S 1054 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' BUaBNG.TLI?CTRICAL P1' Tr ND.
JINLDINC.DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL k� 1054
_ IUILDING PROJECT IDENTIFICATION .
BU LOINGADDRCSS: SANI'T'ARY NO. APPLICAI'TON SUBMITTAL DATE
1103 w1:->uTWC0P ANT-1 . cuf)e;Q_g'40, C*- ► b-
1W VJ 'S W-AME' � � TI0
V0.N ' A Lr!f � ONTRAC OR'S NAME: LIC NO.
J(r NIC �.C/OyNTR^( .p
' D QVAADDESSCHITECIIENGINEER; LIC NO:
ITACTPHONE : ❑ BUILDING
yLJP.{C_RRMVI'IIIII/
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O\ 1 ❑ Consultant Fees Pail 6y Applicant(Initial) BLD El.li PLU—rw 1LNT1
+1 MQ9' f / DLNa
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LICENSED CONTRACTORSnecl.nkanGN 'py. 'ELECC TRIC PERMITFEE ]013 DESCRIPTION
I penny Tdfirm Thal 1 mm harthat under prnvisino of Chapter 9(cmmnca cing
�Cx with Bcclino"a.I nfDivision9ofJm Bnein.xsand Professions Calc,andnly lariat.ix - - RESIDENTIAL
4aOp In PERMIT ISSUANCE RESIDENTIAL
FF++ full li+recande ell. ❑SP WI, [D KITCHEN RF.MOUPJ.
UF License Class Lic,M
U - APPLIANCES-RESIDENTIAL. TION ❑PLUMBING RE-PIPE
LF..Z(y Dam Camruc'or
tn6a ❑ UI.TI-UNIT ❑STRUCTURAL
F.nh mos hall
eow DECLARATION PANELS
OZ`S—' lunderswnd my plans shallMused as peptic recoNs UPT02MAMPS MODIFICATION
El ❑CHIMNEY REPAIR
P 4 F'aQl Licensed lhnlessional 2111-10(10 AMPS IMPROVIiMENT C]SWIMMING POOLS
9 OWNER-BUILDER DECLARATION OVER Until AMPS ❑BATHKEMODI:IJNEPAIK [I DEMOLITION
C R'6 I hereby off tet Thal 1 am exempt from the Contamors License Law far the
k�LU fallowing reason.(Section]OJIS,Business and Professions Code:Any city or canary SIGNS ELECTRICAL DOTTER
3 u. which requires a pcmlk to construct.alter,improve,di isR or repair any.structure
as proom its issuance,also requires the applicant farsach Permit m
o Gleasignedolmecm SPECIAL CIRCUITIMISC.
shy That he is licensed penom to the provisions of the Contanur's License Law(Chaprr9
WppO mmnmencing with5tttion](X101 of DivicionJoflhe Business and l4afexsinn.Crde).r TEMP.METER OR POLE INST.
a y m eG Ihot he is exempt Iheref...I and the basis for the alleged exemption.Any violation of / 1]ITION ❑DEMOLITION
LL%1-s 4r�• . oinn]IIJIs by any applicant far a permit subjects thenpdi,em ,,a civil penally of POWER DEVICES ,❑TENA 1ge FOOD SERVICE
[F-.. ern more than five hundred Anllars($500). VF?MIiNT
CZO I] 1.its owner ofthcpropcny,or my employees with wages as their sole compensation, SWIMMING POOL ELECT'RIC �0//�RVFM
CC22LL willdo the wmk.mad the structure is not intended proffered for.sole(See 7044,1lusioss '1}i rF`
d and Pod..ams Coda I1+c C,mImcmr's`License Law does nal apply Tat nn owner of OUTLETS-SIN I'CHES-FIX'T'URES
property who holds or improves thereon,and who does snub work Iii used to Tha ugh
Mian ,I mpinyas,provided That such innmvemems.re nal inlunded nut mitered for NEW RESIDENTIAL FIAICTR SQ FI'.
aide.if,hpwtvcn the huildingmimprnvemelt is sold within one yanmf coullurom+,the SQ.FT.FLOOR AREA $ISQ.Pt.
overar,thfilder will have the burden ofproving that he did not Mudd or iroprovc pit ar
p - Is
PodI I
07 wner of the property,am exclusively contracting with licensed carnation to
instruct The project(Sec.](144,Business and Professions Code:)The Contractor's Ic-
ecaseLuwdoe.u+rn apply to an owner of Property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who cumacts for such projects with a conuacmr(s)licensed pursuant o the Contranorr
License Law, PERMIT ISSUANCE.
❑1 am exempt un er'ce. ,B&I'C for this reason
ALTER-DRAIN&VENT'-NATER(IAT VALUATION
• weer Data
WORKER'S COMPE S T N DECLARATION BACK PLOW PROTECT DEVICE 'yl �``
I hereby affirm under penalty of p my one of the Mitosis,decluations - _`
;hhveand will maintaina Cenificaten Consent asci(-insurefor Workers Compal- DRAINS-FLOOR,ROOF,AREA,COND. STORI6 TYPE CONSTRUCTION
mon,as provided for by Section 37W of Ne Labor Cade,fur the perforant..I'the
work lin which this permit is issued, FIXTURES-PER TRAP
❑ 1 nave and will maintain Workers Compensation Insurance,as required by Semon '
37II0of ILe Labra Code;far fhaperformance oflhe work for which lospannil islasaal, GAS-EA.SYSTEM.I INC.4 OLD LETS OCC GROUP APN
My Motors Cmnpcosation Insurance carrier and Policy nrnMnnrc
Cmricr, Policy Nu: GAS-EA SYSTEM-OVER 4(PAT
CIIGEICATE OF EXEMPTION FROM WORKERS' GRF.AST'IINDUS'tRI,WASTE IN'fl?RC1il'Tf1R
COMPENSATION INSURANCEBUIT DIVISION PERS
(Thkatectimn neuinolhecdmpletedifthe Permh is forone hundred dollars(SIM) GREASBiTRAP
orle,a) PLANCIIECK IgiE
T certify that in the performance of the work for which this pini(is issued,i shall SEWER-SANITARY-STORM HA.21X)FT.
not employ any Prion in any manner so as m become subject ..,he Worker'Cooper- ENERGY FEE - attak
Z smican laws of California.Dae WATER HEATER WNENT/ELEC R
ZApplies.' t GRADING ITT.
ti NOTICE TO APPLICANT:If,ager taking this Certificate of Exemption,you should WATER SYSI'EMRREATING SOILS PEE
f' become subjectm the Workers Campensmic n Emotions of the Labor Calc,you muss
Wv fonhwith comply with such provisions or this permitchill hedeemed revoked WATER SERVICE
Q
7 2 CONSTRUCTION LENDING ngagerAGENCY NEW RESIDENTIAL PLMB, SQ.FT. PAID Doe rip M
UO k for
rwhich thi Permit
i ixacomrmc.innlendie.agency for the perli+a+wceter
V. F the work Rn which'h6'permit is issued(Sac.TIN],Civ.CJif V
Q U Lender's Nano TOTAL:
Dal 1-ciders Address
ccnify that I have read this application and stem the,the ahmve infunnatinn is BUILDING FEL
hconch,I agree to comply with all city and county ordinances and state laws reaming to QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorize represenmfives nfthis city m cuter upon the SEISMIC IT.
uhave-o enlimned propcny for inspection patpows PERMIT ISSUANCE,
(W.)agree m s:rve,indemnify and keep harmless the Cary of Cupertino.gninM ELECTRIC PliliIL
liabilities,judgments.costs and expenses which may in any wuY accrue vguinm said City ALq'ER OR AUD'fO MliCll. PLUMBING N
in consequeneeofthe gantin,of this permit.
I?E
- -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
M[CIIANICAI.Plili it
SOURCE REGUL TIONS
k4 � 1 AIR HANDLING UNIT(OVER III,IXNI CIM) CONSTRUCTION I'A%
agnawre of ppllcenVConwgar U;e EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION iE
HAZARDOUS 'f IAIS DISCLOSURE
Will an,applicant or future 'dingoccupanorm,nut handle hamnlausnmtedal HE
UNIT(TO T(I(I,IMMI B'I'lll
as defined by the Cupertino Municipal Cale.Chapter 9.12.and the Health and Safely
Cada Section 255]2(.)] HEATING UNIT(OVER 100.000 BTU)
Yes - MNo VENTILATION FAN(SINGI.Ii RESIDI PAID Ore Ree 'ptM
Will the applicant or future building Occupant use ea Air u m devices which BOILER' COMP(THP OR HIRER)BTU)
haauNous air contaminants as defined by The Bay Area Air Qualify Management L:
Y;cL❑' Yea, Fl No BOILER-COMP(OVER 100,000 IT TU)
L5�_�cr
have re ad The haxnnlous materials requirements miler Chapter 6.95 mf the Cul i- AIR CONDITIONER ISSUANCE DATE ,
III&Sail'my Cade,Stefano 255115,25513 mal 25-534.1 andeo:mnd that it the NEW RESIDENT I. SQ.IT.
ds nal currently huvea tenant that it is my respuf ildity In nmlly lhcascupunT
uirensms which must he met prior to issuance of u Cenificam IT Occup:mcy.
ramharired agent Doc 'I.
ISSUEDBY:
OFFICE
RESIDENTIAL PROJECT COVER SHEET
Assessors Parcel Number:
Name of owner. k/.1141
Project address. 11n99 W M IND, 61Z 4'
Contact person. -N-111 N k 3O�F-..A Phone. O Z — n
Fax. ?
Net square footage of lot. G
Square footage: First floor:
Second floor:
Garage:
Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y N
• On what floor(s) is work being done?
Brief description of work.
Code editions: 1994 UBC (Y-N)1994 UFC (Y-N)1994 UIvIC (Y-N)
1994 UPC (Y -N)1993 NEC (Y -N)
Plan Review Process Work Book . Page -7-