S1704 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull DINT:-ELECTRICAL I'LIW\VITND, 1704
BUILDING DIVISION APPLICATIONIPERMIT PLU)HBN;-MECHANICAL
BUILDING PROJECT IDExi*BtCA'TION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMIITAI.DATF.
OWNER'S NAME() PHONE: CON a R'S NAME: LIC NO, NIC CONTROL#
•'ARCIIU ECT/ENGINEER: LIC NO: ADDRESS' ❑
S e �
CON'I'ACr: PHONE: UUILDING PERMIT INFO❑ Consultant Fees Paid by Applicant BLDG IiLECf PLUMB MECH
V ❑ ❑ ❑
CENSED COMRACI'OR'S DECLARATION QTY ELIiCIRIC PERMIT I°L'L'
z 1 hereby arum chat I am Recused under vrn,i,mn,of Chanter 9 motnrmmcmg JOB DESCRIPTION
woo with Section 7X10)of Division 3 of the Business and Professmns Cale,and mylicanse i. PERMITISSUANCI? RESIDENTIAL,
F1= inI lit oae and Ofga. ems.- ❑SFDWL ❑KITCHEN RFMODEL
QUU Liccns n. � hic.p APPLIANCES-RIiSIUIiN'flnh ❑ADDITION ❑PLUMPING RE1'II'li
Fz61 Slum Cnmracn
yQaNUI:1'1-UNIT ❑STRUC'I'UNAI.
ARCIII"rliC'F'S DEC[.DECRATION
PANELS (rAO111FICATION
ZOy,G, lundcrsmnd my plvnushvll he used as public ra;oms n(
UP TO 21X1 AMPS
pZ.—G+ L)INTERIOR IMNEY REPAIR
F-��W Llccn.cd Profe„Iaoal 2111-1000AMPS IMPROVEMENT 0SWIMMING POOLS
CZ�a OWNER"BUILDER DECLARATION OVER IOIXIAMPS ❑BATH REMODEUREPAIR 71 DEMOLITION
I bench}ulDnn(Stec 1 am ummpl rmm the Contmcmh License I,aw fur ilia
X3 i F- following reason.(Section]031.5.Business and Profession,Core.Any city or county SIGNS ELECTRICAL ❑OTHER
W a'N which requires a pcmm to comtmet,alter,innprmc,demolish,or repair any%trucmn
prions its issuance,alsa requires the applicant for such permit o file a signedstammcnt SPECIAL CIRCUFDMISC.
} that he is licenced pursuant to the provisions of are Contmctoh License Ltw(Chapter
�CpO lamnmcncing wish Section sX(F,f Division Sof the Business and Prefesiom Cod0e, TEMP.METER OR PULP INST. COMMERCIAL:
d d c C (hat he is exempt therefrom and he bnsi,for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Salton 90315 by any applicant ford pcnnit nnbjaas theapplicant toa civil penalty of POWER DEVICES ❑TENANT [I FOODSERVICE
not mum than five harcuMdollura($5(ap.
I.as owner of the n.or rot Toms with wages their so le cons arlmn, SWIMMING find,1➢JiC'I'RIC IMPROVIiMI?N'I'
mx,l Y YcIay ga as ,lmvi ❑OTHER
F+ will It thession,and me he Cmem,no',Lie crw ,a.do for.(apply to ar o.,wr of
0. m and Ihtdud,b Cad e:The Cev chemo License[,a.does
such work
s unowner of OUTLET. -SWIIC,I{ES-PI%'TURES
his O ny who build.,or sided es'thech i and who does inch tinte himself or lhnmpM1
his own ennployees,provided that such innprmcmenls are not;mended or offend for NEW R 1NTIAI.RI.ECI R Sp IT.
sale.If.howevcc the building or improvement is sold within one year of completion.the St .IjL IW�REA $/SQ.Pr.
cr-builder will have me human of proving that he did not build or mutative for pur- 1N9
paa I ).
owner f the property an exclusively contracting c( g with license)cancert rs m TOTAh.
1 c
ctaistructth project(S ]OW Hasincr,%ardProfessions C+d:)Th Courriterse,1-
cause
JUL ^� /UW°D
1 wdoes nor apply( owner of roperty whobulds prones theist and QTY- PLUMBING NIT FEE
who conaucrs For such project,with u ennmmaa(s)licensed Eunuant to the Conlmemr's C(,
Licence Law. PERMIT ISSUANCE 1 I Y Ur uvrr;n I IPA)
❑
1; uxcmpt under S— .It k P C fur(his reason
AL'rP.R-DRAIN k VIiN'1'-WATER(hA) VALUATION
Owner Data �f�
WORKERC�
'S COMPENSATION DECLARATION BACK FLOW PRUTECK DEVICE 1 00
-1 (Sterols,eRrm under pemalt,of perjury one of the following declarations:
❑.Ih.ex.ad will maintain a Cinificmeof Convect omlf-in...amr Wod¢ra Com,u- DRAINS-FLOOR.ROOEAREA.COND, STORII-S TYPE CONS FRUCTION
scion,as provided for by Section 3700 of the Lalasr Code.for the performance of the
stark for which this permit is issued. FIXTURES-PER*1 it AP
[g,4.va and will maintain Workers Cnmpenution Insurance,as required by Section
3900 ofthe Labor Code.toy performance of the work for which this permit is i%stmd GAS-EA.SYS'I EM-I INC.4DUE'LETS OCG GROUP MIN
My W k��[[ C ,roc Ton Ise martini Policy y foliar arj-
Carrie TZAiA.�Nw A—Y I'ul'mY NndK•� GAS-BA.SYti'I'I?M-OVER 4(EA)
GERTIFICATH OF 17X 17M IIHON('ROM WOR KE RSOREASEINDUS'I R L WASTE IN 11',RCEPFOR
COM PENS A'I'ION INSURANCE RGH.DING DIVISION FEES
('Ibis cation need not he cnnlpl<mdit the permit is for one hundred dal[[am$100) CREASETRAP
ur less)(His hili
I cenify that int he perfnrmenacelf he work for which this permit;%issued,I shall SEWER-SAN]TARY-STORM EA 200 FF.
not employ any person in any manner so as h+become subject to me Workers'Contpen-
ENERGY 19;13
C) z nation lrw,of California.Dare WATER HEATER W/VENF/EITCTR GRADING FEE
Z O Applicant
NO1 IC17 SYS APPLICANT:If,after making this Certificate of Exemption,you should WATER SYS'1'Eh nBEATING
N SOILS ITF.
? have, coal to the Worker.Cnrnlwn,m pmvi,iom of me Labor Code.You mut
four,� ith comply wim,Deli pmvisinm nr this
permit shall he dcemeJ revoked WATER SERVICE
Q
CONSTRUCTION LANDING AGENCY NEW RESIDENTIAh1'1"M. SQ.14. PAID } e Rat "p
U 0 (hereby alnnm lhatmcn i,a.++.+almnioo lending a,,a,y far erne nv.hmm:maol
W e work r which rod,pa,md I,i..oedec
(S .3097,Civ_C.)
O U F I-d&,,Name TOTAL:
U Icnder',AdJres% TOTAL:
6. I cenifY mat I have marlin,rpph.ua n and sec¢that mC abuse ialbrmatinn is BUILDING hili
,F. rp comear I 1.omn y with all city and county ommanccs and state Saws minting to QTY. MECHANICAL PERMIT FEE
UZ building comwcom,and hemby truth ari'r,ar,,xammlvcsofthi,,ity mennrupm be SEISMIC FEE
ahove-n,xmioned property far impacrxm mexox,. PERMIT ISSUANCI;
(We)agree m save,indemnity and keep barmles.she City of Cupertino against ELECTRIC FE E
Iiabiliries,ludgments,cost and expcn,ex which may in any way revive against wid City ALTER OR ADD TOMUCH,
PLUMBING ITiIi
,CAN ofinegran ing of ihis Par ais
SOURCANT UNDERSTANDS AN[)WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAI.IIiE
SOURCERE(2i„/2M 0 r /�6 AIR HANDLING IINI'r(OVER 10.(Y
JO CPM3 CONS'I'RUCHON'rn%
Sign. urcpplitnnUConnadnr �x J- / d-/SAI,CI EXHAUST HOODWOUCF) HOUSINGMI'11GAHONII?li
HAZARD(itill. "A'HRIALS DISCLOSURE
Will theapplicant mrtamre hmldm,occupam loem-handle hamrdnux mman.1 HEATING GNI'I'(SO IIXLIXX)BTU)
as defined by he Caparison Municipal Coca.Chapter 9.12,and the Stealth and Safety
Calc.Section 25532m)i HEATING UNH'(OVER 10.000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
[)are Raniptp
WillII me applicant or future building occupant use equipment or devices which
cmit haBOILER-CONI'(3111(lR 11X).000 RTU)
rurdous air contaminants as ddined by the Bay Area Air Quality Marmm
grnnt TOTAL:
DL°Inc'^ BOILER-COMP(OVER 100.000 RTU)
❑Ye, ❑No
I havcrmd We harardou.nm.niuh reg..immems under Chapter 6.95 of the Cull- AIRCONDI'NONER ISSUANCE DATE
fumia health k Salary Cad,.Seeinrt,25505,25533 and 25534.1 un rron I IIne I the NEW RESIDEN'UAL MECIf SQ.FI'.
hailding docs not currently have a Icnnnl,that it is resp irobility,,nosily rive occupant
of Ise ngmremenl,whleh mLL,I water perm to I..tnnee of v Cemfieare ofoeeupa Icy.
Owner m author ad agent Dec TOTAL: ISSUED 6Y:
OFFICE