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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATIONMERMIT PI-UNUIING-MECHANICAL.
BUILDING 1'Rt11FlCr IDEMI'IF'ICATIDY
PF'�°°"°� 1575
NUILDI ADUHI!55..
(-/ ?///'Ci e 'e
SAN1'TAHY NU.
API'LIC61'ION SUBMITIAI. DATE
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CONTHOLp
ARCHITECDENGINEER: LIC NO:
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010 �i•-h\u P� M �. fsl —L FSGG
❑ Consultant Fees Paid by Applicant (Initial)
13LIILDINC I'CRMI'1' INFO
BLDG ELEC I' PLUMB MEUH
❑ C� ❑ ❑
LICENSED CONTRACfO 'S ECLARATION
I hereby arum that I and licensed under pawlsfns of Chapmr 9 ¢nmmweing
with Scction7(XXpof l�'I{ lot , Sol the Hu.incvsnnd Pllicenens Gxl• and my license is
in full force anA effcu. ,s�h (f L�
crn��.S.. v ll.... V Lin M -./ r��•- �
Uatey Cmm.t ��^/�""'-"- r �—
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RBSIDP.NTIAL•
I
❑ SPDWI. ❑ PLUM IiN III: EGULL
PIPE
[-]ADDITION ❑PLUMHIURAI IPE
❑MULTI -UNIT ❑MODWIATIh
CHIMNEY REPAIR
El INTERIOR ❑CHIMNEY RIiPAIR
IMPROVI!MENT DSWIMMING POOLS
ENNUI REMODELIREPAIR ❑DEMOLITION
❑OTHER
PI!I1MI'I' ISSUANCEKI
APPLIANCES-RESIDIiNT1AL
ARCHIH!LTS DECLARATION
I undemmnJ my plans shall be used as public«cools
PANELS
Oil T02fg1AMPS
LiccnsW Profcsaionnl
OWNEmarc1.DER DEC, C....lRNI'ION
o Iia the
1 hereby offend o nl I I.S.mcntpl (sant Ihn Canuacrnoc : Anyc city
de soli Cndr. Any city ns county
which its issrapermit recnre%the alsoimprove,such permit t or repair anytrucamm�T/
wh ch re reason (Section ID31 Ituaincns and improve,
prior Iicusedp,aluanttso o ms the for ContranninLicensle ae aw(Cned hmmm�t
9
thathe is Iii.,, it pursuant m the provisions 3 me Commoues and Proe Law , Code)
(cat be isienuithrenion9W0) of DiviainIt, he lluainesspton. Ad ilknionof
that ha is 31.5 b tanyop li and the baafx it rbc alleged exemption. Any oinbninit nl
Section 91UI S by any nppllwm It,,;, Immtit suniecm hm upplleum a+a civil penuby of
nl mom than live hundred dollars ($50p,
i]hmnwncr of thepropcny, ormyemployeeswishwagesa+heir salemmpenamioa
will do the work, and the swemre is not intended or offered forsaly (Sec. 71X4, Business
and Professions Code: The Cnmractor'% License Law d+ra not apply to to owner of
property who builds or improves thereon, and who does such work himself or through
his own empluyces, pco,o ed that such improvements rte notintended or a1IaaY1 for
salcIf, howevei, the building orlmprnvmnem is sold within nuc ywrof con.pletiou,the
nal -builder will hove the burden of proving that he Jia n I build or improve ❑ , pur-
po", ofsan').
I] 1, as owner of the property, am exclusively contracting with licensed mount in to
construct the Tolliver (Sec. 7044,Business and Professions Code:) The Conductors Li
moveLawdoes not apply a+ an owner of pmpeny who hulhb or improves thereon, and
who contracts for such pori with a contmnor(s) licensed pursuant to the Conoucmr'x
License Law.
] 1 am exempt under Site .B& P C for this reason
201-100AMPS
OVER 000AMPS
SIGNS ELELTRICAI.
51'IiCIALCIRCUIT/MISE.
-of I - -
TEM it MET ER OR IK)LE(NST.
COMMERCIAL:
El NEW Ii1.DG/ADDITION ❑ DEMOLITION
] TENANT Q FOOD SERVICE
TIiM13NT
HER
CI OTHER
POWER DEVICH
SWIMMING POOL ELECTRIC
OU ILETS-SWITCHES-FIXTURES
NEW RESIDENTIAL ELIiCTR SQ I'1'.
SQ, PF. I71.00R AREA
SISQ.171
't 'AL:
-
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
-DRAIN & VTNp- WATER (PA)
Owner priorALTER
VALUATION
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
E] I have and will mvinnin nCenlficme of Comenun aelhlnsure for Worker's Compw-
.'tion, as pmvi icd for by Site no 3711(1 (it tile Labor Cndc, for the "'fin ounce, of the
µor which thin puncta is i asund.
[iYl have and will maintain Wnrkcr's Cnmperunlinn Irrsnnmre. av occurred by Section
37Wofthelaair Code,frthc •dimnancc of the wr,rk forwhich thin audit islsau.J.
p
My Wit2 _ Q,
ds Cr u t n lose mtt carrier and Policy '51q11
Camec hG /L6 Policy Nn. (J
CERTIFICATE OIr EXEMPGON FROM WORKERS'
COMPENSATION INSURANCE
(IYtia.vnuicn "am nal be ounlem!ifine penult is Boone bundral Jul em is 1 O
nr less)
I certify that in the perfoddance of the work forwhich this permit is issued, l shall
become subject , the W'ori Compos-
not employ any perver in any noncar so as m a
.anon Ldwx of California. Dam
HACK FLOW PITCH ECT DTVICE
DRAINS -FLOOR POR AREA, CONK
ti'f0RIB3
'PTFE CONS'fRGCI'ION
^^
1+1XTURHS "RAP InY
GAS -EA. .TEA UTLIi'S
GAS -CA. YS .M VER)
s OCC. GROUP
D
ANN
GREASHil ,'a -I ERCEPD)
ID N) BUILDING DIVISION PEES
,".
6107ASETRAP DIY yr
PLANCHHCK PTE
SEWER - SANITARY -S'1OR A. PI',
ENERGY 14,4E
WATER HEATER W/VENT/ELECIH
GRADING PE
FEE
NGTIC1310 APPLICANT Rafter making this Cutilicare of Exemption, you should
becume.vubird In the Worker's Compensation pmv'ninm Ido, Labe, Code, y,,u rmad
fonhwithanutply with such pmvisiune in thio permit ehnll budermed revoked,
CONSTRUCTION LENDING AGENCY
(hereby nffinn that there ixanmcwnion lending agency fonhe perfom,ance of
the work for which this pormir is issued (See. 3097, Civ, C.)
Lender's Name
WATER SYSTEM/rlil!A'1'ING
SOILST TI!
WATER SERVICE
PAID
D Rcccipt«
NEW RESIDENTIAL PLMIL SQ. PC
'IOI'AL:
'TOTAL:
landed, Address
BUILDING Il1.
1 amity mal 1 race mad mice application and orae (hal the above Information is
trent agrccm comply wdh all city odd coumy color e,i dandcluwsrclmingm
building cmntmcoon, and bemby anbnriae mptesenavives of this city to emu upon the
above-mentioned pmpeny for inN codon purposes.
(We) agree to save, indemnify and keep handless the City of Cuper inn against
lmutinies. judgmmids.wsm and expertise, which may in any way accrue vguidst said Ciry
umxeyuunm of the gusting nOhiv permit.
APPLICANT ' UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
- -
QTY. MECHANICALPERMIT EHr
SEISMIC]. .'
FIRM IT ISSUANCE
ACfER OR ADD1'1) M 17C1 I.
El. C TE
PLUMBING TP,
AIR HANDLING UNIT (10 IIh000CFM1
NIECI IAN ICA . FEE
AIR HANDLING UNIT(OVER 10.000 CFM)
CONSTRUCTION TAX
Signature of ApplicanVContrannr Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicmror forum hurdling occupant store indicate limardnu.vmmeriul
r, defined by the Cupcnine Municipal Once, Chupmr 9.12, mW the Health i I tinlny
Code. Section 255320)'1
L] Yes C1 No
Will the app onta or forum building occupant use e,, Air Qu nr Nbar whish
amid hazardous sir contaminants its defined by the Huy Arca Air Quality btanugemmar
DistneR
E] ye, ]Nu
I have readmit loommiva ntatuials mquimmeno under Chapter 6.95 of the Cali-
form. Health & Safety Code, Smrians 25505, 25533 and 255311 understand that if the
building does act currently have a tenant, that it in my resrymsibilidy m notify the overpaid
of rhe rcyuimttxmu which most M met 'nom issuance of a Cenificme of Occupaney.
EXHAUSTHOOD(W/UUCT)
HOUSING MITIGATION FEE
HEATING ON] T('1011(1,1100 BTU)
1 BEAT ING UNIT (OVI!R 100,000 BTU)
PAID
Date Romps x
TOIAC:
VTMTILATION PAN SINGLE RESH))
BOILER -COMP (3111' OR I00,000 BTU)
BOILER - COME (OVER 100,000 BU IJI
AIR CONDITIONER
ISSUANCE ll "
L r �
ISSUED IIT: �O/xr
NEW RESIDENTIAL MECH, SQ. IT.
'PO'I'ALt
Owns nr nwhor"alla"m Use
OFFICE