S 0945 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY "
CITY OF CUPERTINO BUDDING-KLECIRICAL PHRADT NO,
BUILDING DIVISION APPLICATIONMERMIT 1'hU$11IIN'G.MFCIIANICAL S 0945
BUILDING PROJECT IDKN'PIF'ICATION
SANITARY Nfl. APPLICATION SUBMITTAI.ONES
BUILDING ADDRFSS:
0Z) cc) 111Q'�1IQAJI V �
NPR. NAIC:�( �I PHONE: CO: gCNRS NAM ZL"��' NIC CONEROLa
ARCHITF.CTIENGINEER: N LIC NO: ADDRFLSS: C V L� � 'O
✓
CONTACT: PHONE: BUILDING PERMIT'INFO
��5 1 1,OQ / 6 2 4 / l ❑ Consultant Fees Paid by Applicant(Iniliap BLDG EL PL t ME:Cu
1.1CENSEDCON'IRA'COR'SSDECI.ARFA7TION J l l 1 QTY. ELEC'T'RIC PERMI"T FEE JOB DESCRIPTION
1 hereby affirm that I am licensed sad,,provisions of Chapter 9(commencing
OZZ In Seedmt 7ban of Division 3anhcetaiaeii and am..dani Ce de,nd mylirenceis RF ID NTIAL
FOO Wlfull Teres and cRcct. D PERMIT ISSUANCE QSFDWL ❑KITCHEN RFMODHI,
Z_i to
a_u Liccnncc In Lica APPLIANCES-NFSIDEN'1'IAL ❑AUDITION [I PLUMBING RISI'IPE
E~Z W Dae 4 Com,nut"r ❑MULT'1-UNIT ❑STRUCTURAL
RCHITECTS DECLARATION PANEI S MODIIICAI'ION
FnZ I adan,ad mypinncsballh used tumblic records UPT0210AMPS
ZO ❑IYTI:RIOR ❑CHIMNEY REPAIR
OZ-0
F�E'YI Liecesad Professional 201-10X0AMPS IMI'ROVEMIiN'I' EJSWIMMING POOLS
OWNFR.BUILDCR DECLARATION OVIiH Sixth AMPS [I BATH RFb10DEfJREPAIN ❑DIil1D1.ETEGN
Z Q 1 hereby affirm that 1 ran eacmpl from the Comrucmr's License Law lin the []OTHER
eX.06V hglowing mason.ISeninn 70t L5,Business tend ProPossions Ede:Any city ter county SIGNS ELECTRICAL
W 3 W y which revahes a prmat Ia canhoua,alter,improve de likh.ter repnie any ntmclnre
F u'O¢ prlorto its issuance.also means,the uPdic2m,a such peal File aligned statement SPECIAL CIRCU I'I'IM PSC.
N.,. thin he is licensed pursuam mrhe provisions of the Contractor's(.kenos law(Chapter 9
COMMERCIAL
�EN (cnmmene sem it Sermon 7(andth DivLlon9 the alleged
eanndon,Ayvioioda or 'CEM4'.METER OR roLIi INST. ❑NEW BLDNADDI'TION ❑DFMOIJ'I'IVI
a 4 ,Y that he is exempt therefrom and the basis for the alleged exemption.Any viulatian of
X
om Section](D1 Sby:myapplicvm fora permiuupjecp the npplicam macrvil penally of POWI:H DEVICES TNAM1T OF SEE VICE:
na morelnzn Eve hundred delta,($500).
11'ROVIiMFNT
fS� ❑1,az owner of the property.or my employees with wages as theirmlc wmpcnweon, SWIMMING POOL ELECT RIC ❑O'fIIER
F. wi 11 dothe work.and@esoumure is not reendedoreffceed forsale(SCe 70L1,Business OU'I'LIiTS-SWITC4IE$-FIXTUR
L 3 Le and Professions Code:The Contractor's License law does
not apply m an owner of
property who builds or improves thereon,and who docs such work himself m Ihtougb NF.W RESIDF.NTIAh ELIiCI'R 5 'I'
his awn emPloyecc.Provided nonsuch intpmvenema nee not amended or n0"reed for SQ.PR FLOOR ARBA VSSQ.IT.
,,,nerLhowece�r wi 11 hFuil he burdg or en
of pinenlitat he aid nnnatild improve
par.
r-M1uilJer will have•the bards•,of proving That he Aid net M1uild nr improve for pury
aa
qac of ale.). OI.: �/�
1,as owner of the property,am exclusively contracting with licensed contractors to CD
c navuc,0c project(Sec 7044.Business and Professions Cone)I ne Contractor's Li. ��)')•V
renes,lawdoesnotapplytoanownern(prop:rtywhobuildsorimprovesmcreon.and Q'T'Y. PLUMBING PERMIT E II hleur
who contracts for such pmjccx with a licensed pa,aanus:me Cmana mr c ry IIIyU
License law. PERMIT ISSUANCE:
El
I am exempt under Sea. .B S P C for Wis reason
ALTER-DRAIN&VENT'-WATER(GA) VALUATION
Owner Uate ���
. WORKER'S COMPENSATION DECLARATION BACK FLOW PH(YI'ECT.DIiVICIi O
I handwaffirmunder ponohy of perjuryoneofthefollowmg declandWorkers
orker Co
plhavc and will mvintaln aCartiOeam of Cnnxcm lo.a�lf-mxure for Worker's Cnmpet- DRAINS-FLOOR.HOOF.ARh:A,CONE). gq0 '1'YPECONSTRUCI'I(l
xmion,ax proviteJ for by Scctiun 3]1X1 of Ibe labor Code,for the icrfommnce of the FIXTURES-PER TRAP
work for wa,h,his permit is issued.
I�j",'l have tend will maintain Worker's Compenmtion lnwrance.as myuired by Section GAS-EA.SYSTCl1-1 INC.40VTLti1'S OCC. ,li(((lt' AI'N
/j7N of Ins Lubar Calc,far the peAnmmnce of the work for which this permit is issued.
y Worky�Co s/�ti�n Inxmm�an canur:md Polley n ober
GAS-EA.SYST \
Catricc J�.f�11'+��—I'alicy No.:���',IZ EM-OVER 411iA1
CERIIIoIC OMPEN ATION ONFRAN )HKF.RS' GREASEIINDUS'I'RE,WASTE DDERCEP'TOR
C(IMPFNSA'TION INSURANCE BUILDING DIVISION FEIiS
(Thissection need not he complard Blue Permit isforanchumlmldollo,($IIXA GREASE:TRAP I A ECK FEE Q
or less.(
Ifenify that inthe any
lsewmk Er subject
this theEanad Wisicmedlnhull SIiWIiR-SANITARY-S'IT)RM EA.209)F1, li + GYlaili 2 (�
not endplay any person in any manner m as nt become subject nt the Worker:CumPem
Z nation laws of California Date WASTES I IEATER WN17N'IyLFCI'R MING FISH
Z 0 Applicant
NOTICE:TO APPLICANT:It.after making this Certificate of Exemption,you should WATER SYSTEMITREATING OILS W-B
F-' become subject to the Worker's Compensation pevisions nl the Ichor Code,you am.it
forthwith comply with such provisions or this Permit shall be Seemed revoked. WATER SCHVICLi
D.1 Q PA
7Z CONST RUCTION LENDING AGENCY NLW HCSIDEN'IIAL PLMB, SQ.IT. Dino Itcttiplp
G OInefebyaRnnthatthe.is a conswcrion lending agency for the performance of
the work for odeh This permil is issued lice.3097.Civ.C.) )TAI
Of fenders Name TOTAL:
,r {61 Lender's Address BUILDING YE
G 1 certify the,I have read this vppliemion and amethat the uMwe'mf rmnlm.I Ix FEL
f' y cortcm.l agree to comply with all city and otomy oNinanai and sem laws relutingm QTY MECHANICAL PERMIT SEISMIC IT'
U IZ builiingcomtmcfion,and hereby authorize terve.wmativesofthis city toenter upon the
throve-mproperty for propfir inspection Purposes, I'EHMI'S ISSUANCE: EL.[zC ll;.
(we)agree to save,indemnify and kap harmless the City of Cupertino against
,ehililies.juAgmcas,costs and expenses which may in any way acerae agvi nit said City ALTER OR ADD TO M ECR. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL CQMRx6Y WITH ALL NON-POINT AIR HANDLING UNIT(TO H40dCFM) MI:CHANICAL FEi.
SOU C. CGULATIONS. //
AIR HANDLING UNIT IOVIiH 10.00CP1,111 CONS'1'RUCTION'TAX
,tgnewrt of Apel JCo tmaor Dam FXHAUSTHOOD(WIDUC) HOUSING MITIGATION :E
HAZARDOUS MATERIALS DISCI.OSURF.
W II I the.milemn or fume radiant,uccupum sere or handle havardo.,material IIL'ATING UNIT(TO I IXLIMID BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Ileahh,rad Safety fiFAT'ING UNIT(OVEiR h t'lan BTU)
Code,Scaion 25592(x)7
F1 Yes Fl No VFN"1'ILATPON FANS I NGLE RES]DI PAID
Dam Hec,ipla
Will the applicvm or future building occupant use equipment or devices which BOILER-COM P(3HPOR IfO.t]fX I ITS)
• emit District?
nus air contaminants as defined by the Buy Arca Air Quality Munugancnt TOTAL:
Diiola7 BOILER-C(IMP(OVER IDI,IMXI RTU)
❑Yes E]No
AIR CONDITIONER ISSUANCIi DAT'li
I have real the huaadous mamriuk reyuimtrcnts under Chahar fi 95 of the Cali
mi -
fote Health.@ Safety Code.Secoans 25505.2553 and 25534.1 t de star,that it the NEW NESIDHNTIAL MECH, SQ.FI'.
building docs nor currtn0y have a tenant,that it is my tcsrymsibility u,,ably the avvpml
of the requirements which const be ata prior to issuance of a Cenificam of(kcupnncy.
Owner m aahoneed agent
Dote TOTAL: ISSUED fly:
OFFICE