S 1196APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO��j - BUH.D[NG-ELECTRICAL
P ITNO.
BUILDINGDIVISION'G'502APPLICATION/PERMIT PLUMBING - MECHANICAL
J 1196
BOLI.DIN(:'PROJI?CTII)EN'PIFICATION•
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SANITARY NO.
N'PLICAI ION SUBMITTAL DA'Z'E
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•- ;' BIJILDING PERMfl' INFO
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Consultant Fees Paid by Applicant (Initial)
IH.D - ITLEC'1' PLUMB MECH
LICENSED CONTRA( TOR S DECLARATION ION
I hereby affr.i mal tan licensed d p ' � 1 Chapter Y aomm its
with Sen un'l000)ol Davision3oOhe Ru. aJlmfessnnsCslde vnd mylicenscs
rml latex opts encQ� �I a
Licenx➢Caux _'1]I.ic.p `�� oK�
Dmc-�_�tj—Conlrac v1u
.ARCHITECTS DECLARATION
1 uudersnonA 1ny Clonx.eholl he umd m puMlc raonlx
QTy t. I ELP.(}TRIC I I RMIT I : I PEE
+ ' - � �''.
JOB DESCRIPTION
❑SIDWL ❑KITCIILNREM110DIil.
)DITION ❑PLUMBING RE-I'll'1?
DLTI-UNIT ❑MODIFICATIO
MODIFICATION
INTERIOR ❑CHIMNHYRHPAIR
/ IMPROVEMENT ❑SWIMMING POOLS
❑ BATH REMOT EUREPAIR 0 DEMOIA TION
❑OI'lll!R
PERMIT ISSUANCE nfiRE
APPLIANCES-RESIDENTIAL
PANELS
UPT0200AMVS�y�+t
Licensed Prefeesimnal
OWNER-BUILDERDECLARATION
1 hckhy nflirm in., 1 n;n exempl from the Corna'an , Licen..c Lnw for the
fold & (S T ](1315.8: dP f.:' C I�AY city oumy
which respire, .pe ,,all t, alm, onTromi.t 1'h l Ytcure
pno t ec L q . ah pplt I f h Pe 'r l TI .'ymilitate cal
'it.' [at is licensed artal thi n I the C t t I'_r,mm 1 (Chapter)
(commencing with Section Who) o[Dvsion3 of The nosiness and Profmn'm. Ctvle) nr
than he is exempt therefrom and the basis for the alleged e.emplinn. Any violmion of
Section 70115 by any upplicre, for a pe ....it sukieas the applicant m a civil penally of
non more than rise hundred dollum ($SIN).
Q1..(wnerofnhe progeny, onny employees with wagesas lheirsnlc forn,fsarion,
will do he work, and the structure is not intended oronered on.eile(See 70,14, Business
and Professions Code: The Contractor's License Lnw does nor apply to an nwncr of
property who build. or improves thereon. and who docs such work himself or through
201-1000AMPS
OVER IIMXIAMPS
SIGNS ELIC IEICAL
SPECIAL CIRCUI'UMISC.
TEMP, MCTER OR POLIS INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑'i'IiNANT ❑FOOD SIiIiVICF,
IMN OVIiMFNT
❑OTHER
POWIiK DEVICES
SWIMMING POOL ELECT RIC
OUTLP.'I'S-SW ITCHES-Iq XTUR17S
his own employees, provided that such improvements are net intended or offered for
NEW REST DEN I' IAL ELECTR SQ Irl'.
sale. If, however, The building or impnwencnl is sold within one year of completion, 'he
SQ, IT. FLOORAREA
VSQ. UT.
weric,laii lder will lave the burden of proving Thm he did nor build or improve for par-
of sale).
[IT, ns owner of the pronely, tun exclusivelyProfession, with licensed contractors as
A
'A
.
mswet rbc project (See 7I44, Rosiness ad Professions Code:) TTe Conrmsiar's Li-
whserpt milds Law not apply to ownerif properly who or improves thereon,ond
o contracts for such pmiecls with a cnnlmctm(s) licensed pursuant to the Contractors
QTY. 'I1j, i ' PI.UMBINGPERMIT.s •4�T (�'; .FEE
PERMIT ISSUANCE
License Law.
❑Iam scmpnmder See. ,B& P C for this rntson
ALTER
ALTER -TRAIN & VENT- WATER IEA)
Owner ))am
WORKER'S COMPENSq'['ION DECLARATION
I hereby affirm under formally of perjury one of The following eechuations:
BACK FLOW PROTECT. DEVICE
DRAINS-FLOOR, ROOF. AREA, GOND'
❑ Ihavenad will maimtuin. Cenificamof C.nncmmselLinsitrcfor Wnrkcr's Cnmpcn-
sation, as provided for by Section 37W of the Lothar Code, for the performance of theON
STORIES
'TYPE C(INSTRUC'1T
FIXTURES -PER (RAP
Cfor which this Firmin is issued.
hove std will nerinerin Workers Contpenedon Imammr. tis mileacd by Section
ofdte labor Carlo, for The performinceirromwul, far which do, permit is i... ed,
My WarWi. (AryRensmion Insurance carrier andPolicysh, number am.
GAS -ITA. SYS'1'IiM-I INC.40UTLE'I:S
(ICC. CROUP
APN
'SYS
Colace F0.11 Polley No.:
GAS - HA. '1'HM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
�-1
sz Q
Vl
a ^
COMPENSATION INSURANCE
(This section need nut be<omplcted if the permit is (crone hundred dollars ($100)
sir lexs,l r.
toy any in the myofthe work lin permit in issued,lnlmll
not employ Canon in any manner so onmttannm subjectnlhe WnrAcrs'Comltcn-
radon Lawsof California. Due
onl +
GREASIUINDUS'I RL WASTE INTHRCHPMR
I I ISION FEES
PLANCH
GREASE TRAP
EA. 2lM) FT.
.W
ENERGY PIE 7.
is
GRAVING FEE
WAY HEATER W/VFN'I'/I?LErTIt
NOTIAppliCE
NOTICE TO APPLICANT. IL arta making this Certificate re rf Exemption, you shouts
the Workers Compemauon provisions of the Lahr masa
TER SYSTEMrt REA'1'INGM
SOILS PEE
W G
a0
�z
U�
coatm
forthbecowithvoke,ynu
fnrttiwirh comply with such provisions in this pwmit nhallhdameA revoked.
hal
Ihereby Cat(herRUrT[ONLENDING AGENCY
there is len ding agency for performance of
agency
WATEI15f?RVICII
PAID
Dam Re iplp
NEW RESIDENTIAL PLMII. SQ, ]in
W �
O U
p•
V)
U Z
which InThal
rho work for which this pcnniT is inyucd ISec 309], Civ. C.) -
md(Scei30
Lendeh Nome
'TOTAL;
Lenders Address
I certify that 1 have rearl (h',a application d state that the b sit miction isr
correct. I agree to comply with II city d county m mr
d:el r l ll to
build ngcmnxwclnn a dh rchyamh rze p t f fah'. tyl j h the
'q
BUILDING FEL: �
_
QTY MECHANICAL Is'ERMI'r : FEE'
- II'
SEISMICF
atone me t oned pmparty for aspect on purp
(We) agree at save ndemnfy.raIkeep h I.. the GoofCprt lada,l
PERMIT ISSUANCE,
-
asIfiZ
ELECT"MITIGNTIONI
udgmm� s,enlsandcs,sex%Inch nay inany way accme agnnsr mad CityALTER
ofine granting of this permit:
ORADD'IOMECH.imcon....e
PLUMAPPLICANT
AIR IIA NDLING UNIT 0010,000 CFM)SOURCE
NDERSTANDS ANO WILL COMPLY WITH AL1. NON-POINT
REGU NY ONS.
MEC I[TAIR
HANDLING UNIT(OVER 10.000CFM)
CONST"�Dale
HAZARDOUS MA'I'ERTALS DISCLOSURE
EXHAUSTH000(W/DUCI)
HOUSI
HEATING UNIT(To Floods) BTU)
Will the applicant or future building acuarmio a or handle hazanlous material
ac defined ey 0e Cupertino Municipal Coale, Chapter 9.12, and the Health and Safely
Code, Scudnn 25532001 •
❑Ycs �No
BEAT INO UNIT (OVER 100.000 BTU)
PAID
VENTILATION BAN (SINGLE RISID)
lWmi
Wethe applicant orfurorebuilding up: eq mentsirdeviseswhich
OccBuy
et Imzunleus air cnnlaminanvs us Aeilned by the ILry Ann Am Quality Management
Di.vVicl?
Dyes No -
Dare Receipt
BOILER-COMP(1TI'
,1HPOR 100, 000U)
TOTAL:
BOILER -COMP (OVER IIXI,1%10 BTU)
AIR CONDII INER
c mad the bamNous malerluls requirements under Chapter 695 of the Culi-
fomia Flcahh Safety Castle, Sections 255115, 3531 and 25544. I understand Na if the
huddingdoennot normal haveul ants than it is my rcspnnsibiliny To nmify the a:alpanT
✓V-• ISSUANCE DATE
NEW RESIDENI'[Al. MECIT SQ. IT.
o lheroquiremeal which noel be r parr ut isuuno,cof it cert merl'(kcnpem'.
./�
Owner or agent Date
/^�-
ISSUED BY: (y 5s7i f^
,�
OFFICE