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S 3066APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - ELECTRICAL BUILDING DIVISION DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL BUILDING PROJECT IDENTIFICATION PHt1'I' NO J _ 3066 BUILDING ADDRESS'. L"s GV �S D/z ; 26 00 - SANITARY NO. It APPI.ICATION SUBMI T'1'AL DATE ���� /98 ( IWNEIi'S NAME'. �PHONE: CONTRACl012' NAME'. h,C - I J NIC ❑ ///��f CON 'IIiOLq �% O C 7 I J/ ARCA IT{; I/HNGINPER' LIC NO: e ADDRESS: a r, Attire x - CONTACT. llGp ', y••- 'i BUILDING PERMIT,INFO. ��PPJ]ONE SQL H W u ` CO(iY LL ❑ Consultant Fees Paid Applicant (initial) BLDG ELECT PLUMB MECH LICENSED CON HtACPORS DECLARATION I hereby amen mm I , n 1 ae rw anger prcv s oma ter enanmr9 mamma ting 67Y. IN -p FliECfRIC PERMIT: _ _ 's JOB DESCRIPTION - PERMIT ISSUANCE wimS ti 7000) fD".' lfull J Bcct - -S' eme Inns LicN J. Datcn. Dam mmcmr RESIDENTIAL ❑SFDWI. ElKi DCHEN REMODEL ❑ 1i ADDITION ❑ PLUMBING R ❑MUi:fl-UNIT. El STRUCTURAL MODIFICATION ❑INIFRIOR El CHIMNEY REPAIR IMPROVEMENT E] SWIMMING POOI.S APPLIANCES- RESIDENTIAL AR CHIT ECTserecords DECLARATION I understand my plans .hall he used as public records PANELS UPTO 200AMPS Licensed Professional - 201-1000AMPS OWNER -BUILDER DECLARATION 1 hereby affirm dal 1 am exmalet from the Contractor's License Law for the following reason. (Section 9031.5. Business and Professions Code: Any city m ccomy ❑BA'IHREMODEL/REPAIRID�DEMOLITION {K' ❑ OTHER OVER 1000AMPS SIGNS ELECTRICAL which requires a permit In consumer alter, Improve. demolish, or repair any structure SPHCIALCTRCUIT/MISC. - priors; its Issuance, also regmrcs The applicant Lusuchpermine file a aignevlimtemem thnt he is licensed puauam m the provisions nfine Cnnwcmra License LTtw s Copter9 (comic is exempt tSCrefrom and ofD alis aur armsegeBusiness and Pono, A. ieaclat e)or that he is exempt iberefm,n the hp for the alleged exemption. Any violation of TEMP. METER OR POI P [NST. COMMERCIAL' ❑ NEW RIAG/ADDITION ❑ DEMOLITION - POWER DEVICES say harm, wbjects theoppFennt to ucivil pennhy,af ❑TENANT Ll TOLD SERVICE notdorethan5by U0cmtil hundred dollar, not atom than live ,props properly, ❑ I, as owner of mc'lornpeny. fir my employees with wages as their sale anmpensnlinq or O y employees will do.Inwork, ands mre'n nalintended firol. as IMPROVEMENT _ ❑OTHIiR SWIMMING POOL ELECTRIC OUTLETS - SWI 'fC11N_S-NI%T'URFS an,,won, does um unJ Pmfeerions Cnde'. The Conlmdmrs License Law Vas nor apply 10 an owner of The ' ECI'R SQ FT. NEW RESIDENTIAL EL. ` property who builds or improves thereon, and who does such work himself or Though his own employees, provided that such ;mprovemcnts are not I^tcnded or oliercd far sale. If. howevcq the building or improvement is sold within one your of completion, the SQ. PT, FLOOR AREA $/SQ. Pf. cr-bander will have the burden of proving that he did not hulld or improve for pnr- I- Of salC.).- ❑ I, as owner of the propeny, nm exclusively contracting with licensed conhucle'sNO 'TOTAL: not. inct the present (S 9194 Broone,seedP fe,sion,CdJTI Contractors I' OrionL a I pplyT fp par h sides p si d who gets far such projects x that nla t Ks) revised pursuant the Centronics - 't t QTY .rT PIUMBiNCIPER-t•_ '-t YFEE�s' PERMIT ISSUANCE Lin eavaLaw. '❑lumexemplundurrecn. ,B&PCfor Imsreasnn _ Owner Data WORKER'S COMPENSATION DECLARATION I tai ifumundc, prnaly ofi jurynneof the following dcclarntions: AL'rl?R- BRAIN .@VENT -WATER EA) VALUATION / P BACK 17LOW PROTECT. DEVICE ❑ ihnveandwillmaintaina CeniEcnmofConsenitoself-insurefor Wnd.eds Compal-, aace of railcar as provided far by Section 3700 of the Labor Code, f.. the perfomf DRAINS-NLOOR.R01"F,AREA,17.019W STORIES TYPE CONS' I' RUCTION work far which Ibis porta is issued. FIXTURES - PHR'I RAII C] I have and will maintain Worker's Compensation Insurance, as required by Section 3900of Ore LaborCode, IN, adprehann nremf The work farwI,i,b moonlit is.vamad, "M -I INCA OUTLETS OCCGROUP APN My Worker's Compensation insurance currier said Policy number arc: Crrriee Policy EAS OVIIR41? ) ' FROM CER'I'IFICATF.OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE, SFJINIIUS'I'RL WAS'I'li 'CRCIr IWER - IlU1LU1N0 UIVISION'FP.ES (This section need not hecoT^pletnl ;Fine permit is for one hundred dullnm ($10(l) fir leve.) AS PLANCHECK PHP, ' Icertify that in the performance afthe work for which bonsai it is isstTal, Lshall nor employ any pecten in tiny manner NO fix to become subject m the Worker:Compen- -SANITARY-STORM EA 2(( ENERVIflf O HEATER WNRNT/ELF.CTR anion Laws OfCaliforoiu. DateTER Applicant GR N •EE NOTICE TO APPLICANT: If, after making this Certificate of Exenrplion, you should become subject to We Worker's Compensation provisions at the Labor Cnde, you most "WATER 1WFT S .E WA'IRE SERVICH , forthwith comply .,It such pN.Asidn.>,dr this permit shall be deemal revoked, CONSTRUCTION LENDING AGENCY Ihembyatrrm that there is a consmmlion [ending agency far the performance Of NHOV REST DEN 'I'I Al. PLM H. SQ. ET. P Dam RccuiplX the work for which this Permit is issued (Sti 3097, Civ. C,) Lenders Name T L Lender's Address - 'TOTAL: .. FEE 0 1 sdifl y Ih r I hrve read this application and state Thm The above Infonnaion Is3UILDMF correct Iagree In comply with all city and County ordinances and stace laws Mailt buildiii,onsnacimtand heteby earn az puinmfves of m's day to ealmirpomm� i QTY., MECHANICACTI ERMIT • FEE"r 1, .EISMIC FEE PERMIT ISSUANCE E CTRIC FEE abuse -mentions property far ir,,crica purposes. - (We) agree to rove, indemnify red keep hr City of Capetian against ro ALI ER OR ADD TO MECH. PLUMBING FEE Iinhililicr, judgmmns,costs and expenses which may in any way accrue agni^si said City in consequence of the granting of oris permit. HANDLING UNIT (TO 10,000 CFM) MECHANICAL FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTAIR SOURCE ItEOUi,AT10N5. ^ is y AIR HANDLING UNIT(OVBR 10,000 CFM) CONSTRUCT ION TAX Sigwmradl Appli�wvVCnadcon Use HAZARDOUS MATERIALS DISCLOSURE ' EXHAUST HOOD(W/Duct) I[FUSING MITIGATION FEB HEATING UNIT (TO 100,000 BLV) Will the applicant of future building merchant store or hurdle aamrdous malerit I as defined by The Cupertino Municipal Code. Chapter 9. 12, and the Ileahh died Safely Code, Section 25532(4)'/ BEATING UNIT (OVER Ig1.I1W PTU) ❑Yes No VENT ILA'I'ION FAN (SINOLF. RHSID) PAID Date Receipt# Will the npplirnmramarxfuture a bullring by the nt By Area Air order Quality Mlces rageoluh mit huzanlmur air uminminrnrs es defined by the Bay Arra Air Quality Munagenrem BOILER- COMP (311P OR 100,000 RTU) A O BOILER - COME (OVER 100,000 BTU) Distrall ❑Yes F1 No AIR CONDITIONER I have deadline haanrdoms orders, reLr underChaler 695 of tiro Coli quirunen p ISSUANCE DATE NEW RESIDENTIAL MECIL SQ. FT. fain Health us Safety Code, Sections 25505, 25533 and 25534, 1 understand That IT Ore auilding docs mol cuneady have n want that II is my responsibility In notify Ibe occupant 2 4; �y P of the mquirmncom which must be tact prior to issuance of a Certificate of Oavpaney. ISSUED BY: TOTAL: Owner ter Indonesia] agent Dote OFFICE