S 1509 --APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTIUCAL PE UNO
BUILDING DIVISION APPLICATION/PERMIT PI.UMIIING-MECHANICAL. 1509
BUILDING PROJECT IDENTIFICATION
B DING ADDRESS: SANITARY N). APPLICATION SUBMITTAL.DATI
o DRi I— nil
:R'S NAME ` ,' PHONE: CON'TRACTOR'S NAME: LIC NO;
"VHo �+ p NIC CONI ROI.N
�IARCIIITLCfIF.NCINIMR: LIC NO: RFS$: S.yni %a ❑
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CONTACT. PHONE. BUILDING PERMIT INFO
❑ Consultant Pecs Paid by Applicant(Initial) BL ELECT PLUMB MECH
LICENSECONTRACroR'S DECLARATION QTY ELECTRIC PERMIT FEE
[hereby
alBnn than a I am licensed under provisions of Chapter 9(ttnnmmndng JOB DESCRIPTION
"Z with Section 7th0)of Division 3 ofthe Business and Professions Cede,and mylicense is RESIDENTIAL
Iy O PERMIT ISSUANCE
F[y 0 in full force and a@n. ❑SFUWI. ❑KITCHEN REMODEL
�UU License Class Lic.p gPl'LIANCLS-RF.$IUENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
I-Z W Doc Comrionnr
,Z > I understand my Pines
❑MUED-UNIT El STRUCTURAL
Z 07q ARCHITECTS DECLARATION PANELS MODIFICATIONnes shall be ued rdssas public reco
OZ-Q UPT02MAMPS C1 INTERIOR El CHIMNEY REPAIR
Fa.�FpyI Licensed promotional 201-1000AMPS IMPROVEMENT (]SWIMMING POOLS
OWNCYz, 'butIa -exempt
frm Ce Contractor's
OVER PooIAMI'S ATH RF.MODEIIREPAIR (]DEMO},{'[ syr
C a 6 1 hereby.(Bmu,hut I am exempt from the Comruutora License Law for the ��'r��ir!✓�,/`I�IT�
�Lx O IoW.U following reqs,a.permit
i ]construct,
Business and vet de it demolish,
h,or Any city or county SIGNS ELECTRICAL
OTHER
fs734.to wM1ich myuires u permit m cnrewm,,fic Improve,demolish. fit,
repair any saucmre
prior faits issuance,alsoregiims the applicm for such .it to Bleasigned nutemmt SPECIAL CIRCUITIMISC.
too,
that he is licensed pursuant to the provisions of(he Contncmes License Law(Chapter 9 OMMFR IA
q00 (commencing with Section 7000)of Division 3 of the Business and Profession Cam)or TIIR METER OR POLE INST.
6 q m eG that he is exempt conform and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Soviets 7011.5 by any applicant for a permit subjects the aMlicanno a civil Penalty of POWER DEVICES DO TENANT ❑FOOD SERVICE
Cnor more than live hundred dollars($500). IMPROVEMENT
2^0 ❑Las owner afthe profanity,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
W will do the work,and the severe is not intended or offered for sale(Sec.]056,Business ❑OTHER
W
m and Professions Cade,The Contmemr's License Low does not apply v an owner of OUTLETS-SWITCHES-FIXTURES
faroperry who builds or improves thereon,and who does such work himself or mmogM1
his own employees,provided that such improvements nee nm intended nor offered for NEW RF_S11)ENTIAL E1.ECTrR SQ En
sale.[L honvereq the buildin tis sold within one fcomletlomthe SQ.F4.IA� $ISQ.FT.
g orimprovcmen yc:rro p r
nerbuilder will have the burden of proving that he did not build or Improve for purIS
-
pose ofsele.r
❑ 1,as owner of the prepery,am exclusively contracting with licensed contincmm m 1
consumer protect(See.]nNq,Business and Professions Cede:)no CommemrY Li- APR 13 MSD
emes,low does int apply to an owner oI propmy who buildsotinfproves motion,and QTY. PLUMBING HRMIT PEE ^``
who contracts for such projects with n contramm(s)licensed promotion the Commences
License law. PERMIT ISSUAN -Vr,�urtrll
I me exempt under Sec. .R k P C for mason -- INV
ALTER-DRA HE(EA) �VALUATION
Owner Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DE
I hereby affirm under penalty of point,one of the following declarations.
❑I have and will maintain a Certificate of Consentto self-insure far Workers Crimper- DRAINS-FLOOR,ROOF AREA,CD STORES 'TYPE C0NS-TR UCT101
ation,as Provided for by Section 37(X1 of the labor Code,for the performance of the
work for which this pemtit is issued. jRXTURfiS-PER TRAP
❑1 have and will maintain Worker's Compensation ,as required by Section
3] lbs Luhor Gde,iii the perlimmnnce of the wt Por hwit this panni,is issued. GAS-EA.SYSTEM-I INQA OUTLETS OCC.GROUP APN
y Workers Cp�pcn.gon -mit9e G�F� and Pak,nu Mrare: GAS-F.A.SYSTEM-OVER<(EA)
Carriers 7 N/J e]'.troy No,:-R
CERTIFICATE OF EXEMM[ON FROM WO KERS S' GRIiASrANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION[TES
(Desertion need.,it he a:mpined Ham facrmit is forone hundmd d.11on(SIM)
or loss.) GREASE TRAP PLANCHECK FEE
I ormaythut in the performance of,hc work for which this permit is issued,(shall SEWER-SANITARY-STORM IM.200 FE
not employ any Person in any manner sit as m became subject to the Workers Comfort-
0
IiNERGY ItiE
Z sarkm Lawsol'California.Date WATER I[LATER WNE NTMLECR
zOGRADING IFI
AppRcaut
y NOTICE TO APPLICANT.IL it,,making this Connivent of Exemption,yna should WATER SYSTEMnBEATING
F ; become subject to the Won ees Compensation provisions of the labor Cola you must SOILS FET?
Wforthwith comply witheuch prorisitnsor this peroil,hooll be deemolrevoked WATER SERVICE
CONSTRUCTION 1.ENDING AGENCY NEW HI151DIiM1'IAL['LMB, SQ.IT. ['AID
U O 1herebyafmm that mere la a ennstmmion forthrgagcncy far the Performance of R
W F the work for which this permit is issued(Sec.3097.Cin,C.)
T
O U Under's Name BU FEL
OT
r1' W Lenders Address
OA I certify that I have mad this application and state than the above infomion mis
r..Ih correct l agree to comply with all city and county ordinances and state laws refining Its QTY. MECHANICAL PERMIT FEE SE IC PEE
U Z building rimanaction,and hereby ardmine representatives of,his city faemmrupon the
above-mentioned property far inspoetion purposes. PERM["T ISSUANCE ELECTRIC E
(We)agree to save,indemnify and keep harmless the City of Cupertino ogainn
liabilities.judgments,costs unit expenses which any in any way accrue against said City ALTERORADDTOMECH. PLUMBING IT
in communicate of the graving of this permit.
APPLICANT'UNDERSTANDS AND WII.L COMPLY WITII ALI,NON-POI N AIR HANDLING UNH'(To ILAXI CFM) MECHANICAL FE
SOURCE REGULATIONS,
iJ Or AIR HANDLING UNII'(OVER IB.000CFM) CONSTRUCTION TA
Signavr of Applicant/ cumene `f Datc O EXHAUST HOOD(WIDUCI) HOUSING MITIGATE) FEF,
HAZARDOUS ATERIALS DISCLOSURE
Wi[l,heepplicuntor future bolding oecupaatxmreor handle horardtus mverm HEATING UNIT(to Most)B'1'U)
as dei,Sed by the 32m)?Caperther Municipal Code,Chapter 9.12,and the Health and Safety
Coble,Section 25512(u)? BEATING UNIT(OVER I(Xl,tl(XI ItTIA
C3 Yea ❑No NiONAN(SINGLMBTU) PAIDpate Rae",arWiltthe applicant orfuture building occupant use equipment of devices which (3HP OR Ifemit hamnlove sir cnnmminarns as defined by the Buy Ann Air Quality ManagementDistrict? (OVER I00❑Yes ❑NnI lave readthe hvuNnus materials requirements under Chapter 6.95 of the Cali- ERISSUANCE DATE
forma Health&Safety Calc.Sections 15505,25533 and 255311 understand and if the IAL MECHbuilding does not centrally have u tenant,that it is my resp risibility to entity me oecuumof the requirements which must o met prior to issuance of a Cenificme of Occupancy.Oastuamase6mil agent DateISSUED BY.
OFFICE