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