S 1891APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - HI.EICTRICAL
BUILDING. DIVISION APPLICATIONA'ERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IOENIIFICAI[ON
PE tll'NO
1891
BUILDING ADDRESS:
SANITARY NO.
APPLICNI ION SUBMITIAI, DATE
2obB5 AL\1842 Dig.
PH
OWNER'S NAME. ONE:
l
Se \ kMQ
A.
CON' TRACTOR'S NIH. LIC NO'.
NIC
❑
CONTROL#
CHI"I'E T'CNGINBER LIC NO.
ADDRESS:
G-11.1317
CON'I'AC'r PHONE:
{ 1 2 � l
i• Qr
❑ Consultant Fecs Paid by Applicant (Initial)
'i BUILDINGPERMITINFO
BLDG ELECT PLUNIH NIECH
IiFI
LICENSED CONTRACTORS DECLARATION
1 hmrhy minm than I rola ho,o,ed under provi.im,x rf chapter 9 (emmnea ins
QTY. ELECTRIC PERMIT FEE:'
JOB DESCRIPTION
PERMIT ISSUANCE
with Sarlir 17 I1IX110l Divininn s ullhc Husinc.s and Ihule"mr,s Coca and ray Insane is
in full force unit chief r uL 1 /
RESIDENTIAL:
WL ❑ KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
Licen.e Cl 'Lie.# J ,7 'D
I
Date Commcurz
DDITION [I PLUMBING RE -PIPIT
❑SMUCfURAL
MODIFICATION
❑INTERIOR ❑CHIMNEYREPAR
IMPROVEMENT USWIMMING POOLS
ARC[ I IIE= DECLARATION❑MULTI-UNff
I understand my plans vhaIl be used as public rcenrds
I'ANF.LS
UPF02WAMPS
Lievroed Po'hi..inFal
201-10XIAMPS
OWNER BUILDER DECLARA'T'ION
1 herehy affirm that I ant exempl form the Comirelm, Llrense ]-a. for the
frllnwinti ma na (Section 7031.5, Business and Prole .... a, Code: Any city or comnY
ElBATH REMODEI/EPAIR ❑DEMOLITION
[I OTHER
OVER IIXIOAMPS
SIGNS ELECTRICAL
which requires a #stoat to construct, alter improve, demolish, or repair any structure
morto is issuance, also requires the uppllcnm forsuch permit mtile c.v1 net I:
SPECIAL, CIRCIII'TIMISC. If
Nalhci,b,,awxlparsuanuo Rte .... vikonauf the Contractor, IJ,rnxa l.aw(Chase, 9
TEMP. ME It OR POLI. I N S I'.
_
COMMERCIAL.
rem, tmracing win, Section9(00)of Divfsftm 3ol'IkAbmes.and Pmfux.lons Code) Fit
tela, he ix exempt therefrom and the haxis Erma alkged exemption. Any violation of/
Section 7031.5 by say applicant fnr a PermitmbPtn, the applicant I ... ivil pcm0y of
more than five hundred dullan ISMO).
❑1, us owner of the property, nr my employees wilM1 wages os their sr lc compensation.
will Jn Thu work, nnJ The-_swrrure Iv nut:merited nr nlTcrcJ fnr sale (Sea T(W4, Eusine,s
ElNEW BLDG/ADDITION [:1DEMOLITION
El TENANT ❑FOOD SERVICE
IMPROVEMENT
❑ OH HF,R
POWER DEVICES
SWIMMING POOL ELECTRIC
and Prnfessimis Code :'I'he Cnn'a"111s Licenxe Low does not apply "I un owner of
OUTLETS -SW 1'ICIIIS-PIX'1'UI2HS
preperty who bnildx m linpmvel (broom, and who dnr, tach work Innoclf m through
his own ampinye,,, provided than ,ash improvcmnns are not intended or offered for
sale. If. haw'cver, the building or improvement is%old within one year ofcnnipletion. the
NEW RESHIP PIAL ELEC!It SQ E4.
SO FC FLOOR AREA
S/SQ. FT.
will have the burden of proving that he did not build or improve for pur-
poer-twilder
x o f ). Y
1 f (lie pro,any, am exclusivOy comr,wfing with licen,ad Contractors, t
(�
rml I th,.11(5 911411I' nev, andI I', I is Com,) ThCoulaufa, L
ccn 1 w 1 an, a,plyl mf,mv,ny vda, h dd p 0 d
- ,a
QTY. ' PLUMBING PERMIT af. FEES
.hrr,omoaosEmown,wiharnm 1m(Ulnnemdp anal moeCrrt tor,
TJ
PERMIT ISSUANC1
LitI
I am exmtgn under Sec. ,B&I'Clirthismason
Owner Data
ALTER - DRAIN &VENTrHR(EA)
VALUATION
lP
WORKER'S COMPENSATION 017CLARATION
', Ihcrchy nllirm unJurpcnalty nl rju.. enc olthe following drelnntionr.
BACK H(IW PIRYT1,Cr,'EVIC:
I have and will maintain a CertificatefCousent to.clf-insum for Worker'.. Cou,sm-
union. as Provided fnr by Section 37(Xiof the Lahti Code, for the penumm nce of the
DRAINS -FLOOR. ROOF. AS CON
STORIES
'I'VI'E CONSTRIIC'IION
FIXTURF_S - PER TRAP
work for which this permit is ismted
❑ 1 have and will maintain Worker"i"Cnmpemation Insurance, as required by Section
_ �l
3]WoflIF, lnh... Curb, tonheperlhrmmneoflhc work for which thix l'erout ie I .... T
GAS - EA. SYSTEM -1 INC, 4 Oil I' LETS
OCC. GROUP
APN
My Wmker(s Cntnpunsn0un Inammcc Cuvier and Policy numhcnuc:
Pnliuy Nn.'
'
GAS - EA.'SVS'IHM-OVER 4 (EA)
CGRTIPI Op EXEMPTIRWURKI3RS'
COh1PENSATION INSURANAN CE
INSURANCE
(TLix.ectinn mention RcmnplrteJ iDbe permit is Forane hundred Jnllurs lEl W)
rr Ims.)
GREASF/INDIISTRh HASTE INTERCEPTOR
HL DI' DIVISION
GREASE TRA('-
- -—
PI,ANCH K IV/
Iccrdty thal in the pertnnnunceoRhe work bar a4rchthisprrmtt is issued, (•hall
not an Ploy any person in; lnunnn',u as to hccnra, ,a hiano the Wmk,r,' Cumpen-
SIiWP.Ii- I'TA I2V-..
RMh 10IT.
IiN1iRCY
ATF..Ifi VNE i eLEC'I'
'min. Law. of Culifmmis. Date
Applicant
GRADING FE
NOTICE TO APPLICANT: IL after making this Cenificam of Exemption, you should
become subject m the Workers Compensation provixionv of the Laka-Code, You must
ATER SYS 'IE 1RREATIN .
SOILS FEE
forthwiNcumply walasuch provisions Far perrintshall he deemed revoked
WA' „ VI.'.
NEW RESIDHN'IIAL PLIAB SQ Elb
CONSI'RUCIION LENDING AGENCY
I nerehyadErtn that mere is acen,Parlirn Ind'mgagency bar the performance rf
PAID
True Receipt#
the work hu which Nix l'gnnil is isnuM (Sec.31N], Civ. C.)
Lender's Nanta
TfY1AL:
Lender's AJNes.
BUIl- r 1 Eli
I comfy that 1 have ud this application anti state Nm the a sI.. ..... .......
correct. I agrea R. comply wim all city and county.... nances and sato laws miming 10
huilding mnaxlntc(ion, and hrrchy uwh..izc reprexenultive, of Nis city to error lgnm the
I{.
Q'IY.• MECHANICAL PERMIT 1 PEE
"I'
SEI4 hF
PERMIT ISSUANCE
IeL IC RE
ubnvo-mominneJ Empmty for a,we apmpmses
(W'e)agner u,, e, indemnify and keep humdeexthe Cityof Co,enrs, against
ATTER OR ADD TO MECIL
I'LUMRI GFlili
IiabilHies,judgmems,toms and expenses which may in any way acerae against said City
in consequence oflhe granting afthis permit.
AIR HANDLING UNIT (TO IB,(XX)CPMI
MECI NICAI. Hili
APPLICANTUNDERSTANDS AND WILL COMPLY WITH AIA. NON -POINT'
SIURCIi NECULATIONS. /
��'"'1
AIR HANDLING UNIT (OVER lfl,(HIB CFM)CONS'TR
Cf1ON'fAX
Signamrc of�Contmmor n
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST [1001) W/DUCT)
HOUSING NINTIGATION FEE
Will lhcapplicam or future building occupant slomorhandle hazardous material
HEATING ON[ I(TO EfrXI, 1ITU)
as defined by the Cupertino Municipal Code, Chapter 9.12, and he I Iealth and Safety
Code, SW1irn 25532(.)!
[EATING UNI'( (OVER HILIt)(), jr,j)
❑Ye, [-I No
uta equipment rr devices which
Will the air conn nr future building ty the
mil hazardous air contaminants as defined by the (lay Arca Air Quality Menagement
Dixldrn
F] Ye, [:1 No
PAID _-
Date Receipt#
VENTILATION I'AN(SINGLE RESID)
BOILER - COhll' (3HP OR I(q.W I3TU)
- 1( L'
BOILER -GGM1IP (OVER INFAX) (ITU)
AIR CONDI'I'IONIIR
Ilalth rcLdfet bazordoerrie,1155,25533 For unJar Chnptttrx95rfhat Cell-
firmizgdoes&Scurrytlyhaeatrus25eari 25533and25531.1 urdemand thinifthe
building does not currently have u taram. Nat it is mspasl m ramify the
/ 7$$UANCI-fJA9'�#
NEW RESIDPNTIALA1EC11. SQ. PI'.
u, ami came,
of the requinrnumx which must M ..tat #none isslmnee of a Cetfilimtm of (kcupvncy.,
J�
IM
AfW%ISSUED
Owner rr umhon,tal agcnl Dae
OFFICE