S 0515 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECT TRICAh PI;RMrT NO_
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA
We
DMS S
OWNF.R'SNAME: PwroaE: CONTRACTOR'S NAME: LIC NO:
NIC CONT ROLA
ARCHITECUE-NGINEER: LIC NO ADDRESS.
O 4-A-1 r, ❑
CONTACT PHONE: 'C- NU ILDING PERMIT INFO
_ d ❑ ConsWtant Foes Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
bt
LICeNSGDCOMRACTOR'SDLL ATHEN QTY ELECTRIC PERMIT FET; ❑
I hereby of rm at I am Bccensed under provisions of chapter 9(contemner JOB DESCRIPTION
O8Z wim Sxtion]IXND ofnivisionJnfine ltuniners and PmlbcsiomCall dmyticenaris RESIDENTIAL:
ODEl
zW. in fullforce and a 'j PERMIT ISSUANCE
V Licenm la Lic,p JG77 ❑SFDIVI. ❑KITCHEN RE-PIE
i- V APPLIANCES-RESIDENTIAL ❑ADDITION E)PLUMPING RE-PIPE
N Q{tl ¢ CnnlDECL
F> ARCHI'IT:TI'S UIiC1.ARAl'ION PANELS ❑MULTI-UNI'T []STRUCTURAL
Z O y I undcrsmnd my plans shall he used vs puhlic rewNs MODIFICATION
oz UP UP TO?W AMPS
1:1 INTERIOR [I CHIMNEY REPAIR
a r:FW Licensed Professional 201-0000AMPS IMPROVEMENT C]SWIMMING POOLS
CLAATI
C C C Q I M1crcby nfRmt Ilhmhlum RxetnptLfnslmLIlc CNmm use's Liccnsc Law fur the OVER I"AMPS C)BATH RFMODFIBFPAIR ElEow DEMOLITION
6 3 LL F following eraser.(Section 7031.5,Business and Professions Calc:Any city or county SIGNS ELECTRICAL ❑OTHER
m which requires a permit to construct,alter,improve,demolish,or repair any,tmemre
L�'�ce prior to its issuance,alio requires the applicant for such Permit to rile a signed statement SPECIAL CIRCUIT/MISC.
F�y"1 tbar he is licensed pursuant Ir the provisions of the Contractor's License Law(Chapter 9
ty al (commencilrg with Section]IX(Bat Division Sof the Business and Professions Code)., TEMP METER OR POLE[NST COMMERCIAL'
d y o C that he is exempt therefrom and the basis for thu alleged exemption.Any violation of ❑ 'W BLDGIADDITION DEMOLITION
V..m Sermon]1131 5 by any applicant u permit,nhjmts the applicant a civil penalty of POWER DEVICES ANT ❑FOOD SERVICE
^zzno,mous Ilan live hualreddollms 11100),
❑ Las owner of the property,army employees with wages as their sela'atepensafne. SWIMMING POOh ELECTRIC IMi'N;R EMfiN'T
WLC will do fie work,andIle,racmre isnot inaendedorolied forade(SmAIW4.Business O'I'HI?k
H
3eas and rhiom Gale;Thr Cnntrnmds License law dare not apply tom owner of T
OUTLETS-SWITCHES-Iq% URES P AID
property
who builds nr videdvcs thereon,and who Alex such workhio War through
his own however.
the provided mut inch icttprovo lit within arc not iyearat or altered lar NEW RESIDENTIAL ELEC SQ Pl'.
(,,farsale,If bow will hFul hebndrol salt issal heulnncyld...iprove lotpa- SQ.PT.IROO' FT,
sof sd,er will have IM1c banderol proving ILot be AiJ nal buil)or improve Thr pur-
AUG
poaLsvle.),
F11.ax owner at the proper Int cxclaxivcly contracting with licensed commemr,In .)TAL_ CI I Y Or GUF EHTINO
mcinat the project ISce.7(94,Buxinesa and Proles,in t,Code.)Tae Cammemr's Li
-
selawdocsnotapplymanownerolpropertywhobuild,or improves thernm,and QTY. PLUMBING PERMIT FEE
who contused for mel projects with a conameorUl licensed pursuant lir the Contractor's
License law. PERh11T ISSU Cli
E] 1 am exempt under Sec. B 5.P C for this reason
ALTER-URA & -WATIiR(Ii
Owner DateA) I VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT WlIas/'�_�'/Ik
I herchy affirm under Penalty of perjury one of me following declarations: / e�/4�_
❑ I hive and will maintain aCirmficalenf Coment to self-insurefor Worker's Compen- DRAINS-FLOG . .AREA, STORIES TYPEC STRUCI'I(
svtion,as provided for by Section 37M of the Isbor Code.for the performance forae of the
work for which this pemrit i,issued. IXTURES-PER TRAP
❑I base and will maintain Workers Comperiation Insurance,as required by Salina
37M ofthe labor Cale.for the Performance ofthe work for which No Permit i,issued. GAS-EA.SYSTEM-I INC 40 (ICC.GROUP APN
My Worker Compen.atinn lnwmnce carrier and Policy numMr arc:
/ Carrie,ig , l' SPoBY No.: GAS-EA.SYSTEM-OVER4(EA)
CBRTIEICATE OF F,XEMP'HON MOM WORKERS'
COMPENSATION INSURANCE GREASERNDUSTRI.WASTE INTERCEPTOR
(This xccamnnacl nm IN completed iffe t is for one hundred dollar,($100)
or less.) ISION FEES
pcmrt GREASE TRAP
YLANCh
I employ
any Ilm rather performance of the wed,fm which this Acuson is issued.I plait
J 4i
not employ any person in an SEWER-SANITARY-STORM F.A.2W FT.
y manner sal as m hernmc subject w me Worker'Cooper- ENE _
Z select Laws of California.Data WATER HEATER WNENTTLECfR
Z 2 Applicant GRAI , 'PF,
h NOTICE TO APPLICANT.IL.fmf making this Certificate of Exemption,you shouldWATER SYSTEMGIREATING
? become subject to the Workers Compensation provisions of the Labor Calc,you moa SOILS FEE
forthwith comply with such previsions or this Permit shall he deemed revoked. WATER SERVICE
a �
vO CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ 17. PAID
I herebyaffirm thatthereissuad(See.0lending agency forth,perfonnvnce of lite Rcecipt#
Nthe work Ino wM11cM1 thin Inrmit is issued(Sec.3119],Civ.CJ
O L) Lender's HName TOTAL:
Lender s errmAdd.ly TO'I'Ah:
ttdilY y 1 Ilm 1 have re:W thin application and stat 1hul We above Infnmmlinn is BUILDING ITE
V) cmmet.l agree to comply wall all city and county ordinances unit stale laws relating to QTY. MECHANICAL PERMIT FEE,
C.> ZZ huildingam,t...air,and hereby oulborjw repm,.nwdves of this city to carer upon the SEISMICIE
.bout-mentioned prnperty to h,pectinn putpows' PERMIT ISSUANCE
(We)agree ms ave,ardenned,unit keep hornless the City of Cuperlin,ugtimt HL'CIRR Il?I3
livbililica,judgmcnla.unlxand expense<which cony j puny wayaccmr.gr,void City ALTER OR ADD IU METH
in nnseparce the grunting all'or .is peralit. PLUMBIN 'PEE
API MCAN'- ND tRSTAN- AND WILL COMPI LTH NON-POINT AIR HANDLING UNIT(TO lf,gro CEM)
Sol[RC GU S MPC]IAN IC .Flili
AIR HANDLING UNIT(OVER III,(XX]CPM) CONST RUCTION X
plan,a p jr 'ammor aDate EXHAUST HOOD(W/DUCT) HOUSING MITIGATI 'FEE
AFARDOUS MATL'RIALS DISCLOSURE
Willlheap icanl lir(marc building tscupam sore nr hurdle M1umWe.,material HEATING UNIT TO 100.010 BTU)
as dcrined by the C.,moo Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Seetion 255321st):' HEATING UNIT(OVER 100.000 BTU)
❑Yes Fl No
VENTILATION FAN(SINGLE REMD) PAID
Will the applicant i en,a building occupant use equipment or JMana Management
Use Rec ,#
mit hazardous air ttmmmiwms as defined by the Ray Arca Air Quality Manugemem BOILER-COMP(3HP OR IIX),IXI(I BTU)
LI (yI'AL
s ❑Nn BOILER-COMP(OVF.R IIIU.gp BTU)
read the hamadom tndramils d under Cha AIR CONDITIONERrcyuire33 unda .med fore Cilie ISSUANCE DATE
Healthn Sorry Calc e a tend 255(15,255JJ and 2559.1 t oedifyBa mat ifare NEµ,RESIDENTIAL MF:CH. SQ.Fr.notswhichently have a,meta.thatit ismyewof a ertiftoe, fyme coetticant
trcnta which must he met poor m ixsuame or a Certificate ofOccupncy.orsed agent Data TOTAL: ISSUED BY;
OFFICE