S 1860M
•
&aaucANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING MVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT• IDENTIFICATION
•
Plitt I' NO.
J 1860
BUILDING ADDRESS: p.,� -
�J� n1 �ow�
SANITARY NO.
APPLICATION SUBsu rfAL DAIS
OWNERS NAME: PHONE:
mrn a �\2j�
CONTRACTOR'S NAME: LIC NO:
Co
NIC
❑
COMIROLp
ARCHITECT/ENGINEER: LIC NO:
.ADDRESS : M
J� • �L��T� a+F_
CONTACT: PHONE;
i6L Co�2n3_arop
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PL•RMPF INFO'
BLDG :CELT PLUMB ECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed ander prvvi ism or chapter 9 (commencing
with Section ]OgBof Division 3afahc Bonitos, and I'r.fission, Code,and any heroics
in full force and errs 6 n$
License Cl !J Lie.x
Uwc�\�a-9�Gmtmemr'Ipkt'LT
AltCllrEC'PS DECLARATION
I nndersernd my pIads,l all be used as Public recoA.
QTY ELECTRICPHRAIFF FEE
JOB DFSCRIPT
RESIDENTIAL:
E-Isp , xrrCH EN RHMODId
[]ADDITION ❑ PLUMBING RE -PIPE
CMULTI UNIT Ll STRUCTURAL
MODIFICATION
CIMI?R1UR EICHIMNEYREPAIR
IMPROVE 1' CSWIMMINOPOOLS ;
C3 BATH R- ODI3IJREI'AIR CDI :VOLITION
�OT11
pIHi MIT IBStIANCE
APPLIANCES — RESIDENTIAL
PANELS
UP'1'02MAMPS
Liceelyd Prom"llood
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Commnor'v License Law for the
following reason (Section 90.31.5, Business and Pmfes,ioa Cade: Any city or county
which orifices s pmmlt In .....Marfa, alar, improve, den oli,h, or rcphir any .anumre
prism it,isourne..h.,"mor,theit,frml Ensuehpennin. fileasi,adsuncmoal
Lha he ix IicenseA pursuum m the pmvisions of the Coni nears License Law (Chupur r)
mome,romg with Smd.0700X)of Division 3oUhc Rusinc,su.d Prof ,ions Galc).r
thin he i, exempt therefrom and the hvsix for Lha alleged exemption, Any viflmion of
Section 7031.56.any... heart fara pemtil subjects the applicannnu civil penally of
n more than rive hundred dollars ($5(X1).
❑ La, oo w.,k. cd thepany,ur mycmrumade,withwnge,iw.Ic(Se 7044. cn itse,s
im sale (Sea to an Baines,
will do the work, and the he om is tent i Livens o Law does
and brambly whob Gslor TheComment'sthemo Liceaelawdm..urnapply to an owner of
his ow yc dbuilds or improves donerd,, and who does such work blmsdf or through
his own cnapinymq president dna xueh impmvcmcnls Bre nm intended or ofl'n'cd for
sales If, bmrever. the building or improvements cold within one yearnfeompletion,the
owner-truilder will have the burden of proving that he did not build of improve for put -
"'d .1 role,
❑ I, a owner of the property, am exclusively con rseling with premed contractors to
onstruct the project (Sm, 7014, Busimss and Professions Cade )Tho Contractors Li-
Ise Law docs not apply In owner of property who builds or improves thereon, and
w
whocnmmca, forsuch projects with acnntmner(s) licenced Pn"anal,, he Grnhunuo,
License law.
I am exempt under Sm. . B & 1' C for this mason
201.HXIBAMPS
OVER IOOIIAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUTOMISC.
TEMP. MEI 17R OR POLE INS'C
ar
COMMERCIAL: -
C ryEyY BLDG/AIDDI'FION 0 DEMOLITION
ANT 0FOOD SERVICE
01HIH IMPROVE I'I'
❑ OI'HI3
POWER DEVICES
SWIMMING IHIOI. I?LIiCfRIC
OtTI'LFI'S—SWITCIII?S—DXI'ORES
>/
NEW RLSIUIIN'PIAIJiLEC'1'It SQ l ',
SQ. FT.(I(AAJH
A11Lt10
JUL�� AN
/�
VIT�/I' UFUuI'tNI{'
INO
'VSQ. ET.
-
'DyfAL
-
QTY, PLUMBING PER T FEE
PERMIT ISSUANCE
Owner Date
WORKER'S COMPENSATION DECLARA'T'ION
I hereby affirm under penalty of perjury one of oe following decoctions:
]IM1nvc andwillmvinoinnCerailiculc of GnucnunsclB Imure on Worker', Cnmpcn-
,tion, as provided fr, by Section 3900of clue labor Care, for the pe,f,)..ncc of the
work for which this pemsil is issued
[:11 have and will nein am W..Ina, Compeamion Insurance, as required by Section
3700 of the LaMm Code. for lire perfonnunce of the work for which this permit lx issued.
My Worfs Qn nsa Inst{{�[[ candor and l'nhc p,
Carrier: Y Policy No. - res `G'64- d'
C17RTIFICAIH OF EXEN I(IN PROM WORKERS'
COMPENSATION INSURANCE
To,,redon need not becomplered iDhe permit is for ane hundmdd.11ars($1(1(11
or less.)
I ccnify ohm in theperfnrm.neenl'Ibewnrk l'.r which chis pennil is issunl.l sit'
ton employ nny punnn in nny manner so us I0 Wcnmeeubjem m the Workers Con
.,tion Laws of C,lifomiu. Da.
Applicant If
N:I'I?k—OItA1N&Vlr —WATER (EA)
VALUATION
BACK FLOW PR .CI'. DEVICE
DRAINS — II R. ROOE,ARI7A, COND,
STORIES
'I'V I'li CONS'1'ItUCTION
TIM UR PER TRAP
GA' A. SYSTEM.I INC. 4 OU'I LEI'S
UQC. GROUT'
AI'N
S— EA.SYSTEM OVERJ(IiA)
OREASWINDUS I'RI, WASTE IN'I'ERCEPIOR '
BUILDING DIVISION pCE$
GREASETRAP
I'hANCIIGCK FEE
SHWER —SANITARY —S'TOJIM 13A. 2(NIIT.
L'NL'RGY FEE
WATER HEATER WNEN 7rELECI R
GRADING FEE
NOI'ICH TO APPLICANT: If. after making this Certificate ofExenapaion, should
become wbject m the Workers Compensaion pmvisions ohhe LaMsr G , yon mat
fonhwiah comply with such provisions or this panni, shall he deomed to ed
CONSTRUCTION LENDING AGENCY
I hereby u0irm dem them is a ransomed.. Iendagagem, the pertormance of
the work Far which this Permit N i,mn1(Sm. 9097, Ci, C.)
Lenders Name
WATER SYST EMn'RIiA'l'INC,
SOILS THE
WATF.R SERVICE
PAID
Date Receipt Is
NEW RESIDENTIAL PLMB. SQ. FT.
'TOTAL:
TOTAL:
Lender's AAdm,,
BUILDING FEE
d crate at the above information rs
ccnify ohm I have rcnA this npp/�oom,.Min
Meeh 1 agree m enmply with all city m.Min c . andmnelaw,relaamgm
voatmaion. and hereby authornts' es oflhis city o enter upon the
above-mentioned pm,.y for inspection. la,s dmCityorCupertino .,alta
liabili.."'o it ems, cod,me1c. em,,anywayacuragaial>aid City
c of the graming.f this pcAPPLI UNDERSTA'DS AND MPLY WITH ALI. NON -POINT
SOU ai I iGU�IONS
-
Q1'Y. MECHANICAL PERMIT FEEbuilding
SHISMIC FEE
I'I?RMI'1' ISSUANCEELECTRIC
FEE
AITERORADOTUMIiCH.
PLUMBING FF,F,nmqu
AIR HANDLING UNI 'I'(TO WAS) CFM(
MECHANICAL Plili
AIR HANDLING UNff(OVER 1400X1 CFM)
CONSIRUCTION'IA%
Sign err o(Ap11 mm Cnmrucmr D.If
HAZARDODS ATERIAhS DISCLOSURE
Will the applicam or oturel riding mcupam stow or handle lmzntdous material
us der d by the Cupeninn Men' pal Coe, Chapter 9.12, and the Health and Safety
Coc, Saban 25532(x)?
E] yes No
Will Ihenpplicant or loom huilding0mupans u,eequiinion mdi3Oms which
emit baeardos an
uair comimons as dclined by the Bay Arca Air Quality Management
Di .Ric,'!
❑Yes E] No
I have Mad the hnrallous mand 55 5, 25533 of under Chapter ram of the Cali-
forma Health & Seance lly ha Sections .that i 25533 and 25534. 1 undcmvit that if the
,,fine mi..enmomreichbrour t, met lhmismoure,pnnsibilityut notlfyocutinvy.
I ,,fine r.yfimment, which masa be, mel prior to isanana.r t. cenhmm. ortxmpaacr.
E%IIAl15T IIOOD (WIUULT)
HOUSING MITIG61'ION PI!I!
IIEIONG UNI'I'fTO 11X1.(100 HIU)
HIi APING UNIT IOVHR ❑XktX11 it HU)
('AID
Dole Rccciptp
VENTH.ATION FAN( SINGLE REBID)
—
BOILEkCOMP(3111'Ok IW,IIfNI BI'U)
TOTAL:
BOILER— COMP (OVER 100,1100 BTU)
AIR CONDITIONER
ISSUANCE DATE ging,
/��
ISSUED HY:
NIiW RESIDIlVT1AL MECH. SQ.I'1'.
Owner or amhnrizcl agent Date
'DOTAL:
OFFICE