S 1626 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-E LEC!TRICAL PE�I P ND.
ISUII.DING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J 1626
(/I� I//',1(//I BUILDING PROJECT IDEN'TIFICA'TION
BUILDING ADDRESS:
I• • !✓1 ' SANITARY NO. API'LI AT ION Sll MITT DATI
zd
OWNFWSNA I PHONIi'. CONTRA 1�.�M�.Mk'�l 44kLIC�'9:�
/� /�����6 / I��r N/C CONTROha
�ARCIIITECT/LNGINIiIiR: LIC NO: {/ A�✓✓ ✓✓a' " • �( _G. • ❑
CONT'AC'T: I 'A ' 'HOOaNIa� D��� BUILDING HERMIT INFO
VI/LC/a'v /yE ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPI MR MBCH
LICENSED CUNfRACIORS DECLARATION QTY ELECTRIC PERMIT FEE
I bench,rerun mat 1 cern ueen.m enatt prnvisinns nr cltapmr 9 eeommendny JOB DESCRIPTION
with Scnioa 7000dol Dckwo 3onnr,lsa.inn...,r '� Ics �� oar amlmYuan.ci. RESIDENTIAL:
Woo )(-'� }'_ I'T:KMIT ISSUANCE.
F•W_ i"Id
lull tiara and el il'in (f/ ❑SPDWL ❑KITCHEN RIiMODIiI.
QUU Licemc—Lick Y+ API'IJANCIS-RISIDENTIAI. ❑ADDITION [I PLUMBING RE-PIPE
F Z u: Dam Comraaor
y 6 d ❑MULTI-UNIT ❑STRUCTURAL
ARCfI1TECIS D[CLAR TION
L..,D to PANELS MODIFICATION
O
C Z`-'Z I undursunul on,Pbrnsshall no Used.,puMiu rccnrdn
Z`=C UI"I'02(N)AA11'S ❑ ❑
INTERIOR CHIMNEY REPAIR
[7 rn F-y; Licensed Professional 201-1000AMCS IMPROVEMENT (]SWIMMING POOLS
C C Q 1 hereby a1Bmr Ihmh am lex Imptf I an he C mm mr'c Liceme Law hr,the TIOVER 1t11X)AMPS O BATH REMODEVREPAIR DEMOLITION
(�L V followgino,cone.(Seen I703L5,Iusincss and 11...1—ime,Code Any city nr manly SIGNS ELPCTRICAL (THER
l
W 3 W h whidi reandres a perndl to cameoamt,nett,improve.Jeulelish,or repair any ntorcev
a
n
prino'ns issionce,also requires the applicant for such permit to liR.,igrrv1,mmoncni SPECIAL CIRCUIT/MISC. ( ��
LL}
that he is licensed pursuant to the provisions of the Contractor's Licence lase(Chapter H
IaeT�00 (cormnencing with Sleinn]Bf1I)nf Division 3 efthe Bovine,and Professions Cale)or TT RIP.MITER OR POLE LNST. R 1 1:
tY y o eE that he In exempt thercfrnm and the best,Iia thealleged emmption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X a' See tln17031 5 hYn^Y uppllcmn lot'n Penni]suhjcas Iltc npplicnm In a evil pctwlty of i'OWER DIVI(:I?S
E. of more then live hundwil dollars(S.500). ❑IMPROV ❑FOODSERVICE
E.
❑hmownerof the pmpeny,nr myuntployces with wogs as theinole compensaion, SWIMMING FOOL ELECTRIC IMPROVEMENT
E..— willdolhework.and thestruclum isnot intended orolfered forsele(Sec.IDN.Business ❑OTHER
L 3 m and Professions Gude:Thtn
Tire Comercr's License Lew ro
does t apply to an owner of OU'ThFTS-SWI TCHES-I'IX"f
proluny who holds or improves thereon,and who docs such work himself...through
his own colployccs,provided that oath Improvements am nnl imended or offered for NEW RESIDENTIAL ELEC'IA Q ' Of
role.If.howevcc the building or improvement is sold within oncyear afeompfroon the SQ-FT FLOOR AREA $/SQ.FT.
otoner,budder will have the burden of proving that he did not!wild or improve for pur-
pacu(sulc7a�
❑ I,as owner of the p open,ate c,,volivcly sswuactinI wit,b..naYl contra,lors l0
,mvuct the f Jul(See 71U,L Business and Pml'cesiom 111.c,I as CanvarmrM I -
coseLawdoesnotapplyroonownerofprogenywhnbuildsorlmpowtsthereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commands)licensed pmsuam to the Contractor's
License Low, 1117RMIT ISSUANCE
Ej Sunt escmpnade,See ,If AI'C fee this reason
ALI'I7R-DRAIN&VENT'-WATER(EA) VALUATION
Owner Dam
WORKER'S COMPIiNSA'fION DECLARATION BACK FLOW PROTEC`L DEVICE ��i�Q ' O
. I hcrebyafhnn under penuhy of Perjuryeacof Ne following Ac11ted ns: 6 J
❑ I have and will naintaio aCenilicalc of Consent in self-inwrcfor Wnrkeh Cnmpcn- DRAINS-FLOOR.ROOF,ARI SlY)Rlliti TYPE CUNSI'RUCT10�
neon,as provided fur by Section 3901 of the Labor Code.for the pedooe.nee of the
,orwhich his permit is.....J, FIXTURES-PER TRAP
qr I have and will maintain Worker's Compensation Insurance,m required by Section
3700ofthic a or CIA to pc,for - ce efthe work for which this permit is i,reIL GAS-FA.SYSTEM-I INC.J OUTLETS OCC,GROUP APN
My Won mt/dali,, r and Policy n ykygr au.•��
Carrier �(! ePolicy Nnt (L.LJL CAS-EA.SVSTEM-OVER4(IiA)
CUR IIPICKI17 OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE GREASUINUUS'IRL WASTES IN'I ERCEIII'OR
BUILDING DIVISION ILFS
(This vertical need not be completed if the permit is for one hundred dollars($lot) GREASETRAP
or Ices.) PLANCHECK PER
I cculfy]halmile Nerfennance al'Ne workfut ohiOh,h it is I...ed.l Shull SEWER-SANITARY-STORM EA,No FT.
no,employ any pcoon In any banner sal as to be con...object m the Worker:Co open- IiNIRGY FEI7
O z gtian laws oI California.Date WATER HEATER WNENOFLECIR GRADING FEE Q Applicant
H NOTICE TO APPLICANT:If,after making this Cenitieme of Exemption,you should WATER SYSTEMOPREATING
F-' becnmcsunjecl to the Workers Cnmpcnsmem provisions of the tabu Core,you nm,t SOILS PER
hmhwith comply will,n.,M1 pmvi.io I,nn his pe it had he thenad mvoked. WATER SERVICE II��
V
7 z CONS'1'HUCI'[ON LENDING AGENCY NEW RFSIDISN'1'IAL PLM(. SQ.Ff SAID m s cacipt a
U 0 I hereby afhmuhauhem is a ronstrectien lending agency for the pednuremon of Ill
C~ the work for wIvicbthi,permit is hwed(Scc.3097,Civ.CJ
0ki. Lenders Name TAI:
O U Lendm's Address '!(SISAL: ) .,v
>' 1 anify that 1 hove read this application and.seer,theathe above mernerion is I.DwG FEIi .
Fa
rn cornea.lagree tocomply with all city and county ordinances and state laws meatingm QTY. MECHANICAL PERMIT FEE
U Z hnEding eonwcdon.a ad heneny authndu rpmsaondersof,hls city memeruponme s sMie�Fc'
inhoc-mcmomod bodorty fnr in,ecdan purpose's' PERNIL ISSUANCES
(We)agree to q
lov 'mdemall'y and keep harmless the City of Cupertino against I].ISCf 1
Iiabilitit,Ijudgments.costs and es(knrox which may many way uccme ugamssaid City AITER OR ADD'I'OMECH. PLO IBI FEE
in consequence of the granting of his permit.
At'[']ICART UNDERSTANDS AND WILL COMPLY W TIi AI.I.NON POINT AIR HANDLING UNIT(TO I0.001 CFM) MEC NICAL ELF.
SOURCE RP T, IONS. 1
AIR HANDLING UNIT(OVER 10,000071,11 CONS', IC'1'IUN'PAX
Si,11,r�ApplicvnVCaabrwInr Dam IL%HAUSTHWD(WIDUCI} f{pU51NG 11TIGNION PEC
HAZARDOUS MATERIALS DISCLOSURE
Will hm
e applicant or furc(wilding rem store or handle haeatdnus material HEATI NO UNIT(To I otiorl)DIV)
to ddined by the Coven.noMunro tare,Chapter 9.12,and the HeAh and Safety
Co,le,Section 25532h I1 HEATING UNIT(OVER 100,000 BTU)
(]Yes No PAID
VENTILATION PAN(SINGLE RESIDE Date Receipt X
Will Ne i plIbcam er future building occupam use equipment nr devices which ,
mit hwardnu,Or, oneminams;,delli by the]toy Arca Air Quolity Managetncnt BOILER-COMP LET OR 100.00 BTU(
TOTAL
Diorie?
El YO, 1 110ILER-COM 11(OV ER I 0110(hU BTU(
I have tad the hasardousmaerud,rlunen.ats under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Linda Health&Safety Cxic.Secoom 25505.25533 and 25534.1 ondemand ohm d the NEW RESIDENT Al.MUCH, SQ.FI �-2-
,It
/�
bnldll,g docs ala io,nlly calcn'anl, hunrn ray rcpmtseblity ionndythe occupant
nrmaqui weir ma n miaanar,a of a Certircam orarcucency. T
Owne aathn' II ugem v Date TOTAL ISSUED B1"%- D
OFFICE