S 2895 — -APPLICANTWFILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITYOF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAl'E
1 o N. -• 3
UW ER'S AMti: PHONE: 3�C TRACTI R'ti ME: LIC NO:
N/C
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E TENGINEl ADDRESS: JJJ
CdNfACT: PHIME. BUILDING PERMIT INFO,
❑ Consultant Fees Paid by Applicant(Initial) BLDGl/ � zl
ELECT PLUMB ME-CH
❑
LICLNSLDCONIRA 'IORSDF .IARATION QTY. ELECTRIC PERMIT. FEE
In by t mtI f a p of Chapter 9¢mtm mg _ - JOB DESCRIPTION
FQWZ wlthifY 9WIB (D'vislon3oDneBu' mPr.fesi ons Code,atd r,ke se RESIDENTIAL
OS in full force end eR t. PLRMr' ISSUANCE
l F" License Clete Lica ElSFDWL ❑KITCHEN REMODEL
ZU - APPLIANCES-RESIDENTIAL. ❑ADDITION El PLUMBING RE-PIPE
hG a Date e.mmn.r
lk, EFFECT'S DECLARATION ❑MULTI-UNIT []STRUCTURAL
zoo z Or INuaedasruhlicreemes - PANELS' MODIFICATION
p UP TO 200 AMPS
F r3�lx7 ie se .f venalPAIR
❑INTERIOR ❑S IMMING POOL
OVER
1000 AM - IMPROVEMENT C]SWIMMING POOLS
OW 'R-BUILDER DECLARATION OVER It100 AMPS El BATH REMODEL/REPAIR ❑DEMOLITION
I hereby affirm t I am exempt Immune Connadurs License Law fnr me
0.V following revs...(Section 9031.5,Business and Nomisou G,de:Any city or county SIGNS ELECTRICAL ❑OTHER
�+a F' whiCb requites o permit m con.Rall
,Her,impnrvq demalvb,or replan any structure
�� ,,io,I.i,,ismance,vlsosquirne the upplecal for such permit m file o signal smmmcnt SPECIAL CIRCUIT/MISC.
that he is licensed rimmam tithe pro,knaclof the Central r.Lirense Low(CUlts.,9°
(eO
00 b 'FSv, 9000E fD" i,i 3.rihc B . e5 and P f .r sCnde)or TEMP.METER OR POLE INST. COMMERCIAL'
mat be is oventin flablefolin med he best,for Inu B g d corruption A y iniallon r f ❑NEW BLDG/ADDITION ❑DEMOLITION
iiCC 1+
Section 70315 by any applicantl permit subjects tn applicant t "I penalty of MOWER DEVICES
W^m NT FOOD SERVICE
not mom mon five bmulmd dollars($500).
� O [ I,as Owner.f lea plropeny,.r my etnpl.yaes aim wages vs rnclr sole wntponsnme, SWIMMING POOL ELECT RIC IMPROVEMENT
E. will do the worstand lhestruclure is not uncured or offered terse le 9044,Business DOTTER
3 m and Prefessione Code.The Canonical,License Law dnc not apply man owner of OUTLETS-SWITCHES-FIXTURES
mil,who held,or improves there..,and who does such work hlmxelC or through
his own enlpbyem,provided that...a improvements amna intenJed nr nEered'(it NEW RESIDENTIAL ELECR SQ PT.
sale.If.however,the tandiingor improvement is sold within one to he - SQ.FT PLOORAREA $/SQ.FT.
owner-builder will have the burden of proving that he did not hand or Improve for
pur-
poo of sole.).
as owner 1 to pl p try lycontrolling m l d t r .to 'TO'fA
one uleP ] u(ScofR .' ndP resistant,Code:) Comments 1" - x
cit
L d r apply n of fp property hhe,builds
p Contractor
d QTY. PLUMBING PERMIT FEE
uel�f ch
coin c m rsupr,{eco w%Ot o w nmrO ulin
curd pureuunl t,the nntmn r
L"Ime law. PERMIT ISSUANC
lam ex u d ,B&PC mfr is assn
Osie ALTER-DRAIN T-WATP.R(P,A) VALUATION
ORKER'SC IPh:NSA'fION UECLARNUON BACK FLOW PROTEC IC' � O O
I
her yaffirmunderpe�lDofpejuryoneofinefolbwiagdedamti n-
❑ I Mtveand will maintain v Certificate ofConsem t.self-insure for Workers Cntmpom DRAINS-FLOOR,ROO R• ND. S'fORICS TYtP Fv99gTION
wrist, s providedforbyS i 3"100ofthe Labor Code,for the performance of the
work for which din permat Is stUCT FIXTUR&S-PER TRAP
[:] I have and will recandr.W k ComUccoution Iforruence,a,variantbySeclon
3700 f[lie Labor Code,for the PoTherameameof Ed work C.whch lh'permit sixsuul. GAS-EA.SYSTEM-I INC. TLHTS OCC,GROUP APN
My Workers Compensation Insurance carrier and Policy number are III���
Carrier: Fairly Ism: GAS-F.A,SYSTEM- F.R 4(RA) �
CERTIFICATE..OF EXEMPTION FROM WORKERS' •x•(O
COMPENSATION INSURANCEGREASDIND RL WASTEDUFFIRCEMIL
(ThissccGnnnwl not becompleredifrnepermit is for one hundred dollars($100) BUILDING DIVISIQN'PE _
or less) GREASE AP
I certify that in the performance of me wark f.nvhich thisparmil is issucdlshall SE R-SANITARY-STORM EA.200 FT PLANCHECK FEE
not employ any parson in any manner ro ns m beeonnesubject m the Workers'Contpen- ENERGY PEE
Z 'j. sari..Laws of California.Dam WATER HEATER RINENI'/ELIiCB
Q Applicant GRADING FEE
rn NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
become subject r0 the Workers Compensation provisions of me Labor Code,you must SOILS PER
mahwim,omply with loch poolmom e,this permil vhall be deemed revoked. WATER SERVICE. '
Q
O CONS'TRUC'TION LENDING AGENCY NEW RESIDENTIAL PLNIB, SQ,FT PAI
Ihereb [firm that there is.construction leading forme fmncesof Dam Rmeipltp
thereby .agency pun
me work for which this permit is isued(See 3097.Cie.Cd -
Q U Lenders Name _ TOTAL:
Lenders Address 'TOTAL:
aI clarify that 1 have read this applicationd.suite that file thoo,inforandlion is „ ILDI FEE /371
LA QTY MECHANICAUPERMIT'f L 'FEE
V bold . .w iomand hrebyumhor'v representatives of this dtymenmropo upon 6EIS .PPA
nhovo-memi.ned property for inspection purposes. PERMIT ISSUANCE 3 /-�
(We)agree w sn c.indemnify and keep harmless the City of Collection against. ELEO C USE �J Q
ludilides,judgments,costsandexperoses which may in any wayaecl'ue against said City ALTER ORADD TO MECH.
nnseyuence of me gT tin of this permit. PLUM BIN EH
APPLIC Ute]" DS AND WILL.COMPLY WITf{Al NON POINT AIR HANDLING ON]T(1010,000 CFM)
SOU Rf ' T 111 S p MECHANICAL PEE 1
1 _ Y AIR HANDLING UNIT(OVER 10,000CPM) CONSTRUCTION TAX
gat fgpplican1lCt trenor
'Dag EXHAUST HOOD(W/DUC'1) HOUSING MI'[IGATION FEE
HA ARDOUS MATERIALS DISCLOSU E
Will the..plical on fuwre building necupnm scoreurhnnAlehuzanlOus material HEATING UNIT('10100.00 BTU)
is deduced by the Capenino Municipal Code,Chapter 9,12,and Inc Health and Safety
Code,Salter.25532(dYl // HEATING UNIT(OVER IORAO It I'U) ,
]Yes �JNn PAID
VENTILATION PAN(SINGLE RE$ID) Dale Receipt N
401 Will the applicant or future bnildtug occupant use equipmcnr,on devices which .OILER-WMP(3HI'OR IOO,WO RTU)
.mil a....doas air eomm�linvms as defined by the Hay Arra Am Quality Management TOTAL
District'
❑Yes BOILER-COME(OVER 100,000 BTU)
YY
(lave rad the za on,materials "temente under Charer 6. 50f me Call- AIR CONDITIONER
mqm p ISSUANCE DATE
fomie Hen! &S ty 51 e,Secret,25505,25533 and 25534.1 under anJ tl at i[me / A
build) (�n / (havemm�vnt,thatitismyrespnnsildc,ton fymc wupml NEWRB$IDBN'1'IALMGCII. 9Q.Cr
Is,Return prior m issuance of n CectilLclyf n
or mthnri'eedn nl me ISSUED BY:
OFFICE