S 0295 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
�- PIiRMR Nll.
CITY OF CUI'ERTINO HIIILING-FELE MECHANICAL
S 0295
BUILDING DIVISION APPLICATION/PERNIFF
PLUMBINGGPRoJ- T,IDENNll'IC
T s' " -•BUIIAING YR(IJ IiCT,IDNN'I'IPICATION-
- SANI'1'AHV NO. API'LICA'I'ION SUBMITI'AL DATL
BUILDING ADDRESS:
74.1,
OWN F.' VHONL: CONTRACTOR'S NAME. LIC NO: _
NIC CONTROL.
•ARCHHECT/ENGINF.ER: LIC NO'. ADDRESS:
Fmf.1Imm�.ndc,ffcnj
PHONE: i - BUILDING PERMIT INFO
zi
❑ Consultant Fees Paid by Applicant(initial) BLDG rale Ph11 + MF
SED CONTRACTORS OECLARAI ION QTY, S ,IiLECTRICPERMIT +'. `, EEI?i-',' ❑ JOB BSCRIPTION
t I I' d d p vi,,or,n. f Chapter 9(emnow nizz c ng
Foove
's' n3 nfthe d,C ccs JP f sx, CG J ny liwnveY ERMITISSUANCE �SI )WINTIAJ� ❑KITCHIiN REh10DE1,Z 0 Lie.N 30 4/4 7 Z _dare Dae - Comnm �-j'�✓ APPLIANCES-RESIDENT JAL ❑ADDITION ❑PLUMBING RE PIPE
—t�T_AR�CI"S DECLARAI ❑hNLTI-UNIT' ❑$TRUCI'URAI.
F N .end m' lam shall le aced us uhlic meals PANEIS MODIFICXFION
v� I renderer )n r
OZ-d� 11P'r02IX1AMPS ❑INTERIOR ❑CHIMNEY RP:I'AIK
H4 tW Licenced Pal'e,siomnl 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVIiR IgM1AMPS ❑BATH RESOLE REPAIR ❑DEMOLIT
eG I hereby affirm that I am exempt from Inn G,mn,ctor'x License Law for the
a V following remora(Sermon]IIJ LS,Hminees anA Pmfexsirnr Curc:AnY<iry°r cooed SIGNS ELECTRICAL ❑OTHER
1+13 W y which rcyuirex a Permit m cnmwct.alter,impew,demolish,car repair any umcmrc
F��a ,6..rnit,iauance,npnordure,the appliminthe'rch,....itm fileaxi6ucd emt,nrnt SPIECIM CIRCLEUMISC.
pppp,��',rrlI//yy�aNcl that he is licensed pursuant to the provisions of me Cnntmcmrs Lmansu Law(Cnapt,9
0:par ,CZO (amm�encing with Scclion]IKK)Inl Division 3ofthe Business and Fralc..Joe,Curcio, TEMP METER OR POLE INST. COMMFRCIAI'
a y m, that he is exempt 1harcG°m and the Iasis for the alleged cxemptinn.Any vlolminn of ❑NEW BLDG/ADDI'f10N ❑DEMOLITION
if tL Section]1131 5 by any vpplicam for a prone snM1ja'Is the upplicum m a civil penalty of POWER DEVICES
��m not one than live hundred delta,($500) ❑'TENAN'T ❑FOOD SERVICE
=Q 1:ax awner nfthe norm employees with wages as their role cone tion SWIMMING POOL ELECTRIC Ih1PROVEMENT
Q ❑ pr°pe Y yemp Y ! pe sn ❑OTHER
willdolnewod.undthe,urmadis not int„JeJ orolfertd fnnale(Sec.]MY.Buvincx
and l ,,ion,Cale 11 C...........l Law des, a,,p,1 turf OU'I _ETS-SWHCHHS-FI%TURES
a 3^ ,ropemy h h Ids s - p Ih renn J h J ch k himself through
ht. n pl y cs,pm ide 1 that such unproencre,am hot'intended car offered for NEN'RESIDENTIAL LLE CTR SQ FT.
sal II h e the M1 im gt npeve t IJ withinon,Y f pl lion the SRcY'f.g}(IQR�tF.A SISQ.FI'.
ownerhullder will have the harden of provmg fact he did n,1 ht ild ter improve for par- 1 �J
po L 1.1 JUL1 c fth property,nen,dela cry t cling ahT d B. B :t _ 1,,E.: 'W Y/IL 15 ^
construct in poi ct(Sec 714/ Hasner and l f:. n,Cur:)beContractor L - - Wth
ca,:e a t ,ply t of property wl o build p men d Q'�'- I s' PLUMBING PE: MPT FEE•'1,
whot llf ter i ith,eellra.lnt(,)hoc,edn II d Lmm 'I I�UF License l dee etni arta,See. .l+&P C fir roes minoun w. IERMII ISSUANCE V l%UPEHI'INU
ALTER-GRAIN&VEISTA)'F.R IE - VALUATION
Owner Dun
WORKERS COMPENSATION DECLARATION RACK FLOW PROIECT.DEVIGIi
•❑ Iherchy aflirmand,penalty of perT.,oreof the following medurati°m:
I have unit will mnnmin a CertificateofCama.un self-i oto for Wnrkcr'c C°mpen- DRAINS-FLOOR.ROOF AREA,COND. S'I'OHIf:S TYPE CaNS'fR SHUT
ration,as,waind for by S,aion 3710 of the Lnhor Code,for the perfismmnru of the
work for which his permit is issue,. PIX TURES-PER TRAP
❑ I have and will maintain Worker's Compensmion Insurance,as required by Section
370flul he].;the,Code,for he NOT..nnaeeoOlue wnrk(or which Bars permit is,waned, GAS-EA.SYS FHM-1 INC.4 OUTLI?TS OCC.GROUP APE
My Wmker'c Cnm,ennvtinn lnnnrunceeu,around Policy an ur (�'�`/�-��y���� GAS-Ifs.SYSTEM-OVER 4(EA)
Camcr"/If J�1�7,2fsaVL 1'ollcy N°r: G
CLRTIFIC OMP17 E%LMIN INSURAN E K.H ' GRIEASPIINDUSI'RI.WASTE IN'I'ERCEITOR
COMPENSATION INSURnNCG BUILDING DIVISION RiliS
(T21isnOhmm accrual he u,mfo
,lct,d,fthe,enot(is r,re nmaledd..Ilact X 100) GREASEiTRAP
- ter lcss.l PLANCIIIiCK FEL
Icertifythat inthe performance Blithe work forwhich thixpennit isissued.Ishall SEWER-SANITARY-STORM LA.2001T.
not employ any pt,,air in any manner x°usa mcnme,ubjea a the Wade,Co.,.- ENERGY FEE
Zscion Lawn of California Date WATER HEATER WIVES UELECI'R
C C) Applicant - GRADING FEE
NOTICE TO APPLICANT:IL after making this Cernflcac of Emulation,you shnulJ WATER SYSTEM?BEATING SOILS FEE
a �^ became subject m the Worker's Consternation provisions of de
the Labor Co ,you must
[i7 Iti forthwith comply with uch prov,sions.,,his an tut snail an dimmed evoked. WATIiR SERVICE
Q
Uz CONSTRUCTION LENDING AGENCY NEW RIiSID1iNf1Al.PLMIi. SQ.FI', PAID Date Recei,l0
I hereby darn that thus is n construction lending vgency for lhe,ednttwnce of
C.) C) the work far Much his permil is issued(Sce.3097,Co.CJ
04. lend 'N IIYfAL:
W - t T,OTAIkn J Address
I certify that l have mad this application and state that the M f atIs
BUILDING FI
:E
te correct.Iag B nplywth un cityandcounty f 1'11 tigt QT 'MECHANICALPERMIT EE
7huldmgcn.tm,im end hereby volar, ercream fvexnfhseilyu wle unnhe Y • t � � ' SEISMIC FEE
aMve-mentioned prat for inspection per,ow, PBRMIT ISSUANCE
(We)agree to save,indemnify and keep hermlea the City of Cupertino against ELECTRIC FEE
IioNI,w,,.,m,asrh,costs.,Inx,m,c,whichruy in any way accmc against said CityA ITER OR ADD TO MEET I.
PLUS HIND r'
APPLICANT
ce Nthe RSTAN SIrispe WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT A11211ANDLING UNIT(TO IB IpO C,M) MECHANICAL FEE
SOURCE REGULATIONS.
• AIH HANDLING UNIT(OVER IO.IMIO CPM) CONSTRUCTION FAX
Signaumul Applamm Contmetor Dee EXHAUST HOOD IW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupvm xtorc...madle hicandmi,maerial H17ATING UNIT(TO[00.000 BTU)
m,dcfn d IT,the Cupertino Municipal Cale,Chapter 9,12,and the Health and Safety
Cade,Section 255320)'! (EATING UNIT(OVER IOII,IMIO BI U)
0Yes1 PAID -
VIiNILAHONPAN(SINGLE RE,SID) Dim RcvipBN
Will he 11p,Iwml or fume budding occupant use a u' Ipmem or devices which
n"'t hmaraas air coravrmr ntc s defined by the Bay Are AirAir Quality Mnm gem,m BOILER-COME(HIP OR 100,000 HTU) 10TAL:
0Ycs ' BOILI'R-COMP(OVER INEMHBIRE .
' I nave mail the hmminl°us mar ials to made Chapter 6. 5 of he Cali AIR CONDITIONER ISSUANCE DATE
rc,25
fomes does act
Cade.es teran255115,2553]and 255]4.1munfiy m Ina1ifthe NIEW RF.SIULNTIAI.MSCI(. SQ,Pf.
buildin6 a«s urn currently have a tewnt.tare it is my msponsibiliry m mnify the mcnpam '
afarrenn whichm tie met Pri, to sea enfa Cert imam Of( cup ey.
Owner u1 Breed agsnt Date TOTALISSUIiD BY:
OFFICE