S1116 �APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CjWV OF CUPERTINO BUILDING,-ELECTRICAL PIff ND
APPLICATONIRMIT PLUMRINC-MECHANICAL
1116
HOLDING DIVISION
BUILDING PROJF,CI'IDENTIF'ICA'fION
I-BDILDINGADDRESS: SANI'T'ARY NO. APPLIC I[ON SUBMI'TT'AL DATE
_- � Ns; � - tGq�
I?R'S NAME: PHONE'' CONTRACTOR'S NAM)?: LICNO.
/ - NIC C(1N'I'ItOL%
LOVA&j
�ARCHITF.CT/ENGINF,F,R:' LIC NO: ADDRESS: ❑
GON'I'ACI': PHONE ❑ Consultant Fees Paid by Applicant(Initial) BLDG BUI EDICT PERMUMRNFO MECH
177-.7,o32— - t5f wy ❑ ❑
LIGLN$ED CONTRACTOR 5 DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby off..one,h I licensed d p f Chapter 9(commencing
� Z with Section 7000)ofDivision 3 ofmc Bun and Professions Code,and my license is RESIDENTIAL
Op - PERMIT ISSUANCIi
=_a L License
Claand eRcct. ❑$)'DWI. [I KITCHEN REMODEL
e-u Licenu Class I.ic.N APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE PIPE
F Z W Dam Conlmcror
nnGL ❑MULTTLPHT ❑STRUCTURAL
,zlARCHITECT'S IIBCLARATION
FmZ Iundcrswndnryplansshall l ca„dr,,rNil,m,m , PANELS MODIFICATION
OZ=C UP TO 200 AMPS ❑IN'TERIOR El CHIMNEY REPAIR
��~+W Licensed Professional - 201-100AMPS IMPROVEMENT C]SWIMMING POOLS
J OWNER-BUILDER DECLARA'T'ION
C Q I hereby affirm that 1 am exempt from the Contractors License Law far the OVER 1000AMPS El BATH REMODIiI/REPAIR DEMOLITION
3
lL w fdlowitlg ne..n..(See,inn 7031 s,Bionnexs and P...la..ions Code Ali,city or enemy SIGNS ELECTRICAL ❑o'n1ER _ � -�Q(
y which require.,a amill to convouct,alcor,improve,demolish or or repair any.Intu
ere
,0 5 prior i its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUI VMISC.
That he is licensed pursuant to the provisions of the Connector's License Law(Chapter 9
Wap0 (commencing with Section 7”)of Division 3 of the Business and Profusions Code)or TIME.METER OR POLE INST. COMMERCIAL:
n.E e that he is evmnpt marefmm and the hasis for the alleged exemption.Any violation of - ❑NEW BLDG/ADIII'IDON ❑DEMOLITION
Ed^,N Section 7031.5 by any applicant far a Permit subjee,s Lha npplicnm m a civil pemahy of POWER DEVICES ❑'1'I?NAN'f �FOOD SERVICE
not more than five hundred dollars S500). IMPROVEMENT
SSCLos owner of the pmpcny.or my employees with wages as their tale romP¢manion, SWIMMING POOL.ELECTRIC
p. will do the work,and the%tucture is not intended oroRW
ered for sale(Sec.Jf ,Business [I CARER
a i m and Proh,...no,Code The C t t L Law does act rp,lyh,an wl OUTLETS-SWITCHES FIXTURES
propertyMinh ld-ar improve,th nd he doc,rah linkl If through NCW kE.SNEN'1'IAI.F.LECTk SQ PI'. -�
his pl yea Pr ded Ih t nth' p I:ort n t I 1 J ff red for
sale If hs
ooe,the building or improvement is sold withino yearrol completiort'he I Aptly 9SQ'14'
whine Id will havetheh N f prom,that h did t build pm for P ' 1 u
pox f. ). TOT'AL: / .
❑ 1 - f thep , ty exclusively t f , II I Inst to AN 6 p
anti 0th perfect(S 9040BusinessdProcessions Code:)Th Contractor's,..
ccs Lad t apply to a fP property 'h builds P m: o PLUMBING PERMIT QTY. PLUMBINPERMIT EEE Cir
who contracts for such projects with acomrxmr(s)licensed pursuant to the Contactors City ANO
License Law. EPRMIT ISSUANCE VVrCI
❑I and cxcl p)trtder Sec. .R&P C�'fie his nione I 1 II y V
zx� Fa-�y— ALI ER-DRAIN k VENT-WAI FR(EA) VALUATION
in
WORIER'S COMPENSATION DECLARATION/ � r BACK FLOW'PROTECT.DEVICE
In,
hereby off nn der penally of perjury one of the f011oxing Jed;vations: -
El Ihuvc and will muinmina Cenifcate nl Conwnun%df-insure for Worker's Cnmpero DRAINS-FLOOR.ROOF ARBA.COND. STORIES 'TYPE CONSTRUCTION
,tion,m provided m,by Scetion 5700 ri the Lahur Cudu,Toa Ibe perfnnlanee nI'the
work lin which mi,pmm�il is i...od. FIX'I TIRES-PER'I'RAP
❑1 have and will malmaln W'orker's Compensation Imuence,a,required by Section
37M ofthe Labor Code,for the performance of Ne work for which this permit is issued. GAS-EA.SYSTEM.]INC.J OU'T'LETS OCC.GROUT' APN
My Worker's Compensation Insurance carrier and Policy number arv:
Cron, Policy Nn.: OAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASOINDUS,RL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION ITIS
fDlis section need not be completed ifhe permit is for one hundred dollars GREASETRAY
or less.) PEANCHECK FEE
I cartifythal in lheperformeaccofthework fnrwhich lhiapemmil is issued,Ishull SEWER-SANITARY-STORM lin.2N)IT,
nut emPrison any peany manner so ax m bemmn subject m tltireWarkery'Cumpmn- ENERGY PER
ZZ xmira Laws of California.Date W'AI'FR HEATER WNENTIELFC'I R GRADING PEE
O Applicant
NOTICE TO APPLICANT:If,after making mix Certificate of Exemption,you should WATER SYSMU TREATING
r !n SOILS FTI:
become h ora o the Workers ComPcns Ihis provisions of the Lelwr Code,you most.�j ti
forthwith comply will.vuch provision.or Phis permit xhnll tic thenad rcvnkcJ. WA'ILR SERVICI?
WW Q
zn) z CONSTRUCTION LENDING AGENCY Nil W'RESIDENT'IAI.PLMB. SQ IT. PAID Dam ii p
U O I hereby affrm that is a construction lending as...yfenheperfamlanaeof
the work for which this permit is issued(Sec.3097.Civ.C.) TOTAL:
Com) Lender's Name I(YI'AL:
Lender's Address ,
d 1 eenify that I have read this application and state that me aMrve informaw.it is BUILDING PEE
Hy correct.l agree to comply with all city and rounty nNinanecs and slam lows relatingm QTY. MECHANICAL PERMIT FEE SEISMIC PEE
U Z hulldimgcovswchon.and hereby'authorize representatives ofmiscity menter upon the
aMrve-mentioned pn pety for imPaatinn Intl PERMIT ISSUANCE ELECTRIC FEE
(We)agree tat sor,indemnify and keep hunnlnex be Cny of Cuperino ogoln.t
Iiahilitiesjudgmenls costs and expenses which may in ally way accrT B
ue against City ALR OR ADD'TO MUCH. PLUMBING LYE
in msxquence of the granting of thi%permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ONIT(TO IR000CFM) MECHANICAL TEE
SOUR 'REGULAT N
x�
(✓/ AIR HANDLING UNIT(OVER 10,00()CFM) CONST RUCTION TAX
gnaore of Aican ontmmor Date EXHAUSTHOOD W/DUCT) HOUSING MITIGATION PRE
HAZARDOUS MATERIALS DISCLOSURE
Wi a applicant in more huildingucc.pond mtmorhaaft,haxrvdom material HEATING UNIT(TO 100.001 BTU)
ax defined by me Cupetino Municipal Code.Chapter 9.12,and the Health and Safety BEATING UNIT(OVTR Ifx1,lNX1 BTU)Coda,Section 25532(x)'!
❑Yes ❑Nn VENT IIATION FAN(SINGLE RESID) BVD
Uam ke<cipl p
Will the applicant or future building occupant useyuipmem or devices which BOILER-COME UHP OR 100,000 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TH'
District? 13011.1?R-COM 11(OVER I01t0d)BTU)
❑Yes EI No
I have readdre haardous memmils mquircmcnts uoder Chapter 6.95 of the Cali- AIR CONDITIONIER ISSUANCE DATE:
Shama Heald&Safety Code.Sections 25505.5533 and 25534.1 umlerstand and if the NEW RESIDENTIAL MECH. SQ.Pr.
building does me currently have a enact.that it is on,re,mr,ibil'ty it,notify the occupant
M the ngmmementx which most hamar prim to issuance of a Cumficam of ccupancy.
Owner or aumorixed agent Date TOTAL: ISSUED BY:
OFFICE
i.
i t
4
Z
_ L '
�� s o
�I CD Q z
CL
92 w ~
w
Z d
LLJ w o[LUI v
Q w O }}} I
—� cLi
A LIE=
CD
l
Q
C�
�x
Kary Lee Cochrane •
SmiorAarnciale
19200 Stevens Creek Boxlaard,,Suile 200
Cupertino,OA 95014
Office(408)996-0100 Far(408)9969008
M
Texx
TIMM
WINNER
•