S 0936 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUP
BUILDING-ELECfRICAL PE IT NO
BUILDING DIVISION APPLICATION/PERMIT DINGPLUPROINGJECT
-MECHANICAL
IDENNICAL 0 9 3 6
BUILDING PROJECT IDF.M'IFICATIIIN
\/LOWNER-SNME �14
DING ADDRESS: SANITARY NO. AI'PLICAT'1(IN SUBMITTAL DA'fli
5,01U _ De �rzA BI,Vp a/,p G9 . 95�/y IljS
tA4 rf PHONE.: CONTRACTOR' NAME: LIC NO: NIC CONTROL
2 .C. bed 73 ❑
• ARCHITECT/ENGINEER: LIC NO: ADDKh4b0 OO r J.
r.nm,h.n
NTACT. ��I/�f�( ��q PHONE: r�� J BUILDING PERMIT INFO
/ IV �"��I�r✓ CP(- 600 -55Consultant Fees Paid by Applicant(InRiel) BLDG ELECT PLUMB MECH
r2i- 'i -Z(� ❑ ❑ ❑LICENSED CONTRACfOR'S DECLARATION QTY ELECTRIC PERMIT FEEI hereby.flan Thal Iam licensed under provisionsofChapter9(commencingJOR DESCRIPTION
� h Sat ion 111fln).t Division 3 of theBasineaand Professions Code,ml my license is PERMIT ISSUANCE R SID•NTIAL(yuilfomem, efimt _ __� DSFUWL ❑KITCHEN REMODEL
%{..Uzense�IPxs ,l -- Lic.p gpPL1ANClis-RESIDENTIAL ❑ADDITION DPLUMBING RE-PIPE
NQle TSC.'1111� ARCHITECTSP-c L ATION ❑MULTI-UNIT [ISTRUCTURAL
[.. I understand my plans shall he used as public records PANELS MODIFICATION
OZOUP 10200 AMPS ❑INTERIOR OCHIMNEY REPAIR
F-�Fensed Professional 301-IDNIAMPS IMPROVEMENT DSWIMh1ING POOfS
,- OWNER BUILDER DECLARATION OVER I0AMPS ❑BATA REMODEL(REPAIR O DEMOLITION
I hereby ulGmt that I am exempt Inn.the Conuacmr's License Lew for the OTHER
llowing reemn.(Sation]031.5.Dusincss and Professions Code:Any cityorcounty SIGNS CLECTRICAI,Vsich requires a Permit to construct,ulcer,improve,demolish,or repair any structureh0ono its issuance.also requires theapplicant fmmah peoun to file a sined statement SPECIAL.CIRCUITIMISC.
atheislicensed......l ,thepmvinonsoftheContmator'sLicenseLaw(Chapter9 94ommencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMP.METF,R OR POLE(NST.
at he is exempt therefrom and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION 0 DEMOLITION
ction)0315 by any applicant for a permit subject the applicanrto a Civil penalty of �WIMLMINGPUPOLELE��RIC
ER DEVICES ❑TENANT ❑FOODSERVICE.tmnrethan five hundred dollars;Much. IMPROVEMFJiigw
C�Q Dl,as.wnernf the property,or my employees with wages as their sole compensation. DOTHERwill d.the work,and the strcture is not intended ser offered forxnle(ties.]1144,annuess innnd Professions C da:The Conuumoh License Law does nm apply m an owner of ETS-SWITCHIS
L a.. propeny who builds.r improves thereon.and who dors such work himself nr through
his own employees,Provided chit such improvements are not intended or olTered for NEW RESIDENTIAL ELECIR SQ
saleJL however.the building or impmvemem is sold within one year of completion,the SQ.Ff.PL(%)R AREA SISQ.PG
caner-builder will have the harden of proving that he did not build or improve for pur- P A I D
pose of sale.). TOTAL:
D 1,as owner of the propeny,am exclusively contracting with licensed controctms to {� K DD[[//11s�
construct the project(See.7114,Business and Professions Code:)The Contractor's Li. NO• %/ 1{G{I{/
cense law docs not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who commets for such projats with a commends)licensed pursuant,.the Contractors
License law. PERMIT ISSUANCE CITY u',
❑ 1 am exempt under Sec. .B&P C for this reason ULIPEkTINO
ALTER-DRAIN&VI7W-WR'I'ER tEk) VALUATION
1 Owner Date
i WONKERnder PCOMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain aCenifcate of Consent roasif-insure forWmkcr's Crimper- DRAINS-FLOOR.R00F.AREA,GOND. � STORIES TYPE CONSTRUCTION
sation,as Provided for by Section TIM of the Lour Code.for the performance of the
work for which this permit is issued. Fl%TURLti-PER TRAP
0 I have end will twiumin Worme,C.mpcnsmi.n Insurance,as required by Section GAS-EA.SYSTEM- INC.b OlJ'1'L[ff5
3900of the Labor Cal,fur the peifumunaeof the work for which this permit is issue OCC.GROUP APN
CMy amWcrkc�i s Ilgylyn/y£rr)y{ icy
Icy NIa-jqVcj!bk3- GAS-EA.SYS'rES-OVER 4I EA)
CEROFICATEOF FXL TION FROM W(RSERS' GNI?ASEANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PEES
fuis.,in.need na bectanpletud ifthe permit is f.neehundred ckllms 01110) GREASEIRAP
or less.) PLANCHF.CK PEE
I cenify that in theperfoonaerfthe work for which his permit is issued.)'hall SEWER-SANITARY-STORM EA.200 FT.
nm employany any marine pas c I object mI eWwe -rl Camper, ENERGY ITE
Z smlonl,aws fC fomla_hq 1_ "`+ rWATFRHEAfERWIVENTIFLECUt GRADINGFEE
O Q NOTICm �111���TI�LLL
(A NOTICE TO PPLICANT:11,ever Task his Cenifcate of Exempmn,you should Wp'!LR SYSTEM/TRL'A'fING 501IS FIiE
I^ �" become subject to the Workers Compensation provisions of the Labor Code,you must
foahwah comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
ISI Q
CisCONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PLMEL SQ.PT. PAID
Dae eceipttl
V 0 1 herebyaRvmthauhere iso Imswetion lending agency for Performance of
O— the work for which this permit is issued(Sec.3097,Cie C) TAL:
U Lender's Name TOTAL
U Izmder's Address PBUILDING PER
I cenify that 1 have mad this application and stale that the above information is
Ly to corecL l agree to comply with all city and county ordinances and state laws mining to QTY. MECHANICAL PERMIT FEE SEISMIC FER
LJ bmidingconstrutimmand hambyraumnan representatives of this city to enter upon the
abovomamioned propeny for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree m save,indemnify and koep harmless the City of Cupertino against _
liabilities,judgments.costs and expanses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBINGFEF,
in onsomence of the granting of this pemrit.
APPLICANT NDERSTAND$AND WILL 91PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 C12 MECHANICAL ITE.
SO l CERE LATIO S. J v
I srI ,I I AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signa re of ApplicamVConracm { Date I EXHAUST 11001)(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATT? IA DISCLOSURE
Will,hart,eentafutinachadingr cupam score or handle huwrdmus ma¢na1 HEATING ON]r LM IgL0N10T11)
as defined by the Cupenina Municipal Cale.Chapter,9.12,and the Health and Safety HEATING UNIT(OVER I W,ao,BTU)
Code,Section 25532(a)?
❑Yes VENTILATION FAN(SINGLE RESID) PAID
Da¢ Receipt p
t Will the applicant or future building met",use equipment m devices which BOILER-COMP(3HPOR 1Ig),(NNl BTU(
mit haund.as air conntminams as fined by the Bay Are.Air Quality Marugemenl TOTAL'
'District? BOILER-COMP(OVER 1110,001 B'FU)
Yes
I have read the hazvdous materials requirements under Chafer 6,95 of the Cali. AIR CONDITIONER ISSUANCE,DATE
famia Health&Safety Cak,Sections 25505.25533 and 25534.1 undersmrM that if the NEW RESIDENTIAL.MECH. SQ.PT.
building does not currently have u tenant,thin it is my responsibility to notify the occupant
Plan,mquiretnents which must he met from t.issuance o(.Cenilic ria of Occupancy.
Owners aath.d>.ed agent _ Data TOTAL: ISSUED BY;
OFFICE