S 0726 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL m5ir NO Oma ^^
BUILDING DIVISION APPI,ICATION/FIERMIT PLUMBING-MECHANICAL \V / 26
BUILDING.PROJECT IDEN'1'I FICATION
ILDING ADDRESS'. SANITARY NO, APPI,ICATION SUBMITTAL DAD
11L17 YI� US r -this csnteacfie3
'NER'S NAME: PHONE: ACT'OR'S NA F.'. LIC NO(Alp '
r `_ ZZ
7q eqdtte C CO.�'TROLp
• l .
ARCHITECT/ENGINEER: FOLIC NO:[J DRP.SS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑
Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECIT
AA N
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm thus 1 mn licensed am-,It kions..Chaps r 9(commencing JOB DESCRIPTION
WOZ who section m1001 or Dmish,n3o0neeminearand Profecsi.nscuJc,mdmylmenseis RESIDENTIAL:
W O p PERMI I'ISSUANCE
F W F L full force and elle ❑SFDWL ❑KITCHEN REMODEL
aZW Date Contr APPLIANCES-REWDENTIAL ❑ADDITION ❑PLUMBING BEPIPE
N a a Date Commcmr
ARCHLTLLTS DECLARATION ❑MULTI-UNI T' OSTRUCI"URAL
Z Fp vv,Z l understand my plami,hall be coal z public records PANELS MODIFICATION
04-4-0 UPTO203AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F4tw Licensed Poducssloml 201.1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DIiChARAq'ION OVER 100 AMPS O BATH REMODEUREPODEMOLIT1 N
Ne
IY w G 1 hereby affirm that I am exempt from the Contractor's License Law for the !/ 4
a�LV%W 3LL ti 4dlnwing im (Section 7031.5.Bmvmessand Professions Code:Any n'.y or county SIGNS LLPCTRICAL OOTHER AD Nt n
which construct.
�
rot, a peon..ser c.n,rha r alma improve,demolish ore a,il any amnurc
��' that he
lisnsed pubnrd tot he lhcapplicam Thr Contractomsh r
mEense,Law
SPIiC1ALCIRCUIT/Sfl$C.
� } Bim M1e is licensed pursunm to the pmvsmm of the Cnmmcmr's License Luw(Chapmr9
lad C (commencingwith Senion7dralo'Diskion3ofthe Bminessund Pmfessium Csde)or TEMP.METER OR POLE INST COMMERCIAL:
dao that he is exempt therefrom and the basis for the alleged exemption.Any violmion of O NEW BLDG/ADDITION ❑DEMOIJ NON
1C^ Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
dal—rn OTIiNANT OFGGD SIIRVICF.
no.mom owner
five eprogedollaryempl
F�>' IMP OVIiS1ENT
=6O do he worrof.hc progeny.or myemployees with wages bucale(Sok aft,Business SWIMMING POOL,ELECTRIC we will du lesions suit he seConticnors Licaeda Law
apply 90H4, wner of ❑ hR
3 m and Professions Code Use Contractors Licence law dons no.apply m if owner of OUTLET'S-SWITCHES-FIXTURES
hisprolpiaty won builds ns.or improves thereon,and won does such tine Mmol[or 0mugh
his own employeese building that such improvements w am not:mended or offered for NEW RESIDENTIAL F.L[CfR SQ FT.
role,IL however,the building orimpmvcncm is sold within one year of unnpldinq the SQ.FT.FLOOR AREA $ISQ.F-n
wner-buimer will have.he burden of proving that he did not build or improve for pur-
posc of«tile.).
0 h as owner of.he property,am exclusively contracting with licensed mntmnon to TOTAL: q
vauun.he pr ject(Sea?044,Business and Prole,,ions CMc:)qra Current s Li- P�
cense Law does not apply to an owner of property who builds or improves theocrat,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a eommenm(s)licensed pursuant to the Contra
,
License law.
❑lam cae}np.and . T� __.B&PCR: PERMIT ISSUANCE i mDEC
.9 arC
Owner 16UA1
AU]'ITR-DRAIN&VENT-WATER(EAI I VALUATION
WORKER'S COMPENSATION DECLARATION BACK II,OWPRUIEC'1'.DEVICE Uf l.U)-tlY l llvu
1 hereby affirm under penalty of perjury one of the following declarations:
O l have and will maintain a Ccrtificam of Cmtsenno self-insure for Worker's Compcn- DRAINS-FLOOR,ROOF AREA,COND.
m.ion,as provided for by Section 3100 of the labs Code,for the performance of the STORIES TYPE CONSTRUCTIO!
work for which.his permit its Issued. FIX'I UR12S-PER'FRAP
❑1 nave and will maintain Worker's Compensation Insurance,az required!by Section
3700ofthe Labor Code,for the perfuncence of the work for which this permit is issued. GAS-EA.SYSTEM-I INC,4 Oil I'LEI S OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number art:
Currier: Policy No.: GAS-EA.SYSTEMOVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEI NDUSTRL WASTE INTERCEPTOR
Mis secossu mend not Mcompleted if the permit is(drone hundmd dollar($IIX)I BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
I certify that intheperform it e.the work for whichmis permit is insund,IsbJI SEWER-SANITARY-STORM EA.200 FT.
not employ any pusnn' y m .m the Wnrkcrs'Cumpen- ENERGY PEE
Oz cation Lawnof Gc�+f�� .an,„a�nn-cyy�l lu_M1�11��tsp� WAFER 111?Al'ERW/VENT/ELEC'1'R
A,fdicam - /� 1111/, -LI^ ,z GRADING FEE
ren
NOTICE TO�ANT:If,a m ng this mficam of Esempu.n,you should WAIIiR SYS'I'EWI'BEATING
e > become subject..IM1e Workers C.mpens con xiensofthefabrCnde,ymouct SOILS FEE
forthwith cumply`s'ith such rovimurninduu,promo shill bedcurnim—kW, WAFER SERVICE
Q
7 z CONSTRUCTION LENDING on a,."a Y NEW RESNENTIAI,PLMR. $Q.FT. PND
L) I for by aftionwhich
thatNSamu i isaco (Sec,397,Cing agency for the perfnnnance of � Rccc 1M
f1. .he work for which:his permit is issued(Sec 309'!.Civ.Cr
Qf"t Lenders Name ']DIAL:
r Lenders Address TOTAL:
I unify out I have rtaJ.his applica.iun and stam.henhe above inlinmaion i.v BUILDING I3"
� (A nucel.Ia,.in..:nply with all city and county ordmanms and am,I....chair,to QTY. MECHANICAL PERMIT FEF, ss
U Z building connwetion.and herehyauthorne reprenematice—fthiscity to comutm rade SEISMICIG
abnvcmeniomed property for inspection purposes. PERMIT ISSUANCE
(We)agreem sass.indemnify and keep harmless IM1e City of Ceramist,against I?hGC'I'RI'TEG
liabilities.judgments.costs xndexperues which may many way name ugainntsaid Cuy ALTERORADDTOMECH.
in ennacqucnccof the gaming ofdds permit. PLUMBING Ti
APPL.ICAN”UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(To 10,1100 CPM)
SOU ,'ULATIO' MECHANICAL '
�y O, AIR HANDLING UNIT(OVER 10,050 MO CONST RUCT10N'I
Signamrcof APphead nt acmr L ate EXHAUST HOOD IW/DUCT) f{OUSING MITI(iA'DO FEE
IIAZIR11o11 4ATl!ItIAI.S DISCLOSURI?
WlLbcappliconmrfum. uildingrccupamstnon m handle bromesnu material HEATING UNIT(TO I W,000 BTUI
is defined by the Ctmecum Municipal Cale,Chapter 9.12.and the Health and Safety
CMe.Section 25532(x)? HEATING UNIT(OVER 100,00 BTU)
OYes ❑Nn
VCM ILATION I'AN(SINGLE HESID) PAID
Will the applicant or furore building occupant use equipment or devices which Doc amp.p
Ld—not
gnus air commit an defined by the Bay Area Air Quality Management BOILER-COMPCIHI'OR IIMI,INN113TU)
TOTAL:
es ON. BOILER-COMP(OVER 100,0y1 B'N)
ve mad hatumdous materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
th&Safety Conk.Sections 255in it is 33 and 25534.I uwnormand tom if the NEW RESIDENTIAL MLCII. SQ.IT
s mol afety Cy lk.S n n...arteriIhm i.is my add Z5 b ,1 m notify Ibuo,if tot
rements which mast be me plot owerace ofa Cmfream.rlxcu tin,uthorized agent Doe 'rOTN,: ISSUED BY.
OFFICE