S 1250 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEIW IT NO.
PLUMBING-MECHANICAL J 1250
BUILDING DIVISION API'hIGCPION/I'ERM17•
BUILDING PROJECT IDENTIFICA'I'[ON
SANITARY NO. AIPLICA'IION Sl113M1'1"PAL DAT
HUILDINGAUURESS; Ii
j 3 d'/ fir G 3 90 -1-R
OWNER'S NA 1E: 'HUNK: COM1TRACIUR'ti NAM[: LIC NO:
H r O H C S C N NIC CONI Rol.r
ARCHITIC17 iNGINEER: EJC NU: ADDRESS: ❑
IA A- r //
CON'PAC'I': PHONE BUILDING PERMIT INFO
SaSFy safie 5 �4�d'Jyj7Z7J-r ❑ ConsultantFre$Paid byApplicant(IaiHdl) G ECL' PLUMB ME:CH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am Rwmed tinder provision.of Chapter 9 mammeneing JOB DESCRIPTION
OKZwith Section700(not Division3onhc Business and Pndcssion.Code.and my Incense ix RESIDENTIAL:
PERM I'I'ISSUANCE
OO In bill fnrsc mW all-I ❑SFDWL ❑KITCHEN REMODEL
=-i-TUU l,iccnx C1 I.ICN 39a— 3.vJ f_
�zw Uarn Canoes �'GHB APPLIANCES-RESIDESPIAL El ADDITION ❑1'I.UMIi1NG RE-PIPE
URAL
was AR IO ECTS DECLARATION ❑MULTI-HNIP ❑S'1'RUCIC 1*1
~v0)Z I ndia,undmy Plansshall be must as puhh,records PANELS \_/�ODIWCAI'ION
ZOZNO UPTO 200AMPS ❑INTERIOR LTtlhJ NEY REPAIR
Licensed i'rol-urinal 201-1000AMPS IMPROVEMIiNT QE). IMMINGPOOLS
� J OVER IMNIAMPS ❑BATH RI?MODEIIRE'NR ❑DFMGIJTIO
OWNER-BUILDER DECLARATION I� /
Q 1 hereby a1Fnn that I air uanpl Irvin the Contnwmix Licari-Law tut me ❑OTHER R P //;[I
J C/ 1 tlG
a'oY U fallowing muton.(Sccliun]1131.5,limina,and Pnrfcxtio I,Code Any city or county SIGNS ELECTRICAL
a13 W N which ree i¢s a pencil to construct,alter,improve.demolish,or repair any structure
I_'u' /
�st prior to ha inxuance.also requires the applicant formah prm,ino file aligned omcmeat SPECIAL CIRCUIT/M ISC.
tharhen Reensedpoaaomtothu provixim,x of the Commcu,rs Licence WwfChapmr9 COMMERCIAL:
[+a1�00 (commencing with Section 701 Division 3ofthu Ravines,and Profcxdans Corior TEMP.N117ER OR POLE INST.
d y o y Thal he is caempt fatalism,and the haxis far the allcyed excalation.Any violation of ❑NEW BLDG/ADDITION ❑UI?MOLITION
x..N Secuun]191.5 by any appbennt fill a le...It subjuts meaaplicam m a civil wealy It LOWER DEVICES ❑'TENANT ❑Fool)SHRVICE
not more than live hundred dulhus 65000. IMPROVEMENT
EI 1.as ownertb0e proi(it myeIaplvyccs with wages as their sale compensation, SWIMMING POOLE?LEC'IRIC
OTHER
Is:p., will do the work.and thcmmcma isnot intended ooffered ed for sale(Scc.]DW,Business ❑
W 3 w and professin oCuda The Contmnor's License law does not apply to an owner of out LITS-SWITCHES-IlX'I'URES P A D
property who builds or improves thereon,and who docs such work himself or through
his own employers,provided that such improvements are nor intended or offered for NEN'RESIDENTIAL BLEC R SQ 19'.
title If.however.Ihebeildingorimprnvemenl ix sold within ane Ycar ofcampdrion.the SQp��vP{j)OICARFA b/SQ.PP.
ur-bnllder will lease the burden of anrving that he didall hulld of imanwe to all- ,r'HK 2 ANS
p ccof au), TOTAL
❑I,as owner of the properly.am c.nusivelY contacting wins licenced cmrrmemm m CI I Y OF
consumer the pi(See.70,G,Business and Professions Cade:)The Cunin-ar's
I,- V Ur Cr 1 I IIY
tt law dies not apply to an owner of property who balm ter improves thervnn,and QTY PLUMB ,I IT FEE
who contracts for such projectswith a contrai licensed pursuantm the Courts s
License Low. 1'ERMI T ISSUANCE
❑ I um asemplundcr See. ,B&P C for this reaam
ALI EIR-DRAIN&VEIN' lila(. VALUATION
aloes Uaa n• WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DI;I hereby athnn under acre le ill perjury one of rhe following decDraions:❑ I base and will maintain a Certificate ofConsent m sclf-insua for Warkefs Compcn- DRAINS-FLOOR.ROOFIAREA.CrTYPE CONSTRUCTION,brio .-p - by S C 3]10 f th L b, C d f Ih fe f ane oftheorkf tti:Fwm t J FIXTURES PERTRAP
and
avant, '11 I W k C 1 'tI q dby Sara37000 the Labor L We.bbe pvftnwaysfine wolk f ewb Wthspami.ixssued. GAS-IA SYSTEM-I INC.4 OUTLETSAINMyWnrk[�s'x Cnmpeosatoninsurunec soas . GAS-IiA.SYSTEM-OVIiR4(13A)
Caaicc l/i/T�ffD� PnlicY sLRDFICATE�/rT'6(.�r1lBIsim OMWORWOR I:t.S' GRI:ASFANDUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCEON IliliS
(Thiesecrion need nut becomplemd ifthe permit ishoone hundreddollan 6lIXB GREASE'BAP
I'LANCH[CK PEIi
Iecrrily fibs,,,the acrfunnnnccuf,Inbeklin which thio the Wi,xlssu Colowll SRWI!12-SANITARY-STORM I',A.21N1 PI'.
nm employ z fw^^n in any manner sit ax n,M1cmme xuhjcct In the Wmkcn'Con,acn- IiNIdtGY FEE
z .,,an Falx of Caifomla.Ilam WATIiR IWATER W/VRN DELECR GRADING FEE
O Applicant
y NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should WATER SYSTGMO'RPATING SOILS FEE
h' became subject n,the Worker's Compnnwtirrn provisions of the Father Cate,you must
ai tonhwith comply with such provisioner this permit shall lcdcemed revoked. WATER S17RVICE
Q
a
C'ONSIRUC'I ION LENDING AGENCY NI?W RIiSIHIiNT1ALl'LM B. SQ.isl'. PAID
U 'Z' Ihenh I'fim,munhere'omcanswerinn lending ngencyf she lrcrfnmmna of Uum
4p1
UO
L" the weak for which this pcnnn is issued(See.3097.Civ.CJ TOl'A I,:
OU Lender's Name TOTAL:
r U Lcndels Address
BUILDING F;1 candy that 1 have read this application and state that the above infoncarion in
iF. tan correct.l agree In comply with all city:ad county ordinances and state laws relining to QTY. MECHANICALPERMIT FEF, SMSMIC FEE
UZ building umalmcliond and hereby all.... rapretnnlnlivrt of lhltaityhrenwr upon the
abovmmcmintied property for hopecdnn parpn.m. PERMIT ISSUANCH 1:AF TRIC FE[
(We)agaem save.Lndmnaily and keep mamas,the Cly of Cupenfnu agaitm
liabilities,judgments.costs and expense which may in any waya<cmeagaimr said City ACIERORADDTOMECIL PLUMBING FE
in canuquenee of the granting of this permit.
APPLICANT UNDERSTANDS AND>J1.1,LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO[D.000CFM) MECHANICAL BE
SOURCE RBGUI.ATIONS.
�� AIR HANDLING ON]T()VIiR 10.000 CFM) CONSTRUCT 'i'AX
Signet AppliI alCummo -/ Ula EXHAUST HOOD(W/DUCD HOUSINGMIDG FEE
I IAZARDOUS MAIRRIALS DISCLOSURE
Will the applicant or future building occupant store or handle haazNommaarial HEATING UNIT(TO 100,0%0()RTU)
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety HI;ATING UNIT(OVER 100.00 BTU)
Cafe,Similar 25532(x)'!
�Vcx ❑NuVEN'I'1F.A'1'IONFAN(SINGLERF.SIDI PAID
Dole Receipt
Will the mmdicam mfuture bn'dding omuleal mm rytdp
mant or'alias whish BOd.ER-COMP(31111 OR 100,000 B'1(3)
e m
mit hr,rdi air commma
ams as de iced by the Bay Arca Air Quality Mamgcna'at 'IOI'AL:
Distant! BOILER-COMP(OVER 1011,1%1)BTU)
E3 Yes ❑No
I have read me havudous nsaarials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE[)ATF
bm,im Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if he NEW RESIDENTIAL MECH. SQ.FT.
building dtu nor currently have a mnant liar it fix my m.pm..dal Fly In notify the uampnnt
of he railcar, ants which amt ban,,,Prior In issmnec ops Cemifieam of Occupancy.
Owner or authodmd agcm Data TOTAL: ISSUED BY:
OFFICE