B 0484 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECERICALt PERMITN;e0484
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BUILDING DIVISION APPLIC ION/PERMIT PLUMBING-MECHANICAL p00o�
BUILDING PROJRf"'f IDENTIFICAT10N,
BUILDING ADDRESS: SANITARY NO. APPLICA'I]ON SUBMITTAL DATl
�9
NER'SIN Q O� HONE: CONTRACTOR'S NAME, LIC•NO:
V NIC n nCONs�TRDi.p
C., L. CER: LICNO: ADDRESS:- ❑ �-J `q y
CONTACT: PHONE: - BUILDING PERMIT INFO
6 — /p ❑ Consultant Fces Paid by Applicant(Initial) BLDG HLLEECTT PLUNGE M>EC{E
El LJ LJ LI
CENSER TRACTORS DECLARATION. QTY,. ELECTRIC PERMIT FEE
I hereby a nn d I am licensed under pmvisl sol of Chapter 9(commencing JOB DESCRIPTION
OZZ with Section](NIuoul to lon3ofthe BminesxanJ l'ra sd, my license i. - RESIDENTIAL:
610 0 m 'PERMIT ISSIIANCH
a61F In full force an eRu ❑SFDWL O KITCHEN REMODEL
rc U License. s Lau APPLIANCES-RESIDENTIAL• El ADDITION El PLUMBING RE-PIPE
NQ0. Dae TSDEt
RCHITf:CTS DEC ❑MULTI-UNIT ❑STRUCI'URAI.
F NN•� I un erstam m hall M:uneJ as blit records '- I PANLI-S • MODIFICATION
ZOlaq YP:mss Pu -
lll"f0200AMPS '
OZ O ❑INTERIOR ❑SWIMMINRPOOL
-I Licensed Professional 201-E(MIOgMPti BATHR MOD. 0SWIMMTGPOOLS
99=; OWNER-BUILDER DECLARATION OVER["AMPS
[I BATH REM01]GL/ftEPAIR 0DEA101.ITION
a U 1 hereby.(lion on I am exempt from the Cnntmcm Code:
License Law for the
�y(O0.0 follwhowingivicam.unn,. worat n]03L0. t.allBlisps,inaprce,drRssions Code:An,u,m onrarreounty SIGNS ELECTRICAL ❑01'HF.R
61 L W-5 which requires issuance.permit to construe,alter,improve,demolish,nr repair any swemre
qz
mn�g paths(licensedpalter,to the the
ovisio so for suchCoupemdnoicensle a e Law
statement 51'ECIAL CIRCUIT/MIS..
f`�> Out Ile in licensed pamaant to me prn.•iaronarrthe cnma�tnrauarselaw(Coale)r9
61x00 (commencing with Section7")of Division 3 of the Business and Pmfcssionn CLWe COMMERCIAL:
)or TAMP.METER OR POLE INST.
that io is exempt therefrom and the basis for the alleged exemption.Any violation of a EI NEW BLDG/ADDITION ❑DEMOLITION
6X1 VI 9emion]o315¢y may upplieam Parva permit auhjwms the npplleum¢ua civil penalty of I'OWLk DEVICES ❑IENANT ]FOOD SI?kVICI?
not more than five hundred dollars(8510).
Z Y IMPROVEMENT
6 ❑Lav he-k.the th.marame I, csimendeswitb er,cl assh,(Se le 0,1K.Bst.. SWIMMING P(R)I,ELECTRIC
f O will do the wort.and the no Cureisnors License ow does not apply
y(a an naprof .OTHER
63$ and Professions Code no The oyes l pica License law sees not apply s if owner of OUTLETS-SWITCHES-PI%TURI
S
his o ny who builds or improves tsuchi and who Juts e n wnrk himself or through
his awn employeese building that such improvements are not'Par of or offered lie NEW kF.SIDEN'I'IAL ELECTIt SQ PI'.
sale.l4 howcvcq the building orimpmvemem is sold within one yea of completion,the SQ.FI'.FLUOR AREA 5/SQ.II'.
ownerbuilder will have the burden of proving that he did not build or improve for put-
poaenfsale.).
0 1,as owner of the property,am exclusively contracting with licensed reappears to IOTA
reappearsconstruct the projem(Sec.]044,Businessand Protestant,Cale)The Compelors I.i-
c .se law does nm apply to nn owner of propcny who hands or improves thereon,and QTY, PLUMBING PERMIT FEE'
who contracts for such projects with a cemmemrin licensed purmnu
no the Contractors /
License law. PERMIT ISSUANCE. (d
❑ Ium exempt under O
Sec. .B&PC(Or this reason
ALTER-DRAIN&VENT-WATER(PLA) VALUATION
cr Date � ' / /]
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECL DEVICE ✓11 `
1 hereby orate under penalty of pe jury one of the following declarations:
❑Ihavc and will muinmin aCenifcate of Consenvn sdf-insure fur Workers Cnmpcn- DRAINS-FLOOR,ROOF.AREA,COND. STORM?S TYPE CONS iRUCTION
ration,its provided lin by Section 3700 of the labor Code,for the performance of the
work lie which this permiti.c issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Swam
"al of the rCodc.forth perfo fthe wnrk for whi this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work r' Compensmion ren ca/ripypml y
Carden 6j�zr GAS-EA.SYSTEM-OVER4(GA)
I'll• A COMPENSATION
TONIN FROM WORKERS'
COMPENSATION INSURANCE GREAS[%INDUS'TRI.WAST.INTF,RCEPI OR
�/seen�� �yfy/�� /p��{7{7��j7j7��e//e�.P/��f'(��/'' 11//11 IIUILDING DIVISION FL'ES
or less.l�rYf}Mhn �erRfr Kc raHtlCw4rksTorawl/CRthis pemiittiis issued'I still SEWF.RL SANITARY-S'1'UkM EA.200 Ff. P fiF. E.
not employ any Eorom In any manner so as m becoom m1preun Ore Workers'Cnmpen. mRGY M e
0� action Laws of California.Date WATER HEATER WNENVELEC'M ADING EEE ,
Z Q Applicant
.N. NOTICE TO APPLICANT:If,after making this Certifiesre of Exemption,you should WATER sys-rcM/fREATING
a ,
Jacopo, ubjerp m te hWorker's Compensation provisions of the Labra Code,you must SOI ME
Run lith comply with such provid nn his permit shall be deemedrevoked. WATER SERVICE
fi
V O unionCONSONLENDINGAGENCY NEW RESIDENTIAL.PLMB. SQ.FT PAID Date Remi,.
I hereby union that themis
is aa construction onsnion lending agency Pantie v
perfortnce of
the work for which this Eemit is issued(Sec.309-/,Civ.C.) r-�
0 I-" Leader's Nave IT
0. Lender's Address - TOTAL: a BUIL NGE H I certify that I have read this application am
and came thin the above infommem is
J,, mrmt.I agree tocomply with all city and county ordinances and state laws relating. QTY. MECHANICAL PERMIT FEE
C.) Z building construction,and hereby minimize minitenmtives of this city to enter upon the - 5 IC E b
above-mentioned propcny for inspection putpauv.
(We)agree to save,indemnify and keep hamdess the City of Cupercm against Pf?RMI'P ISSUANCR F,.F IC FE 'a ,
liabilities,judgments,coils and expenses which may in any way docrve against said City ALTER OR ADD TO MECH.
in cnnseyuence el the gaming of this permit PI. BIN.EEE
APPLICAo' UNDERSTAN SA ' WILL COMPLY WITH ALI. .ONI'OINT AIR HANDLING UNIT(TO 10,000CFM)
IiCIIANICAL IEE I
SOUR E IILAI'IGp
CC r1 AIR HANDLING UNrr(OVBk IQ000CFM) ONS'I RUCTION'I'AX 17
Signa M' (J are EXHAUST HOOD IW/DUM) H (SING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstone or handle bacemous material GRATING UNIT IT 100.000 It'I'U)
as defined by the Cormino Municipal Code,Chapter 9.12,and the health and Sol cry
-Cade,Sectlan 25532m)Y '/ - BEATING UNIT(OVER I(NI,(N0 BTU)
Q Yes L�Naa VHNTILATION PAN(SINGLE RFSID) PAID
emicurf
✓IoM Date Rttciptp
4Yllthe air comemanm huinned by the Bay n,use
Air Qnar deviceswhich
BOILER-COMP(3HP OR I(NUXX)BTU)
emit int? ous air conraminams as Alined by the Ilay Area Air Quality Management I'
District?
❑Yes. BOILER-COME(OVER 100,01)(0 BTU)
I have read the tcrials requirement under Chapter 0.95 of the Culi- AIRCONDITION17R ISSUANCE DATE
fora(.Ile &Safety Code,Sections T5505,25533 and 15534.1 nlcrstuna Nal il'the N17W RESIDENTIAL MECH. SQ,IT. <0-
-
buildtn n tcurrcn0y have umcnun't�t�yy�tgy/kaast;tSseYmBynrCCCs ory�n(sip�bi�litti/y//}�/oyyn/upliifyt��F/ keelson `! r
-0 th u'enrenttLwhj h mux mIU/ Y/ 701`0 A�BVA. / /�
O�evl`5Mbonl rrd/.,cclm / TOTAL: a �,0-
IT-or/ ISSUED BY:
OFFICE