ofApplicat onmaarn Ue EXHAUST HOOD(W/DUCD I'1'I GAT ION 'sE
HAZARDOUS ATERIALS DISCLOSURE.
WiIItheapplicantorfuture budding acntpemstore or handle hazardous material HLA'I'INC.UNIT GO 100,000 BTU) A.
as defined by dre Cupertino Municipal Code.Chupler 9.12,and the Health and Safaty
Gude,Section 25532(a)R HEATING UNIT(OVER 100,000 BTU)
ED Via, El No VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building I use equipment or devices which Date Receipt#
Ip dbythenBOILER-COMP(3HPOR I(O,000BTU)
ecoid hamrdous vir comaminams as JCGned by the Be,Area Air Quality Memgemem TOTAL:
� - finsluml BOILER-COMP(OVER IOO,WOBTU)
❑Yes ❑No
I have rend the hazardous materials Ls under Choler 6,95 of the Cah- AIR CONDITIONER ISSUANCE DATE
mg25533a p
rnmlogHealth
es&Safetytly hoe a tinas255ati 25533and25534. to aid
notiy amid th that Ilan° NEW RESIDCNTIAL MECH. SQ.NI'.
capart
of the re does not currently have a tenant,that it is ua ce du Cerif m notify the onus
of the rWuimmcnu which must be mel prior issuance of u Certificate of(Awapnmy.
Ownerurammazele,cur hale TOTAL ISSUED BY.
OFFICE