S 3147 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL pe IF NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3147
BUILDING PROJECT]FIRST IF'ICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PH NE: CONEf1ACfO 'S NAME: LIC NCI:
tCcouz CI n >5 NIC CONTROL#
ARCHITECT/ENGINEER: - LIC NO. AUU :SS: 11• Z, LCP�ti '-1/%✓r J ❑
CONTACT: PHONE: u BUILDING PERMITINFO
ilq(o ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MIECCHH/
K`K vl ❑ ❑ ❑ IJ
ICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
Won, with Section 7NXD.FDivisioo 3..fthe Business.od Professions Code,and _my license is R RESIDENTIAL
WW� in full farce and cue 7� PERMITISSUANCE
VhF.. Lmcense Class C X20 " -'l.ic.a ZS /V ❑SFDWL O KITCHEN REMODEL
Q Uto ppPL1ANCE5-RESIDENfIAI. OADDITION [I PLUMBING RE-PIPE
Drn "ARCHITECT'S UIiCLAV ' ION PANELS [I MULTI-UNIT ❑STRUCTURAL
I understand my plans shall be used as public records MODIFICATION
OZ UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
F4t Llccnwd Poue"mr.1 26I4XI0AMPS - IMPROVEMENT ❑SWIMMING POOLS
90 OWNER-BUILDER DECLARATION OVER I(I0)AMPS [I BATH REMODEL/REPAIR 0U OLITION
1 hereby affirm that I am exempt from the Contractors License Law for the
6 U following reason.(Section 7031.5,Business and Professions Cock Any city or county SIGNS ELECTRICAL ❑OTHER
tar 3 U.y which requires a Permit to construct,alter.improve,demolish,or repair any structure �C.✓L.�.4CJt'
F�iiii gpinitsissuance,al.wregniresthcapprcantBvwchp.itmme.si,mbisatemeISC,
s SPECIALCIRCUIVNr
main
he is licensed pursuant the Provisions ofthe Contractor's License Law(Chapter 9
ul (commencing with Section 7000)of Division 3 ofthe Business and Professions Csdc)ur TEMP.METER OR POLE INST, COMMERCIAL:
6 L oy that he is exempt therefrom and the basis for the alleged exemption.Any violation of O NEW BLDG/ADDITION O DEMOLITION
Xmli b
f
Section 1031.5 by any applicant or a permit subjects the l
e appicano a civPenalty of POWER DEVICES
I.1..y t tcivil lt
❑TENANT DI'OOD SERVICE
not mute than five hundred dollars($SW).
F > IMPROVEMENT
,S6 O I,as owner of the progen,in my employess with wages as their sole compensation, SWIMMING POOL EIA/RIC
will do the work,and rho souetore is not intended oraTemd mrsale(Sea 9(144,Ouxlness ❑OTHER
uaU and Professions Code.The Contractor's License Law does not apply m an owner of OUTLETS-SWI'I'C LIS-19X'I'11RE5
o'a property who huildx or Improves thereon,and who does such work himself or Through
his own employees,provided the,.such impmvmncnes are not intended or offcral far NEW RESI)EN'I'1 L RI.HCTE R SQ L
wnerbuilder withe have the ofprmmnl ix mW worn on wild your
or improve for
SQ.PI'.FLOOR AREA LSQ.FT.
builder will have the ,iburden d proving the,he did not bayou or improve I'or pure
From uI sale.).
O L as owner of the propene am exclusively contracting with licensed contractors,to TOTAL:
comande,the Writer(Sec.10,4.Business and Pmfessions Cale:)The Contractors Li.
cause Law does not apply to an owner of property who builds or impmens lhsmon and Q'FY. PLUMBING PERMIT PEE
who cannon for such projects with a conterstor(s)licensed pursuaono the Contractors
License Law. PERMIT ISSUANCE
O I am exempt under Sec. ,B&P C fortis mason
Owner Dore ACIiR-DRAIN&VENT-WAT17R IV A) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PRIITIIC'T.DEVICE ��
• I hereby affirm under penalty of perjury one of The following declarations: �790 s
OlhaveanJ will maimaln aCerliOcadol CnIsere,oxclf-insure for Worker'p Compen- DRAINS-FLOOR,ROLE,AREA,CO ND. ,TORIyS 'TYPE CONSTRUCTION
oduch,as provided for by Sermon 31(X1 of the Labor Code,for the performance of the -
wmk hichthis permir shoved. FIXTURES-PER TRAP �� `
�.Ifi and will maintain Workers Compensation Insurance,as required by Seclinn
3101 ofthe labor Code.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC,4 OUTLETS OCC.GROUP APN
My Workers CprWynsarigelnsra carrier and Policy.. I�c �/Q GAS-EA.SYSTHM OVIiR4(Ep)
Card— / /� NA Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRI,WASTE RCEPTOR
BUILDING DIVISION F_miS _
fFhis scainn Iced not be completed iDhc permit is fnrone hundred dollars($I W) GREASE TRAP
or IcssJ PLA
NCHECK FEE
I oy any per In the any man n r oalThewmk farme whichsubject
this Permit is ins,ed.'Co flon- �
oat enmpin any s, as I SfiWER-SANIT Y-STORM EA.2IXI FT.
y any person in nn , In hcatmc huhjecl l.,he Workers'Com wn- IiNERGY PEE
w,iam lowsof Cullf.nim.Dare WAI UR IIF ER WNEN'1'/11I.1:CIR
Applicant 1 (.JIIADING FEE
ti
NOTICE 11)APPLICANT.If,.tier making this Cenific to of Exemption,you sound WAT SYSTEM/I'RRAI'INC,
a , hecnmasuhjecl to the Workers Compensation provislonn of the Labor Code,you must SOILS FEE
fsolwith comply with such provisions...this permit that no deemed revnted. WATER SERVICE
0. La
CONSTRUCTION LENDING AGENCY NEW RFSIDENTIAI.PLM❑. SQ.FT. PAID
UO hate Receipt
1 hereM1y amrm that there is a a,mwction lending agency for the perfnrmence of
the work for which this permit is issued(Sce.3091,Civ.C.)
[Jr U Lender's Name T AL:
�{Fa Lender's Address TOTAL: BUILDING FEE
I certify that 1 have read this application and state that the above information is
ra to contract.l agree to comply with all city and county ordinances and state laws relating to QTY. MECIIANICAL PERMIT FP'
G building conewalon,and hereby authorize represcatatives of this city to enter upon the
uhovo-nmmioned pmpsdy for inspection purposes. PERMIT ISSUANCE
)agree to save,indemnify.,,it keep armless the Ci,y of Canadian eguind E mR
abilhies,I ndgmems costs and expenses which may in any way accrue against said City ALTER OR ADD TO Isl PLUMBING FEE
inconse, a a ling of,hlspormit.
A PPLIC "U E Sl ND. ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CDU 10.0X1 CFM) A F.'IL100 7fJ
Asot iG ATI `Ft7s77OD
VF C AIR HANDLING UNIT(OVER BLOW CFM) CONFTRUCTIONTAX
Si of Applic C Dote I EXHAUST FOOD(W/DUCI'1 L
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FF;E
Will the...heartorfuture buildingoccupant stars.,handle haAcran materia HEATING USE'f(TO ido.000 B'I'U)
as dkined by the Cocoa...Municipal Care,Chapter 9.12,and the Health and Safety
Care.Section 25532(.)'! / HEATING UNIT(OVER 100,000 TUTU) 79nYes IU4R' VENTILATION FAN(SINGLE R ESI❑)
Will the applicant or future building occupant u.w equipment nr devices which Dam Receipt N
emit ha...J..a air contaminants as defined by The Bay Arca Air Quality Management BOILER-COMP GHPOR I(XVIHI RTIJ) (�
District?Distric7 7 70
❑Yes BOILER-COMP(OVER 100,010 BTU)
L'E.
, AIR CONDITIONERh sadth nJas quirements under Chapter(.95 of the Culi- ISSUANCE DATfismia I & y mCl .8533 and 25534.I understand that if the NEW RESIDENTIAL MECIL SQ.FLbuildin sea t is my mspnnsibilitymratify he acupumof the Is whichmissuance ala CeniOctcpf fupu U "� ��/y
.utn.d:eda a, ! floodTOTAL: -1 - Jy ISSUED B'F+�
OFFICE