S 2002 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL FIRST N0. /� OO `/'/�
BUILDING DIVISION APPLICATION/PERMIT - PLUMBING-MECHANICAL J L
BUILDINR CROJECT IDKNB'iFICATII)N'
VARCHITE�/ENGINEER
SS. - SANITARY NII APPLICATION SUBMI'1MAL DATE
7 PIIONF:: IRACTOR:SNAME. LIC NO' ly.v/9,}e.lwe coN„Iola a.- LIC NO: ADDRESS: ❑ �XG �`
CON T. �^IPHONE: BUILDING PERMIT INFO
❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRAC MRS DECLARATION QTY ' 'ELECTRIC PERMIT FEF. •t
I hereby„Iran that Ian loran,ee d p f Chapter 9(comm g - JOB DESCRIPTION -
Ce4z with Section 90apofD'vs'rn 3 ofihe Bm and Profession,Cees and nylr n, RESIDENTIAL:
Fs O O PERMIT ISSUANCE '
Fs
is full fofeoand effect ❑SEDWL ❑KITCHEN REMODEL
aUzU License Class Lic.M gPPLIANCGs—RESIDENTIAL ❑ADDI'HON ❑PLUMBING R TIPF.
0 C 4 Dem Cornmemr
ARCHLI 11CYS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
z O n 4 1 understand my plans,holl he used to pablio re, 1, PANELS - MODIFICATION
Oz�I.o UP T021XIAMPS
E:1 INFERIOR El CHIMNEY REPAIR
F.y.CW Licensed Professional 201-1000AMPS IMPROVEMENT C]SWIMMINGPOOI.S
K2 OWNERBUILDERDECLARATION OVER IWOAMP El HAITI REMOD IJREPAIR ❑DEMOLITION
1 hereby afar. but I am exempt Trmn me Commrors License Law for o,a ,O G E 2S
gypP�(C,�O F U following reason.(Saturn 7031.5,Business and Profession,Cole:Any city or county SIGNS ELHLTR AL ❑OTHER T
ul3 W y
which requires a permit l .t t,after,inoprove.demolish, P y structure
pr. It kawshp L File ao,ordamormarn .
2�y Tho h . dams to tit p n of C t s I c Lv (Clapmr9
,� (commencing wnhStation
ninal a for...to,sOhe Businessandon A.,o.s Code)or TEMP.METER ORP BI COMMERCIAL
d on that he is exempt]any applicant
li and on beer,for the alleged exemption.Any l perch.of ❑NEW BLDO/ADDITION ❑1700D SERV]
Wm Sermon 7031.5 by any apPliwnt f.rapennh eaklecm,Ore appliconua.civil aennhy of POWER DEVICES ❑TENANT ❑FOODSERVICE
not more Five hundred dollars($500).
F z r IMPROVEMENT
.it
wiLothe Work.thepmpoacrummym intended withwagesrale(Sot.vompensatiov, SWIMMING PLO[,ELECTRIC
will do the work,and the he Con is not intended oroEerel for sale tu(Sm n air Iivan,of [I OTHER
m and ,Iy Who
Code:The Cmntraemr,License Law does net reply In air owner nl' OUTLETS—SWITCHES—FIX'1'URf35
property who huilds or impmvs Ihercnn,and who docs such work himself or through
his own employees,provided that sash improvements cannot immndeecor offered the rrr NEW RE$IDEN'TIAL ELECTR SQ FF.
SiPT.FLOOR $/SQ.Pf.
Nale.If,howevo,The building rr imprnvemenl i.old walurn oycefofompleioq
orwineromidor will have the burden of proving that he did not hadd or Improve for par-
Rose at con.). -
❑L s mwnerofine progeny,am exclusively contract ,an licensed contrro u rs In
construct he p,,act(Sec.70,14,Bsinss an I Poell ions Code.)'Ihe Conw<mrs Li- -
seLawdoes nntapply manowner orproperty wheunits,m' e,
tmprove,them .,end QTY ,•PLUMBING PERMITm_ FEF.
who commas for such projects with a uml..dorts)license l Pursuant m Ire Cnmremre
License Law. I'ERMI'F I.SUANCR
Ellion-vermarderSec. ,B&PCfmrI,o eazon
)wear Date AFTER— RA &VENT—WATER(RA) VALUATION
WORKERS COMPENSATION DECLARATION BACK PROTECT DEVICE �y,���.v
I hereby af.m.mader pe..11y of perjury street he fill Aving daelma airs: V O c)
❑ l have and will maintain.Canificnm of Censer to self-insurefa-Worker's Comp en- DRAINS—FI. 01: RA.COND, STORIES TYPE CONSTRUCTION
same,as provided for by Section 3900 of the Labor Code.for the performance nr the
Inch work for wch this permit Is Issued. I ESTUREs—PER
El 1 have and will maintain Worker's Compamation Insurance,as required by Section
391go1'the LaborCode.hathe performance of the workierwhich this permit is issued GAB—RA.SYSTM-I INC OUTLETS OCC GROUP APN
My Worker's Compensation Insumace currier and Pol.......than are:
Carrier'. Policy No.: GAS—EA.SYSTEM-O Q IstiedO -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/1NDUSTR,WASTE,INTERCEPTOR
(Thiosattinnnecd not he committed ifthe permit is tonere hundred dollttcv($100) . a SRU ILDING DIVISION`I'(;ES,v
CRGAS1
or less.) E'[RAP
PLANCHY"-'�A'
I certify that in the performance of the Work for which thispermitls issued lshull SEWER—SANITARY—STORM EA.20019'.
not employ any person in any maroon so as to become,ubjer In the Workeri'Common ENERGY PEE
Z Nation Laws of Califomiu.Dam WATER IIEA'I'ER WNI>N'I'/BLEC'I'k
Applicant GRFA .F
y NOTICE.TG APPLICANT:If.after making this Certificate of Exempuan,you imium WATER SYSTf�?REATING
hecome subject to Lha Workers Compensation provisions of ma Labor Code,you mail SOILS FEF. '
fonnwitheontply with such provikanar this pormit,lall bedeemedruvoked WATER SERVICE - x -
WWW Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT, PAID
V Q Iherehy off that there isawnslmrinn landin6 agency rnrme perf.munce n( Dam pl
W F me work for which this permit is i,acd(Sca.3097.Cie C)
Q U Lender,Name TO'I'AI.:
Lender,Address
�•a' 1 cenify that 1 have mad this application and state that the above information is BUILDING FET'
.fir (A correct.I agree or comply with all ally and crafty ordinance and,tom laws rclming to QTY. MECHANICAL PERMIT. - FEB'
U Z building eosfriction,and herehyvmh ni,o,representatives ofthis city In enter main the I SEISMIC FEE
shove-mendonel property for eopestimm purposes. PERMIT ISSUANCE
(We)agree bs-ave,indemnify and keeplances,@e Gty,nr Cupertino.,at..t / LLGCTRIC PEE I
liabilities,ludgmems,mots and expense.,wbicWnoy in any wry arcane vga...loud Gay ACT HR OR ADD'TO MF.CH.
in em,rqucnm of the granting of ani,preen, PLUMBING PGG
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQ000CFM) (�
)I CE AT S. MECHANICAL 1:EG f V
AIR HANDLING ON[P(OVER RO(MCFM) CONSTRUCTION TAX
Signature of Appliamt/Cmlmclor Date EXHAUST]IOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant tar rommebuildir,nempa..lammnr handle hazardous national HEATING UNIT(IT.)H)0,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Headband Salary
Code,Section 25532(a)1 p,���/// HEA'T'ING UNIT(OVER 100,000 BTU)
0 Yes �b VENTILATION FAN(SINGLE RESID) PAID
Dane keceivta
Wi11 teeonr inti na or m,a buildingby thenBa use ea Air Qat of devieos which
emit
ict' ns vlr ennmminanT,oe deunrl by the Ray Area Air QmJity M.nngement BOILER—COME(3HP OR[00,000BUTT _ / O
1'OI'A
Distad” BOILER—COME(OVER 10(1,00(1 B'ID) r
,r ❑Yes YNo
AIR CONDITIONER
I have rend the handlers materiel,requirmnenhc under Chapter 6.95 oRhe Culi- ISSUANCE DATE
forma Health&Safety Code,Sections 21505.25533..,125534.1 nndemhmd that Hite NEW RESIDENTIAL MECH. SQ.EF. (� /( em
To di Ic.renlly have a tenant.That it is myresponsibilit,m amity he cort,ont o y!/
eft m/s-"� mmol he et Brisrm i...anee of a CrIfin.ue of Occyppnfy. �p
Owns or.amedz', agent 5 Y^sDDaate/ OT ISBUED BT
OFFICE