S 0921 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUu.mlvr.-ELELI RICAL PERM..'NO.
BUILDING DIVISION APPLICATIONIPERMFP PI,USuslhG-MECHANICAL S 0921
BUILDING PROJECT IUF."IF'ICATION
BUILDING ADDRESS: _ SANITARY NO. AI".(CATION SUHMI"PI'A.DATE
Csk_ZtA32O� t \o1 CIO rnM a�IhAuC ! p
OWNHICS NAME: PHONE, CONrRACTOR'SNAM ' LIC NO:
L
y¢-7- Av.• two �t-S3"i0 Avg!- C.owStO-..colo 194 NIC cuN'raoLa
� ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
ri 136 E•1JAtaA ST 11—el- -4 k-1'a Gu 0105.1 1
CONTACT: IF 14 PHONE: BUILDING PIiRMITINFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MCCH
❑ ❑ ❑
LICENSED CONTRACTORS DIECLAR61'ION QTY (ELECTRIC PERMIT FEE
1 hereby amen d,m I.an rcemed under pmvinion It Chnmer 9(mmntood„g JOB DE:CRIPTION
Q=Z with Semlon7)(0fouf Div'uinn 3 of the Business and Pooft,,don.Cude.andmy license lx RESIDENTIAL;
FO Tull force unite a. PERMIT ISSUA NCE
Wo in 0SFDWL ❑KITCHEN REMODEL
IPIaULicense ClT
s SINIAL El ADDITION [:]PLUMBING R17
P
U -oNrCIpGi Contractor' APPLIANCES- E
a, ARCHED: DECLARATION S ❑MULTI-UNIT ❑STRUCTURA.
Fpm PAFMODIFICATION
ZO-Z
I undersmnd my Alam%hall be med.,public mcorJs
OZ—O UP T02gOAMl'$ OINTERIDR ❑Cf11MNIEY REPAIR
(-4F•LL Licenced Pr..f,,,iocl 201-1000AMI'S IMPROVEMENT 0SWIMMING POOLS
-� OWNER-BUILDER DECLARATION
C`.L�•4 OVER 10g)AMPS ❑BATHREMODI:LIRIEI'AR DIiMOLITION
Cad I hcrchy ufGnn thin I sun cxnnpt from the Cnnuuc'ar',Liccncc Law lar the
L O i U tollnwing rearm.fgcmion]03 L5,]3usinecs and Pndescinn,Coda:Any city Ur cmmUy SIGNS ELECTRICAL *&,e
'3LLI' which mquimq l to construct,alter,int denihih,onm Wemre ��'�t Y� x-
y ' IK P P Ys
prat ts issuance.alsoy the ppl t for suchPe 'tt fl 'F dsmtcmcnl SPECIAL CIRCU IT/MISC. uL r
f�T
that he 1 dp ua n th p n: fth C I I L - La (CBap¢r4 COMMERCIAL \rr
Iu�pO (commencing with Section 7(XXB of U'uvonJofthe tlusiness and Pmfe:i :Calc)or TEMP.1,11.7171AOR POLE INST”
d Xe C tba he is exempt therefrom ani the basis for the alleged exemption.Any vmidu n of ❑NEN'BLDG/ADUI'f10N ❑DEMOLITION
W Section]031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES ❑TIENANT ❑FOOD SERVICE
re than five hundred doll...($50X). IMPROVEMENT
f�C n" Lmowneroflhepopcny.or Ty employee,with wage,a,'he!,solo cnmpcnsmiuu, SWIMMING POOL ELECTRIC
'll do the work,and the structure is not inwndul or oficmd br.sule(Sec.7(Wun
4,13siax% ❑OTI3ER
W 3 m ..it Prafexxinns Code:The Cnnlmetor',Limns%:Law docs nal apply In an owner or OUTLHI'S—SWI"ICHUS—FIXTURES
property who build,or improves thereon,and who docs such work him%clfor through
his own employees,provided that.such improvements are not intended or olfamd lin NEW RESIDENT had.IELEC R
sale.IL however.the building or improvement is sold within one year of completion,the
SQ.1-7,FLOOR AREA LSQFI'.
.
ow
sur-builder will have the burden of proving that he did not build or improve for par- _
pone of mle)" TOT �1
1,as owner of the Tarot,um exclusively commaing with licensed ammn
trecs m N It)
consumer the pmlect(Sec.70.14,Husine,s and Pmtcsions L Wee,The Contractor,Li-
c se law does not apply loam owner ofproben,shohard,Orimprow,mere%m,and QTY. PLUMBING PERMIT FEE JAry
who amlmns Rnwch Or 111s w Ora moracups)licensed pnnomuo the Cormalo's q �6 ANSA
Liccncc Ww. PERMIT ISSUANCIE {/
� Imne Sec. .If&PC 6rthi,ream
ALTER-DRAIN (EA) (, LppAIION
Owner Ha,d)`� " en f iplu
Ii R'SCOMPENSATIONDECLARAT]ON BACK FLOW Plan ECT.DEVICE OO 00
hereby ill maintain
ai uain a Comfic to perjury one of the follow ing Workers
orker io o 1
plhave and will main mina Citur370ofComam Rnel6insurefor Workersce of ttm DRAINS-PhOOR.ROOF.AREA,COND. STORIES TVPECONSTRUCTION
.mien,as provided for by Section Plq of the LuAm Gxlc,for the performance of the
r Ln which this',omit is lnmcJ, FIXTURES-I'IiR'TRAI'
w I huvc and will maintain Worker,Compensation Insurance,rix n,mmJ by Section
Xlohbc Labor Gxle,Ibr the parbvnmncc of'he work lits which Ibis Aconin 6lsned GAS-EA.SYS'I'IEM"1 INC.40UTLIfl:S OC—GROUP AI'N
My W(rker,Compemation Insurance carrier and policy nmnbcr are: GAS-IEA.SYS'IHM-OVER4(EA)
Carrier: Policy No.:
CERrBicArF OF EXEMPTION FROM WORKERS' GRBASUINDUS'I RI,WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thi„eetinn modmabccomplemclifthepem'it is fnrone hundreddollanl51f ) GREASETRAP
nr le".) PLANCHIECK FEE
I certify that in lheperfoomnceef Ne work for which this permits issued,I shaft SEWER-SANITARY-STORM EA.2IXIFI.
not employ any pennon In any manner xn as m become subject m the Worker Compen- ENERGY Il?h:
z sultan Laos of Calilbmiu.Date WATER[][:At ER WIV17N'I'TLECI'R
zC) Applicant GRADING ItiE
NOTICE TO APPLICANT:I alter making this Ceri licam of Exemption,you should WATER SYS'I'IEM/IBIEAI'ING
h ermine,object Ir the Worker'%ConTcm ation provision%nl the tabor Code,Y%m nmol SOILS IdiE
forthwith comply with such provisions orchis pnmil shall be deemed revoked. WATER SERVICE
L ❑ jPAIDz CONSTRUCTION LENDING AGT:NCY NEW RFSIOT:NI'IAL('LMB. SO.FCDam Hes n MU O 1 hereby affirm thatthem is a conswction lending agency'for the erformance of'he work for which this Pcrmh d(Sec.3197.Civ.C.)
Isndcrx NameTOTAL1..1 LcnJcr'sAJJrc.a TOTAL:
dl ecnify"hal I huvc mail this aTlicution and..tum OmI'bc aboven man.nt i% FEcuem,t.]agrcemcmnply wish alldry and coamyordin.nce%anJ store law%rel'ningm QTY. MECHANICAL PERMIT FEE EEUz building rAR5lmnlon,and hereby untbonsnescnnmrve,ofnti,city to enter uqm thaabove-mentioned pmPeny for inspection puBmses, PERMITISSUANCIE FEE
(WO agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgment%.costs and expenses which may in any way ancon,against said City ALTER OR ADD TO MECH. PLUMBING FE
in ..sequence of the granting of this Permit.
APPLICANT UNDERSTAN ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I(LOUI CPM) MECHANICAL FEE
SOURCE NS.
l3(/e7 7 AIR HANDLING UNIT(OVER 10,00007M) CONS'1'HUCf10N TAX
Dem EXHAUST HOOD(W/DUCT) HOUSINGMD'IGATIONFE I.
HA7ARDOUS MATERIALS DISCLOSURE
WiIUhe applicant or future building oce.pron anteor handle baurdWs material HEATING UNIT(TO IM.Bfl(1 BTU)
as defined by the Cals,man Municipal Code.Chapter 9.12,and the Health end Safety
Gale.Section 25512(.)'1 HEATING UNIT(OVER I00.01)BILI)
❑Yes ON. VENTILATION FANS INGLE RES]D) PAID Ume Reccil
Will the applicant or future building Occupant use equipment or devJ
gO1LEH-cUMP(311P OR IIIU.IN1d PTU)
mit hammdous air conlnntinams as defined by the Hay Area Air Quality M 'DOTAL:
DicvimP BOILER-COMP(OVER 10gINID 1O U)
CYe., [:1 No
I have read Ne hicaman,mammals requirmnem,under Chapter 6.95 A]R CONDI'1'IONTR ISSUANCE DATE
food.Health&Safety Gyle.Swliom 25505.25533 mW 25534.1 ualresmnNEW RESIDIENI'[Al.MECH. SQ.P-n
building does not woman,have a mwm.that it is my m%p roibility to notify t
of therequ mcrosw uslMt fu Ccnifica¢rf Oc
t7
ar Utah ... TOTAL: ISSUED BYoner :
OFFICE