S 1096 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 1096
.BIIIi.DING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY IN APPLICATION SUBMI'TI'AL DATE
5- A sn,u L AA-1 F,
OWNL i'SNAML: ('HONE: CON RAC(OR'S AML; LIC NO;
E f9N ]77-SY®2 I/` ti Of u NIC CONTHOLa
:•ARCHITECURNOIGI`N [R LIC NO. ADDRESS: ❑
CONTACT: /(- PHONE: BUILDING PHRMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BJr ELECT PLUMB MECH
r�
Lnthat I.UC(1NTRd underS DECLARATION QTY. ELECfRICPERMIT FEE
I Daren,amrmt that I art,licensed ander rnwiainn.of Chapter 9lcnlnmeneing JOB DESCRIPTION
Woz with Swtion]IXXB ill DivisionJnf the Rusineso and Hofcssiom CMe,antlnry license i+
FIB in full force and eRem V PERMIT ISSUANCE
aVz�FJ License Class - L10.K Z T)Wh ❑KI'I'CIIEN REM110UE1,
ya4 Dxdc Cnmrxolor APPLIANCES-RESIDENTIAL ❑AUDI T[ON ❑PIA)MBING RE-PIPE
ARCIII'I'=N DECLARATION PANIFS ❑MUIII'I-UNIT ❑SIRUCTURAI.
ZO-Z Iundemmnd my plan.shall beusedmpublic awards MODIFICATION
OZFD UP'TU 2W AMPS INTERIOR El CHIMNEY REPAIR
�4 ; LibenseJ Professional 201-IIXX)AMPS IMPROV17MENT SWIMMING POOLS
ad OWNBIt,exempt
Cann'InN
C I hereby affirm whet 1 ren exempt frntn the Conlrvetnr'.c License Law for Ibe OVlili IIIIXIAMI'S
ID BATH RIeMODBURIiI'AIR [_1 DEMOLITION
F LLO L V folhroing reason.(Section 703 1 S,Business and Profess inns Gale Any city or boom, SIGNS ELECTRICAL ❑OTHER
LLO y which requires a permit to construct,alter,improve,demolish,or repair any structure �l
js'� prior mits issuance,also requires the applicant for such perminn fileusigneA smdemeot SPECIAL CIRCI11n'/MISC.
that he isiicensed pursuan,o,hermyinions of he Contractors Livors Law lChapter9
(commencing with Somion 7OIXBof Division 3 ofthe Business and Professions Code)or Tflmly.METER OR POLE INST COMMERCIAL:
6 S c that he is exempt therefrom and the basis far the alleged exemption.Any violation of
El BLDG/ADDITION El DEMOLITION
F.^m Sectimi
Section 7031.5 by any applicant a pert subjects the applicant to a civil Knotty of MW17R DEVICES ❑TENANT ❑FOOD SERVICE
m
2 more than Ove hundred dallun 15500).
O ❑ I,nxowrer,q lhr
empeny,orn,y employees wile wagesa,mw,sale nmgamsatinn, SWIMMING POOL ELFCTRIC IMPROVEMENT
will do the work,and the structure is not intended or offered far sale(Sec.7144,Business ❑OTHER
lY 3m and Professions Code:The Conmamea License Law does not apply to an owner of OITILCIS-SWITCHES-IT URES
^ pmpar y who builds in improves thereon,and who encroach wad himseB or through
his own employees,provided that such improvements are not intended or offered far NEW RESIDENT Al,ePR SQ FI'.
vale.IL however,(he building at intproventenl is enld within one year of bompletion.fite SQ.PI',FLOOR AREA $/SQ,FT.
owner builder will have the burden of proving that he did not build or improve for par-
❑1,,,owner of the pm.70,1 am exclusively cnntracaing with:)[Thee Contractor's
ren t. EI VE
ase La the pr Jwl(Sec.7044,weer of and ity wh item ds or
pro es luc on.and
wh�se Luwencs Dolapply canownerofmmouro who builds or imp roves Combe,and Q'Iry. PLUMB ER I°Eli T
¢nnlracks far sucM1 prnjws widhenmtmeor(s)licensed punuam do,he Commc,nrs OCT Liming law. PERMIT ISSUANCE lX O 19117
I am exempt under Sec. ,B&PCforthisreasnn
Owner hale AMER-DRAIN&Vldxf-WAI' ) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTIiCT.DEVICE •_-
1 hereby anion under penalty of perjury one of,he following dwlarations
❑I have and will maintain a Cedificate of Consent to selliin.nre for Worker's Compere DRAINS-FLOOR,ROOF,AREA.COND.
anion,as provided far by Seelion 3701 ov Lha Labor Cndq home perfnrnwnce of the STORIES TVI'Ii CONS'I'lllJf PION
work fill which this pcmrit is loam. FIXTURES-PERT RAF'
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
37IXbfthe LoMn Gee,for me perforrrearmufm,work for which this panni,is issued. GAS-EA.SYSTEM-1 INC.4 ODULIi TS OCC GROUP
APN
My Worker's Cnn tion lnmmnwcarrier vnJ Policy anotherore:
Carrier: P_xensu a Till No.', Ca 6d(Y6�S� GAS-EA.SYStFM-OVER4(HA)
rJrrC(l?HTIFlCA OP BXBMPI']ON FROM W_Ok KERS'
COMPENSATION INSURANCE. GRI!ASI➢INDUS'TRL WASTE F.RCEPI'OR
(This section reactor,be completedifth[perm,is furore hundred dollaax(SIM) BUILDING DIVISION FRES
or less,) GREASETRAP PLANCHECK op
I rertify deal in lhapertionanwaoflhewnrk mrwhich his permit islexubd,Ishill SliWlili-SANITAR -STORM Eh 200 F1
not employ any penon in any manner ones In become subject lo,hc Wnrkerx'Compere ENERGY THE
Satan laws of California.Data
Z�O Applicant t WATER HE WNENT/ELECTR GRADING FEE
Fi y NOTICE TO APPLICANT:If,alter making this Certofaa.of Exemption,yon should
hecmne subject m the Wnrkerx Cam WAt'IiR$ .TF.M/I'NIiA'fING
a G 1 pensvhis lona sof the reed code,you must SOILS PP,R
�
forthwith comply with such pmvisionx or lois permit shallMdeemed revolved. WAT' SERVICIi it
a0
� z CONSTRUCTION alONLENDINdingiiAGENCY ;W RCSID[NTIA1.1'hMli. SQ.I°T A-
1
f,Q Iherehy affirm dhauhem iso conmmeinn lending vgmmy fnnhe Perfnrmunbenf pepthe work for which this pes wed(Sec 3)97,Civ.C.)
OLenders Name J.d-
V handers Address TOTALTOIN.:I certify that I have read this application untl sane thu„M above mai a in.is wrrwd.I agree to comply with all city and nanny ardlnanee.ane state laws retain, o QTY. MECI IANICAL P13RMITbuildingconswenon,and hereby authorize representatives aphis tidy to enter upon the shave-namo oiled Property for inspection pmPow,.(We)agree ta save.indemni fy and keep hannlessthe City of Cupertino against l PERMIT ISSUANCE Iimilitics,palgroare.costs and expenses bithnody in any way aarmiglain.asmat City AM[It OR ADD TO MECH.to nscquarm ill thin gruntingof this permit.
APPLICANT UNDER. NDS AN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO❑IXXI I, CFM) O
SOU BREGULATIQ MECHANICALA.
AIR HANDLING UNIT(OVER III,fXp CFM) CONS'TRUCHON X
SigmmtircnfApFlinml/Canmu:ml' Uulc fi EXHAUSTHOOD(W/DUC'T) HOUSING MI'I'ICA pON PBI?
HAZ RDODSMATERIALSDISCLOSl1RE
Will the applicant or future building occupant state orhandie hazallous material HEA'L'ING UNIT(TOIOOJXIO BTU) ZO
as defined by the Cupertino Municipal Code.Chapter 9.12,andthe Health and Safety
Cade,Section 25532(a)P HEATING UNIT(OVER 100,1X10 111 U)
❑Yes Fl No
YEN'I'FLAT[ON PAN IS INGLE RCN I D) PAID
4,11 me applicant or future building occupant use equipment or devices whim Date Receipt X
BOILER-COMP U
emit hmnrdous air contaminantscontaminantsvs ed the Jefmby the Bay Arca Air Quality Management ( HP OR 100,000 BTU) 'TOTAL;
D
istrict?
s 0 N BOILER-COMP(QVER 100,000 131
read the hmardaus materials requirements unser Chupter/.95ofine Cali- AIR CONDITIONER ISSUANCE ATE:
&Safe,Cade,Swtinns 255(15.25513 and 25534,p understand that tithe NEW FIRSIDEWHAL MECH. SQ.IT.
ern currently ha meadx which mood Mom,porta issuriummaCertifiemeofOccupancy.honud agent Dme 'I OTA I,: ISSUED BY:
OFFICE