S 1460 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
Ty
OF CUPERTINO BUILDING.ELECTRICAL Pb17 FNG J 460
BUILDING DIVISION (/� pi'�ICATION/PERMIT PLUMBING-MECHANICAL' J "'1 IVB
v C7 u i BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: S /1r SANITARY NO. APPLICATION SUBMITTAL NA—U
ER'S NAME: !PHONE: �- CONTR4kTOR'S NAME: LIC NO'. ���
f NV (!6W S'(. C1 CONTROL#
ARCHITECT=E INER: LICNO: y'PRRI;$ , �6q3 res 4aT�s 9503 Al
CONTACT: PHONE: BUILDING PERMIT INFO
J6H mossTA4Nimr 35-6-6$A ❑ Consultant Fees Paid by Applicant(Initial) PLUMB PL MECH
LICENSED CONTRACTOR'S DECLARATION QFy ELECTRICPERMIT FBI, 1L3FC-
1 hereby arum that 1 am licensed under prevenient,of chapter 9 mrmmencirg JOB DESCRIPTION
X00
AaZ with SCctl1Xp
on90of Dlvlsmo 3ofmo BUllneo.rel Prefeed..Cole,and my Income is N IAL.,
' PERMIT ISSUANCE
Fes.. Liecre full Class
and c0 n Q�� 'DWI. [I KITCHEN RF-MODEL
0UV License Class Lica (�1— APPLIANCES-RESIDENTIAL ITION El PLUMBING RE-PIPE
I- t=1 Dom _ _ Gummier
tL ARCHIT 'S DECLAkA' MULTI-UNIT ❑STRUCTURAL
Z O Z lot ersmnd my plans,M1a1 ed asp PANELS MODIFICATION
c cc UP T02l1I1AMPS IOR El CHIMNEY REPAIR
2111-IBIMIAMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR El DEMOLITION
6I hereby affirm that I am exempt from the Contractor's License Law for the
CiyS 0.Wi U V following reason.(Section"1(31.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
which refracts a wnrml to construct,alter,improve,demolish,or repair any structure
0�n-' p...no hsiautunee,also refrireeme.pplicam l'orsuch'cut,to filo.signedstammeu SPECIAL CIRCUIT/MISC.
`^y malMlSlicgwil parsomn mmeplf Diviorm ItheC Hulfinde Liters Profession'
CodmrY
drei p that he is exempt therefrom
and of Division 3 mile eged exempt on.Any
vi Code)or TEMP.MP.Tp.R OR POLE INST. COMMERCIAL,
Sec he i,.exempt therefrom and the basis for the alleged exemption.Any viP nian of ❑NEW BLDG/ADDITION ❑DEMOLITION
a7; Section]0315 Him
any hundred
tfor a rs G50rmit subjects the applicunrtoacivil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
ZQrut more roan five hundred dollars(8500). IMPROVEMENT
❑Lasrwoeroflbe themba,army tintended.,o Bred ft stl,(Snle mmpenvotion, SWIMMING POOL ELECTRIC
g. will Nudist...and meswnureiatots Limudm.,offered act
to aio,.siness ❑OTHER
3 m and Pmfessions Code:The Co,them. License Law does not apply to.nn rthro of YCLUILETS-SWITCHES-FIXTURES
pm"try who builds or improves Ihsuchn,andppe who docs such work intended
or or rued for
his own employeese provided r m snob meat is old within ate nal intended or offered fire NEW RESIDENTIAL ELECTR SQ FT.
sale.if,hnwer will have defoundmpmvementifndlliiomyldorimrove fory(he ,r SQ.FT IT EA $ISQ.PI'.
owner-builder wall have mo founder o[proving Wm he did ort build or improve for par- �tl1 ���•r`'\yw,1
pus of soli.). IQ$,
1,as owner or the pmpeny,um exclurively untratkng with licensed exmra^mn In 5
rostrum pmjecl(Sec.'lM4,BYYmes,and Profession, The CnnlreClrrs I.I- ` pp
I must warts urn apply ln.n.
wnu of property who builds or imprmes thereon,and QTY. PLUMBI1raf vVl'� 'li EE _
wh rnn (t
e,ts for Inch with.contract I sed P...cano the Coal rs
Lic nsc Law. ,
.R&P C for this reason PERMIT ISSUANCE
ALTER-DRAIN As VENT-WATER(EA) VALUATION
Dan
P.R' C PENS ION DECLARATION 13ACK FLOW PROTECT.DEVICE �� O
I hereby t m under peva iy of perjury one of the fallowing declarations:
❑ I have and will mairesina Cenilicanof Conscnuoself-insure forWorke's Coni DRAINS-FLOOR,HOOF,AREA,CONE. STORIES TYPE CONS9'RUCTION
saber,as provided for by Section 3700 of dm Labor Code,for the pemormance of the
work for which this permit is issued FIXTURES-PER TRAP
❑I have and will maintain Workers Compens.li..insurance,as required by Section
3900of the Labor Code,forthe performance ofthework forwhich this permit is issued. GAS-E.A.SYSTEM-1 INC.4 OUTLETS OCC,GROUP APN
My Workers Compe,caren Insurance ramie,and P.licy number are:
Caricc Policy No.: GAS-EA.SYSTEM OVER 4(EA) '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUS'nith WASTE INTERCEPTER
R TIC 96VISION rrLltS
( ^welcapar,d nothcumpletediflhepermitisfnrrneh^ndmddoliam($IW) GREASETRAP
or les. PLANCHP.CK PF
I cenifymm inure pc, prom" bo mince su,,mc Tsh.1I SfIWRR-SANITARY-STORM EA.2W FT.
not ploy ry l erson is an one, a d t 1 rkerF Crappeo- ENERGY FER
z ration .t WATER HEATER WNENT/BLECfR
JF GRADING PEG
ti1 APP A a making Ihin enifcate r :xemplinn,you ahnuad WATER SYSTEMRREATING
a
bruit abject m the W r is Compe....ion provisions ol'the Labor Code,you must( SOILS FEE
L7J forthwith comply with nuc provisions or Ev,"trout shall bo deemed minted. WATER SERVICE
d Q
U O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. •SQ.Ff. PAID Da Receipt N
I hereby which
thi that mere is a constructionce30 lending agency forme perfrrtnance of
the work for which this pemtit is issued(Sac.3097,Civ.CJ
(l" Lender's Name TOTAL:
U
Lender Address TOTAL.
I BUILDING .E
certify that have read Ihis.pplicoron and state shot ma above inmvtio
frrn is
r+.In correct.I agreom comply with.il city and county ordinances.nd tram Lwsnelmingm QTy MECHANICAL PERMIT FEB
V hon In,const 'nn.and hereby.uthorim repmscrtmives of this city menter upon the SEISMIC
above-It nW pmpeny forim'pemirn putpnses- PERMIT ISSUANCC
e)egse to save,indrnmify and keep harmlesx the City of Cupertino against ELECTRIC 'EE
liaE liea.judgmems,comsand expenses which may in any way aurae against said City 111'ER OR ADD TO MUCH.
onsefue.degn the bra^lingolm, /I PLUMBIN FEE,
AI LICANT UNDP STANDS 1 no rEL 'IPL WITH A .ON- IR HANDLING UNIT TO 10.000 CFM) MECHANIC
C'.
AIR HANDLING UNIT(OVER 10,000 CPM) CONS'I'RUCTIONTAX
SI erre of Applies 11 Dam EXHAUST GOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ouupam atom or handle hazatdoe,m.mrlel HEATING UNIT(TO 100,0100 BTIB
as defined by the Capsomer Municipal Code,Chapin,9.12,and be Health and Safety
Cole,Sept..25532oo? HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑Nu PAID
� VENTILATION PAN(SINGLE RP.SID) Dale Receipt"
Will me.p,iie..,or future building aeupam use equipment or devices which
unit interaction,air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP OHPOR 00.00aBTU) TOTAL:
Dimrlct? BOILER-COMP(OVER 100,001 TU)
❑Yes ON.
I have read the hemmous matcdals requirements under Chrprer6.95 ofthe Cali- AIR CONDITIONER ISSUANCE DATE
foruia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building reissued currently have a team,mat it is my m,,mdhiliry m notify the overturn
of the regniremuns which must he met prior to issuance of a Cendiente of Occupancy.
Owner nr aulhnriud.gem Dere TOTAL ISSUED BY:
OFFICE