S 1422 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RICA PFIW IT NO. 1422
BUILDING DIVISION APPLICATION/PERMIT PI,UMBIN(1-MECHANICA L l`J
BUI(DING PROJECT IDFINTIFICAT'[ON
BUILD INC,A DURESS: SANITARY NO. APPIJCA'11ON SUBMITTAL DATE
O F NAME: �YII(1NF,: CO TR CTO NAM LIC NO'. Y
0 �S��J / NIC CONTROLp
..,119111111, If 40q-ARCII TEC(/ENGIN13Ek; LIC NO: r ADDRIi": ❑
b
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ISLDG ELECT PLUM11 MECII
❑ ❑ Ir ❑
LICENSED CONTRACI OR'S DECLARATION QTy. ELECTRIC PERMIT FEE
I hereby affirm that 1 um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
FWCZ wllnScnion 90001 of Division 3ofthe liteiricrand Prnf.ssion.Cndu,andmy lien,,is RESIDENTIAL:
�� 'n full force and eH PERMIT ISSUANCE W- /_ ❑SPOWL ❑KITCHEN REMODEL
Q Z U License❑,Is Lie a APPLIANCLS-RESIDENTIAL []ADDITION ❑I'LUMNING HE-PIPE
N6 W Datc '3 Canlructor
F�,a ARCHITITT'S DEC(., ITN PANELS ❑MUM[-UNIT' ❑STRUCTURAL.
Z C)To Z 1 understand my plans,hall be used as public retards MODIFICATION
OZ=-M (11.10200AMPS ❑IN'PERIOR El CHIMNEY REPAIR
r4tuj Licensed Prac,mrml 201-1000AMPS IMPROVEMENT SWIMMING POOLS
Z� OWNER-BUILDER DECLARn'fION OVER RXIO AMPS QBATIi RI?MODEIJRI?PAIR ❑DEMOLITION
CCa In hereby that i exempt the Contract L 1 for lnc
�316F following ng (S f "1031 S B - � d l f.. :Core:Any 'ly army SIGNS I:LGCIRICAI. OTHER noTZ; n 1/
-oh 4 p tl t t II p d 1'_M1 p_ y I cwrc ��" 1(a er r
F' a poor to t.issuance,also requires the applicant for such promo w Glu a signed statement SPLCI AL CIRCUI'I'IMISC.
atatneisli"n...Ilmnaa......flue pn,msrnnvnnne Can:rvcmrs License Law(Chapter 9
I�+I�CO (commencing with Section 701of Division l of the Business and Professions Crate)or TEMP.METER OR Po f(NST. COMMERCIAL:
(hat he is encore,Ihcrctrom and the heis lira gnof life ullcl exemption.Any violation ❑NEW BLDG/AUDITION [3 DEMOLITION
W-w Section 7031.5by.nyappbcam Escarpment subjectzlhe applicant oacivil p analwof POWER EVICF_S ❑TENANT ❑FOOD SERVICE
not mom than five hundred dollars(1500).
❑ Las owner of the pmpeny.or my employees with wages as their sdc com,ormation. IING POOL ELECTRIC IMPROVEMENT
F- will do the weak,and dommucum is nularl-de oraffored Gtrmle IS,9BH,Businns ❑01HER
W 3- and Prnfeaions Code.The Contractor's Littns.law does nal apply'et an owner of U .EI - C E' FIXTURES
pmpeny who builds or improves tenor,a d who docs such work himself ser thmugh
his own employees,provided that such improvements arc not intended or off for NF.W RIi.SIDhff HE SO FT.
mWn.IL however,IhebuiiJingar impnrvemcnl is sold within am yerndmmpletiun,the SQ.Ff,FLOOR AREA $/SQ.1-1'
er-builder will have the burden of pmving that he did not build or improve for put-
poo of'1
Cl 1,its owner of the property,am exclusively connecting with licensed contractors la 'POTAI.:
construct the project(Sec.70,14,Business and Professions C(xlc:)Ile Contractors Li-
selawdorsoalapplymanowneralproperty whohuildsor mproveslhercmnmW QTY. PLUMBING PER IT FEE
who contracts for mch pntiece,with a contracmrts)lnensM punranuo the Contmetnrs
Li,enecL , P17RMI'I'ISSUANCE
01 am exempt.niter Sas .B&P C far Thi,reason
Owner Date ALTER-DRAIN&VENT'-WA'Ifk HiA) VALUATION
WOkK12k'1 C(1MPENSATION DF,CLnNAI'ION (SACK FLOW 1'k(YI I.CT.DEVICE
I hereby allot under penalty of perjury one of the following declarations:
�Ih.veand will mamlainaCenifieneol Consent msclf-inure for W'orker's Cwnper- DRAINS-FLOOR.R( ARA[T$ RIiA,C.O SORRLS TYPE.CONS'ITUCI ION
stunt,us provided far by Section 37W of the Labor Code,for the performance of the
wnrk for which this permit Is issued. FIXTURES-PER TRA('
El I have and will maintain Worker's Compeasution Insurance,as required by Section
3900oflhe labor CM,lialhe performanccofthe work for which this formal is issued, GAS-EA.SYSTEM-1 � '. OUTLETS OCC GROUP MIN
My Work 'a 1>:'ft' ,m Inst uncccarncr and P0licymrtthuru -) n
Carrier. Policy icy
IS '�0� GAS-PA.SYSTEMO R41ISAprh ' IL I �
CIiR FICAT1301 EXEMPTION FROM WORKI3RS'
COMPENSATION INSURANCE GRIASFIWDUSTRI. .BY TE INTERCEPTOR
(IItiX,el n.cd not bccoloNeuvJ ifthrpcnnn is Porno.hundred dollurs S100) BUILDING DIVISION FEES
or lcss.l GREASIi TRA(' PLANCHECK IEE
I ceruffth,in he ps,rponmin,rofilnevank mi,eirul ''aucd.Inhdl
SOWER-SANITARY STORK fA.2110IT.
oat pl ype:nn y t est b object 1.theWeak..'Gtmpen- ENERGY FEE
,7, sour 1 C no D I Iw
ZQ Appl t ���/-�y���y WnfF.k nfAndk W/Vervl/Elaicfk GRADING FEE
.N.I NOTICE TO�CA T f,a ennaking Ilrn Certificate of Exemption,your should WRIER SYS'I'HM/I RIiAI'ING
a , become Ajocl to if,Workers Compnsmion provisions of the labor CMe,you must SOILS ITE
Ida forthwith comply with such provisions or this permit shall IN,deemed revoked. WA'PEk SERVICE
0
Z) z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL Pi SQ,FT PAID
U Q Ihrmb,011 fhullnercisformer...lionlcndingugemylonbcperformanceof Dare Receipts
F^ the work for which this permit is issued(Sec.3097,Civ,CJ
O U LcnJcr's Nave TOILL:
} Lenders Address TOTAL'
I sandy that I have nerd miv.pplicfnion z I slate That IIIc above adonnmioa in l BUILDING FEE
F N rnned.l agree to comply with all city and county oNinances and sm¢Iaws rclaung rot QTY. NJECHANICALPHRMIT FF,F.
UZ building conslmelion,and hereby authorizer,presenmfivcs ofthis city to ane.upon the SEISMICP
above mmationed pupyny lire inspection puryoscs
PERMIT ISSUANCE
(We)agree to.save,indemnify unit keep harmless the City of Cupertino against I ELGCTR .TH
liuhil'nics.judgmm�ts.costs and«proses which mny in any way accrue agains xaiJ City ALTERORADDTOMECH.
in wnxyuencc of the gmming of this permit. PI.UMBIN( IB'
APPLICANT'UNIOERS'IANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.IXp CFM)
SOURCE REGULATIONS. MFCHANICAI TL
/[,y..,e.�N� l '^/� AIR HANDLING UNIT(OVER IILIKK)CFM) CONSTRUCT )NTAX
���5 •••rntNNN�rc'nf Applmunl/Conlyddar� I I 16o�io P.XI IAUST HOOD(W/DUCF) HOUSING MIT
sATION ITB
HAZARDOUS MATERIAIS DISCLOSURE
Willlhea,plicum or farm builAing occupminto..or halalie hazurdunsmmcnal HEAPING ONI'I(TO I OO.(AX)BU)
as defined by the CuMnino Municipal CMe,Chapter 9.12,and the Health and Safety
Code,Section 25532001 HEATING UNIT(OVER 100,000 B'PU)
❑Yes ❑No
VIN'RLAI'ION FAN SINGLE RI3SID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt s
-Inn hazardous air ntoaminantsas defined by the Hay Area Air Quality Managcamnl ROILL'R-COMP(311P OR 111(I,fNXI B'1'll)
Uixlrirrr I ' 1
❑Yes 0N BOILER-COMP(OVER 100.000 BTI1)
I have ren the bamNom matml.ls requirement,under Chapter 6.95 of he Cul i- AIR CONDITIONER
ISSUANCE DA'Z'E
f mid IlcnitM1.@$ufrly Clxlu SadOm 25505.2551.1 a x25534.i u nadifynd that if the NEW RLSIUENTIAL MECII. SQ.FT. ` .-S _ � g
buildingJ¢nnol wrmntly M1avea Nnanl.
that it is my respmsibilitymnolify the lecupant G /
Of nc gWautcnn hie Imutb.mct prioros ema,col'a CenlHcmeaf Osxapuncy,
rgrn^ m TOTAL: ISSUF.DBY: T so
OFFICE