S 1346 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PES[TNO, 1346
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECDANICAL" r'`1
BUILDING PROJECT IDFxrIFICATION
BUII.DING ADDRESS; SANITARY NO, APPLICATION SUBMITTAL DATE
101 a CIiLoqa
OW EN' —rHSJ[Jli: c NTNBC7'OR�'S•CA E: LION `
(51-74
aF S8 l:/lL NIC CONTROL.
J� 0RCHITIiLT/'NGINP. LIC NO: U SJ Ac� S )C;P� ❑
r1oN c-a43so
C TACT: 9�V PHObt • BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) LU 6LE(T PLUMI{ MECH
L m that II a CONTRACTORS DECLARATION QTY, ELECTRIC PERMIT F
I hereby unirm that 1.m licensed ower provisions of Chapter 9(commencing JOB DESCRIPTION
QOZO with Secure.7")off)" on Jofthe Basins and Professions Cede.and my license i. PERMIT ISSUANCERESIDENTIAL,
in full forccund effect. 1 ❑SFDWL ❑KI'TCHEN REMODEL
a—u laccns a Lich—{ APPLIANCES-RESIDENTIAL. El ADDITION ❑PLUMBING RE-PIPE
.'a nate C.too
JITF.. E .LANAf10N ❑MULTI-UNIT ❑STRUCTURAL.
,=ooq=O
is a APANELS MODIFICATION
ZOy.. ;/ UPT021XIAMPS ❑INTERIOR ❑CHIMNEY REPAIR
�4 -W essional 2ULI(NN)AMPSIMPNOVEMF.NT SWIMMING POOLS
WNER-BUILDER DECLARATION OVIiR IOoOAMI'S ❑BATH REMODFUREPAIR ❑DEMOLITION
by affirm
ff rin that I mn exempt from Ibe Cnmmctnr'a License Law for the
JgS�aU f00owingmagar Section 90315,Business and professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
In 3 t4 Na which rc9uim,a'molt to emsauct,alter.improve,demolish,or repair my scoman,
J priono its issuance also requireslhe npPlicont for such permit In fileasigneJaalcmeot SPECIALCIRCUUNISC.
999WY that he is licensed pursuant to the proviannsoftbe Commustors Liceme Law(Chapter 9
0 DEMOLITION
cc^p0 (commencing with Sttlinn t(MXA of Division Ltf the llusineas und Pndessionx CoJc)or 'TEMP.MITI'IiR OR POLE INST. COMMERCIAL:
cc c C that ha is exempt therefrom and the basis rat the alleged exemption.Any violation of ANT G/kDD TI ❑FOOD SERV CE
^y Section 7031.5 by any apPllcnmfnrvpermil suhlemstbe opplicanl ea.civil Penalty of POWER DEVICES i""�N1 h
t marc than five hundred doll.,WOO). IMI' VEMENT A/
ESQLas orearof the nt.ofm laces with wages:as their Dole eat nsainn, SWIMMING POOL ELFCI'RIC
C ❑ ProPc Y Ye^'P Y b M1 ❑ITT
F wJl do the work.and the svunure'ro nnnmended ondiercdfor sole(Sec.tDl4,Business
W and Prom..iona CMe:The Cnmrnemr:s License Law Jaw not apply to an awner of )U'f1.P.TS-SWI'TCIIES-FIXTIIRI?S
A'
his
o ny who huilds ar imprmn thereon,upJ who nts such wnrk himself or through V Y
his own employees,PnrviJN that such improvements are nm imendeJ ar offered for NEW RESIDENTIAL F.hECfR SQ
sale.IL howevets the building orimprovemem is sold within one yea of rompldinn,the SQ.14. AREA 5/SQ.FT.
owner-huilder will have the burden of proving Nat he did not ImiW or improve lin par- �J s a s
pnsc ursale.). / sQ
❑1,rowner of tke proPcny,am exclusively nmtraeling with licensnl<mnlramnn m r (\L C
construct the pmjem(Sec.9044.Businessland Profession,Co..:,She Gt....u,s Li-
cnselaw dotes no,apply to an owner ofpropeny who huilds or improves tbemon,and QTY. PLUMBING,PERMIT FEE r1 I
whn contracts for such projects with a contractors)licensed Pursuant to the amtraaora
License Luw.
PERMIT ISSUANCE S
❑lam exempt under See ,B&PC for thus reason
ALTER-DRAIN&VENT-WATER(EAI VALUAQON
Owner Date j.]/� 0--
WORKER'S COMPENSATION DECLARATION BACK PLOW PROI'F.Cf.DEVICE
(�.IJ�(�1��
hereby affirm under Penalty of p jury one of the following declarations: -
❑I have and will maintain a Certificate of Con.senno sell-insure for Workers Compen- DRAINS-FLOOR.RODF.AREA,COND.
SR
E] TYPE CONSTRUCTIO!
..tion,as Provided for by Section 3900 of the lalxa Code,rnr the pc,fnrmanee of the
work for which this permit in issued. IXTURES-PERI RAP
❑ I have and will=!main Worker's Compensation Insurance,as required by Section
39110 of the labor Code,lot the wrformmece of the work for which this Fit is issued. GAS-FSA.SYSTEM-I INC.4OTTLETS (KC.GROUP APN
My sCn Zion lSsurvncc wrriuoli Policy •ra
MyC. �L'�J1 L� Policy Nn: GAS-EA.SYSTEM OVER 4(EA)
aCERTIPICATE
OF;F.KEMPGON FROM O KERS' GRFASMNDUSTRL WAS'1'E INTERCEPTOR
COMPF.NS ATION INSURANCE BUILDI ) 'IDN FRES
(This section need make completed ifthe permit is foronc hundred dollars($Ilk)) GRIiASE"TRAP
or less.) PLANOWCK FEE
Icmifythu in the artmemn.mhe work fnwhich thispermit is issued,I shall SEWER-SANITARY-STORM EA.2")F7.
rot employ any permnin eny manner sn asmkecnmc whjecnntM Wnrken'Coogan- ENERGYFEE. )VV V.
scion Laws of Coloratura.Date WATER I IEATHR WNENT/ELECTR
Z 0 Applicant GRADING P'
4 NOTICE'1'0 APPLICANT It,after making this COodicale of Exemption,you should Wq'IER SYSTBM/I'REATING
a , Failure object to the Worker's Compensation provisions of the Like,Cale•you must SOILS FE
W fonhsom comply with such provinirimur,his Permnshill he deemed revoked. WATI2R SERVICE
CONSTRUCTION LENDING AGENCY NEW RISIDENTIAI.PLMB. SQ.Ur PAID pa Rtteiptp
VQ I hereby affirm that them ii,a construction lending agency belle performance of
W F the work for which this Permit is issued(See 3097,Civ.C.)
TOTAL:
C U Lendcrs Name
lender's Address TO
(}moo y 1 certify that 1 have read this application and state that the above information is BUILDING HE
L+ fq correct.)agree to comely wilh.11 city and county ordinances and mine laws relating an QTY. MECUANICAL PERMIT FEE SEISMIC E
L)Z building construction,and hereby stramo mprasemmives afthis city tomurupon the
abnve-nmntin red Pnspc ly u:pccnion pugorscs. PERM IT ISSUANCE
(We)agrce In sa ut mnify and keep harmless the City of Cupertino against IiLIiCI'R IZfi
Iiahi lilies,judgmems,glinsexpenses which may in any way aeeme.,.a.,,said City ALI1iR OR ADD TO M ECI I. PLUMB GFEE
'nconnegtte^ceofl gra ng.flhi,permit.
APPLICANT ONE 'ANDS A ' Wl 'LY WITH ALL NON-POINT AIRHANDLINGUNIT(TO 10,"CFM) MECHANICAL.
SOURCER U. N.S.
J AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
Sig p vnUCotnm Da EXHAUST HOOD(W/DUCT) HOUSING MITIGATION F
HA7AR OUS MATERIALS DISCLOSURE _
Will the applicea or fuarc Fuilding nccupnnt afore or handle hazardous mateial HEATING UNIT GO 100,M)B'M
m dellned Inc Cupertino Mnnicipul Cele,Chvp¢r 9.12,and the❑eu1N and Safety
Pde,9cclion 25552(^)4 I EATING UNIT(OVER 100.000 BTU)
❑Yes ❑Nn PAID
VENTILATION FAN(SINGLE RGSID) Date Receipt
Will the applicant or future building occupant use equipment or devices which UOILF.R-C OMP CUP OR 100,0ag 13'fU)
froh haznNons air cnnwminants as defined by the Bay Arca Air Qualily Management TOTAL:
District? BOILI7R-COMP(OVER 100.000 BTU)
[I Yea, El No
I have read the hazardousmmenuls rcquitememx under Chapte,6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Gonia Health&Safety Code•Sections 25585,2557]and 25534.1 umbastvnd d.if the NBW RESIDENTIAL MECH. SQ.PT.
building docs not currently have a tenant,thin it is my responsibility W notify the occupant
of the requirements which amnt be met prior an issuance of a Certificate of Oncupancy.
Owner or...Or iutd agent Date L ISSUED BY:
OFFICE