S 4375 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBINo-MECHANICAL S 4375
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI MAL DATE
OW ER'S NAME: PHONE: CONTRACTOR'S NAMI3: LIC NO/..
l!/ NIC CONTROL p
CH ITIiCUIOUI NIP it: LIC NO: A[AORESS: ❑
CONTACT: PHONE: dUILUING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ � ❑
LICENSED that I a CONTRACT'OR'S DECons of hap QTY ELECTRIC PERMIT FEE
I Hereby affirm noel I aro licensed sneer provisions nr cnaplm 9 feommenn:ing 408 DESCRIPTION
�pOwith Sution l(XX))of Division Sof Ne BQusinnsand Nofessions CuJe.a d�l
stall lbianse is Y13NMITISSUANCE RE_SIUFNTIA
n¢ ptG , Slk [�' ❑SPOWI. [I KITCHEN REMODEL
aVU Licenc ..c,can 1 Sl APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RI:PIPE
hWnate Contraelnr
FOm ANCI{I1EC9';9 DT;CLARATION 11 PANELS MODIFICATION❑STRUCTURAL
Z O,,2 I unJcmanJ my plana shall be used ac public records MOUIPICATION
MPS OZ
'/)— UP TO 200 AMPS El INTERIOR (D CHIMNEY REPAIR
F,4tu Licensed Professional 20I.I000AMPS IMPROVEMENT I]SWIMMING POOLS
447_1 OWNER-BUILDER DECLARATION OVIiB 11X10 AMT'S C1 BATH RF.MODEf/REPAIR C1 DEMOLITION
C C� I hcrcby alnnn that I um exempt linin Inc Contractor',hiccnce Law for IM1e
'a4Xi 6 U following reason.(Section 11131.5.Business and I'ntfesome,Gale:Any city or mum, SIGNS ELECTRICAL ❑OTHER
W 3 LLy which requires a permit to construct,alter,improve,demolish,or repair any structure
F�Oa poor tails issuance,also miasma the applicant fmorch Permian file a signed national SPECIAL CIRCUITIMISC. 2 til g�
that he is licensed pursuant in the provisions of the Contractor's License Law(Chain,,9
Wa0o (commencing wish Seainn 11X10)0(Diviainn}of the BusinosunJ Vrufcssiore Cndc)nr TEMP.METER OR POLE INST.
L p�a W that he is exempt therefrom unit the basis for lire alleged exemption.Any vinlnion of ❑NEW BLDG/ADDITION [I UBMOhITION
W Section 911315 blaly any applicant for a pemtil subjects IM1e applicant to a civil penalty of POWER DEVICES (]TENANT ❑FOODSERVICE
F' not more than five hundred dollars(S51XB.
IMPROVEMENT
�=G ❑Las owner of the propcny,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
F- will do the work,and the structure is not intended or offered forsale(Sec.10.0.Business []OTHER
Wim and Professions Coda The Contractors Lmense Law docs not apply to an owner of OUTLETS- CHE �1X9'II RES -
propcny who Wild,or improve,Ihcrenn,and who does such work himself or through ._. Evil,I
his own cnplovm,p osimc l thus such impr orna nts arc not intended or ofleard for NI7WzfflNZ h ELE SQ T-L
sale.If.however.the building or inipmvemenl is sold within one year ofcompleion.the \ FI'.FLOOR ANSA S
will have the burden of proving that he did not build or improve for for-nerbuilder JUL - 119'19
❑ I,as owner of the pntpert,an exclusively contracting with licensed vontmcmrs to 4 Aif P
m,rues the Prnject(Sec.9044,Business and Po ke,mm'Code 1 the Cria ahor s.
m Law dues hot...ly ,, owner of pi who builds or intprovr_s me u n 31NG PERMIT FEF.
who a su mels forsuch projectswith a wmraemr(s)licensed far aoatit to lirarcs A By
License Law, `
\As f MRI DANCE
El am among,under Sec. .B IF
"j"s rcasoa
1, iR-DWAIN&VEIT-WATER IEA) VALUATION
WORK17R'S COMPENSN'ION IJP HACK FLOW If I'.DEVICE
IhercbyaffimunJcrpnaltyofperjuryo following d' _tions:
❑ Theses andwillmainminaCenificae of Cense I AI OR.ROF .GOND. STORIES TYPE CONSTRUCTION
scion,as provided for by Section 37W of the La c per}os ants, the
work for which this permit is issued. RES
❑ 1 have:,,,]will maintain Woke-G.n.isnoution In. by Section
3lglohhc LaMn CoJe,frtthu performuiccof mr workh eman is koed. < - S IA41 INC40U'I'LIUS OCC,GROUP APN
My Woe p int.or 'r and Policynt c GAS-FA. YSTF:M OVF.RJIEA)
C. Policy No.:
C OF EX PTION FROM WORKS S GREASFIINUUSTRL WAST[IMTRCF;PI'OR
COMYLNSA ON INSURANCE BUILDING DI VISION FEG9
sThlssemimt need int becompleedlt the per mit i,forimehtmdcd dollars($IIX)) GRIiASETRAP
it less) PLANCHECK ITE
Iccnify that in depedormuneeafthe work(orwhichthi.epermit isi,aacd,l shall SEWER-SANITARY-STORM EA.200 FT.
not cmlanyany person in enY trwnne b�4 l ,I he W�crs'Co.,.- ENENGY FEE
Z ration Wws of l a tc _1 ' WATER HEATER WNENTMLEC R
Z Applicant /-� � n-P GRADING TEF:
Z
N NOTICE 10 APPLICANT':IL utter making Ibis Ceni he of Excionlim, III should WAT I7R SYSTI7MIl BEATING
h't hecome nhoam m the Worker's COmpensmion pmv'tsimis of the Lubar Code,You mutt SOILS FEE
fonhwith corh,ly with such Provisions or this perroo dill be JeemN revoked. WATER SERVICE
a �
7sZ COTthTNUCIIGNLENDING cy NEW RERESIDENTIALPLMB. SQ.FT. PAID
U Q Iherehy affimttha there icaconswninn lendingng agenagency for the performance of Date aeiPtN
W F-' the work bor which this Nosh is i...ed(S..3091,Ci,CJ
U LenJcr's Numc TO'fAh:
leader's Address TOTAL:
�.. 1 BUILDING FEE
1 certify that 1 have rtaJ this application and sum That the above information is
,F. (n correct.l agree m comply with all city and county ordinances and state laws mining QTY MECHANICAL PERMIT FF,E
V Z building enm action.and hereby authorise representatives of this city to camruptm the SEISMIC FEL
ahnve-mmhHotied prnpuny for InsKrom purpose,. PERMIT ISSUANCE73S rD
(We)agree m ore,Wde,orml'y and kccp harmless the City of Cupeninu against ELECTRIC FEE
habilam,judgmems,call,and expenses vinchntay in any w^yaccmeageiml mid City ALI'US OR ADD IX)MECH. PLUMBING IEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIN HANDLING UNIT,(To 10,1X10 CFM)
MECHANICAL FEE
SOURC iNEGULATIINS.
/ �'1 AIR HANDLING UNIT(OVER I(I,IXXICFM) CONSTRUCTION TAX
.
nature of ApplicanVCnntactor / , Date EXHAUST HOOD IWIDUCT) HOUSING MITIGATION FEB
HAZARDOUS MATERIAL ISC OSURL
Will the applicant or future building sca nest c or handle havurdous material HEATING UNIT(TO 100.0010 BTU)
as defined by the Cupemiso Municipal Collo,Ch t .12,and the Health it Safety
Code.Section 2553200? HEATING UNIT(OVER 110,011(1 13T U)
Yes 7 No
V13N1'ILATION IAN(SINGLE RESID) LAID Data Receipt#
Will the applicant or furore building occupant use equipment or device,which BOILER-COMP UIiP OR 100.000 BTU)
ethrustersitthrusters air contin inmu as defined by the Bay Area Air Quality Management TAU O
Disma! BOILER-COMP(OVER Ififf(M)BTU)
F7Yes ❑No
I have lend the humrdous materials E ander Chapter 6,95 of IM1e Coi- AIR CONDITIONER ISSUANCE DATE
rty 2i533a
fomiu Health ir Safety CINq Scaions 255115 25533 art,]25534.1 understand Chit if IM1e NEW RESIDF.NTIA1.MSCI{. SQ.FT. -7—r
Molding IT
he n an haveatc t, n' rapm,ibiI f cif IM1e occupant (/
of thcr LL o aaapancy.
or ailinautbnriiedugcnt Dare )T ISSUED BY; I�
OFFICE