0478 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEj IT NO. O
478
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL l`�
BUILDING PROJI'lCI'IDENTIFICATION
BUILDINGADDRESS: SANITARY N(I. APPLICATION SUBMI'19'AL DATI
OWNE 'S NAME: PHONE: — CONTRACTOR'S NAME: LIC NO: .NIC CONT #
ARCHITECT/F,NGINEER: LICNO: ADOESS: fl NIA`i..A FO. ❑ alz
L
CONT�_ J / � PHONE C'W/� - BUILDING PERMIT INFO,
❑ Consultant Fees Paid by Applicant(Initial) BII ELECT PLUMB MECH
Z � ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTy ELIiCI'RIC PERMIT I°E
I hereby affirm that 1 um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OWZ wim$<aion]fX5)tfDivisitn3 nfthe Business and Professions Code.onJ mylicenseis RESIDENTIAL:
FOOin ull tome onJB
effect. PERMIT ISSUANCE
W" l ❑SPOWL ❑KITCHEN REMODEL
lu� License Class Lia# APPLIANC17S-RESIDENTIAL ❑ADDITION ❑PLUMBING RE PIPE
Xaa Date Contractor
f.Om ARCHITECCS DI3CLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O n Z 1 unde sand my panelled)he ileal lis public accords, MODIRCATION
OZ;J� UPT021NIAMI'S ❑INTERIOR ❑CHIMNEY REPAIR
r14 Licensed l'afcssional 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
OWNHR-BUILDER DECLARATIONOVER IIIfX)AMI'S [I BATH REMODEIIREPAIR Ll DEMOLITION
y�W W 6 1 hereby affirm that I am exempt from the Contmcmrs License Low for the
x 3 6 F following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
YI Ir,sn which relations a permit m construct.abe,improve,emission,or repair any s rchne
(_a•Og pdnnoin issuentt,atso requiresthe vpplicem for such permino filen signed sa¢ment SPECIAECIRCUIT/MISC.
athat he is licensed parsuuan a the powillimisof the Cmurecmrs License I.(Chapter 9
W a� (commencing with Section 7000)of Di vision 3 of the Business and Professions Cale)or TEMP.METE1L ST.R OR P( COMMERCIAL:
a that he is exempt therefrom and the hmis for the alleged exemption,Any violation o! - ElNEW BLDG/ADDITION [IDEMOLITION
W
Section 703 IS by any applicant for a pennitxubjects the applicant o a civil penally of POWERDEVICIcs <ENAMI" ❑FOOD SERVICE
w ;I'lie
than five hundred dollars($500),
�'kvf
I= d no;I'lieI fid the pngenY•nr my enpiny0as whh wages os their>nlc mnspensminn, SWIMMING I'O( ,I?LI?CI'kIC PROVF.MIiNT
C willdo ihework,and thextrvclum son,intended m ollered forxale(See.]W4,Ru,loess HER
and Poificsdnna Cade:The Comrmmr's License Law does not apply to on owner of OUTIXI'S- ITCIIES-MIXTURES
G .. property who builds or indicates thereon,and who does such work himself oT through
his own employees,provided that such improvements arc not intended m otfcred for NEW Rli M?NTIAL El., IR SQ FT.
sole.if.hnwevec Ne building.,monasteries is sold withinone e..f completion,the SQ.FT.FLOOR AREA Si FT
monalbuilder will have the burden of proving that he Aid not build or improve for put. 61
poseof,vl
ia
st av owner of the property,,Business
and Professions with licensed
ommunes to TOTAL:
Or .dao the project(Sec.](N4,Business and Professions Cade:)The Communes Li. -
wninLaw does not apply toanowner ofproperty who builds orimports dicame,and QT PLUMI31 PERMIT I°EE
ho comnaat for such projects with a connuctons)licensed pursuant o the Contractor's
License,law, t
[:31 con exempt der Sec. ,11&P C for this reason PERMIT ISSUANCI'
ALTER-DRAIN&VENT W" A) VALUATION
On, Date
WORKL'RSC MP A'I'1 ;CLA ATIOt BACK FLOW I'RO113C'I'.DEVICE L 0OG
I hereby affirm under penalty of perjury rte f the follteingdedaations:
❑Ihavc and will maimaine Certificvmnf Cance Donal(-insure for Werkcrs Compem DRAINS-FLOOR,ROOF,ARBA,CONE. STORIES TYPEC UCI'ION
sation,as presided for by Section 3]00 of the labor Code,for the performance of the
work for which this permit is issued FIXIV RES-PER THAI'
Fl I have and will maintain Workers Contamination Insurance,as required by Section
3700 of the Labor Code.for the performance of the work for which this permit is issued. GAS-FA.SYS'I'FMI INC.4 OUTL. OCC.GROUT' APN
My Worker's Compensation Insurance carrier send Policy nm
uber ere:
Carrier Policy No: GAS-HA.SYSTHM-OVP,R 4(E
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF.ASFIINDUS'I'Rh WAST" TERCF.PTOR
COMP17NSKDON INSURANCE. BUILDING DIVISION FEES
PLA
Ice,,) NCf11iCK PI?I:
(Thko,ctimarld not beer iplemdlfthupennit is fo 0 r hundraldodaa($100) GREASHTRAI' _
ar -
Icenifythatinthe perinrmurum of me work for which this,mon is issued.I shall SEWER-SANI'I'A -S1'ORM EA.200 IT. PAI
not employ oily persxm in any manner so us or become su rim'n the Workers.'Cnmpem �ER(iY ITIi
OZ .moon lmws of California.Duro WATER HEAT/ WNENT/fLECTR
Z O Applicant ' GRADING PER
aNs NOTICE TO APPLICANT:If,of c,making this Certificate of Eaanpnian,you should WATER SY P.MIFREATING
hamate subject to the Worker,Cnmpenstahm p oti,sim,afthe Lothar Code,you must MT
LLJr forthwith comply with such partisans or this permit shall he deemed revoked. WATE .ERVICI!
Q
7Z CONSTRUCUONLENDING AGENCY N' RESIDIiNTIAI.PhMB. SQ.Ie �TM yl Vs/ a,^"'Date Rcccipt
V 0 work
far
which rat ranhefo ixati(Seeni30 len ding agency for perfnrmfince of -- _
(Jon 1" the work fa which this permit is issued(Sea 7(X17,Cu.CJ
I.cndcrx Name _ '1 1'AL: ' [
f..J Lcndcr'x AJdrcse TOTAL:
S1 certify that I have read this application and state that the above information is n BUILDING IgHe "
fn eorren.]agree to comply with all city find county ordinances and sante Laws relatingm QTY. MECHANICALPERMIT 'E
fJ z building mnxtmction,and hereby authorize mprrmoutivesof Nis city tocrecrupon the SEISMICFEF.
Ic
drove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEF.
liabilities,judgment,cats and expenses which may in any way vase illumt said City ALTER OR ADD TO MECH.
in aamcquence of the granting of this permit. PLUMBING LTH
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NUN•POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL F171.3SOURCE REGULATIONS.
AIR HANDLINGUNIT(OVER 10," M) CONSTRUCIIONTAX
'ignumrcol'AppllcameContncmr Dam EXHAUST IIOODIWIDIICII HOUSING MI'fIGA'fl(lN s
HAZARDOUS MAI'HRIALS DISCLOSURE ,
Will the applicant orfnum building occupant store or handle Lnznrdans material HEATING UNIT(TO HN),(—A)
as defined by the Cupertino Municipal Ca rbe.Chapter 9,12,and the Ibmlrh and Safety
Gala,Section 2553200? IIHATING UNIT(OVP-R6 M)BTU, 'yI
❑Yes Fl No VENTILATION FA ' SINGLE RF_SID) PAID��'�•
Date Recent#
Will the applicant or future hadding occupant use equipment1'itt
or de5 which
emit hazardous air contaminonts as defined by the Bay Area Air Quality Management BOILER-CO UHI'OR 100,(1(5 BTU)
District; T
❑Vest 7N - BOILER- OMI'IOVCR 100,(NXI BTU) �.
I have read the hazardous materials requirements under Chapter 695 of the Culh AIRC DITIONER - ISSIJANC.F.DAT.
forma Death&Safety Cts]o,Spin o.255(6,25533 unit 25534.1 i alumtnad that If the NA RESIDEN'UAL MECH. SQ.FE
budding tows not currently have it mnnnt,thin it is m'mi'lasibility to notify tico"uluant
of tin quirement which must be met prionnismm�ee ofn Cenifiema of Occupancy. �\a�1.aj�'�
Owomorouthodzedagent - - Date
TOTAL: ISSUEDBY�V
OFFICE