S 1124 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PI' aII NO,
BUILDIM1'CDIVISI(�N APPLICATION/PERMIT PLUMBING-MECHANICAL �J 1124
IIUILUING PROJECT IDEN'rIFICAA'ION
BUILDING ADDRESS: SANITARY NO, AI'1'LIG111ON SI111NI'I'IAh licit
- X►6\$'1 tAC,CA>irrw
OWNER'S NAME: YI IONIi CO IRA 'I'OR'SNAMI3: LIC NO.
� 1 �\� _ �,`_ NIC CON IROI,M
RCHITECTIENGINEER: LIC NO. ADDRESS: ❑
CONTACT: PHONF,: BUILDING PERMIT INFO
❑ Consultant FCCS Paid by Applicant(initial) HLDtl 1.1-1-C'r PLUMB MECII
❑ K ❑ ❑
LICENSED CONTRACTORS DECLARATION Q'FY. ELECTRIC PERMIT FEE JOE DESCRIPTION
1 hereby affirm that I am licensed under provisions of Chapter (commencing
QyOOY 'm hSull force a00ffuf Dlvi,xw3of the Bteieenand Pedes-cel,Cde,andmy license is RESIDENTIAL
PIiRMII'ISSIIANCG nd effect. ❑SFDWI. ❑KI'ICI WN REMODEL
6UUl,iccnac Class L ❑
Tic APPLIANCES-RESIDENTIAADDITION ❑PLUMBING RE.PIPE
�Qa Date Comranor sil URAL
ARCHITECTS DECLARATION PANELS ❑MULTbIJNII' ❑MOUCICAI]O
F m'Z I understand my plans.shall W used as public recooly MODIIgCA'1lON
ZO,'`• UP TO NXI AMPS OIN'1'HRIOR ❑CHIMNEY REPAIR
OZ--�
Pv�„f',LL Uunmd Pm[essinnal 2111-IIXXIAMI•S IMPROVEMENT []SWIMMING POOLS
§-a OWNER-HUILDER DECLARATION
(VER 1000AMPS I3AI'11 N13MOU1SI/NII'Alk )I:MO.
1 hereby affirm that 1 am exempt from the Contractor's licence Law for the ❑O'Ilil?k
aU following reason(Section 7031.5.Business and Professions Code:Any city or v coumY SIGNS ELECfRICAI.
Ixil 3 a y
which requires n permit to constmn,neer,improve,demolish,Or repair any amnarc
Moto prior In as issuance.alsouniccs dwapphrout formeb pear iOo fdeesig^eJ st^Ism^m SPECIAL CIRCULINISC.
dal} mat he is licensed pursuant to the provisions of me Contractor's License Law lChapmr 9 COMMERCIAL:
,Mac (commencing with Section 9XD)of Division 3 of the Business and Professions Csdr)or TEMP METER OR POLI?INST.
a a�d e C that he is exempt thercfmm and the basis for the alleged exemption.Any violation of ❑NEW IJLDG/ADIJI'I'ION C]DIiM01.1'FION
W^m Section]031.5 nay any applicant for apermit,idiput the applicant ,,acivil penaltyof POWER DEVICES C1 TENANT FOLD SERVICE
not more than five hundred dollars fS5O0). IMPROVEMENT
=Q ❑ Las owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
F_
will do the work,and the wiucture is not intended or opened for sale(See.704,t.Business ❑O TI11.R
W end profession,ilCodedsor the Conwemrs License Law does not apply eif Owner of OUTLETS-SWITCIIIiS-FIXTURES
his O progeny who builds or improves thereon and who Jacs such tints himself or though
his own employees,provided that such improvcmwts are not intended or offered for NEW RBSIUBNTIAI.I?hLCfH SQ tT.
sale.IT however.the building or improvement is sold within One yew of completion,
the SQ.17K FLOOR AREA SISQ.PI'.
er-bw1der will have the burden of proving that he did not build or improve for pur- PAI e
pose of sale 1� TOTAL: �'1
❑I,as owner of the n y contracting wi
pope y..B sines an tmcon to heeCeams, s tO p4
cause La me project(xec.o anf. nee of and pmfiury,who
Cod,)iThe veetnmr on.anLI-d
M
cause Lawdresrnow
suchapply man ovvnerofpmpeny wM1esedprmaw to the
moron.and QTY. PLUMBING PERMIT PF,E ^/
who contracts far such pmjuts wimneontrnneds)licensed pumuam mile Conwetors
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. .B&P C for This rennin
ALTER-DRAIN&VIiNT-W - 1 VALUA Q
whet Date '
WORKER'S COMPENSATION DECLARATION BACK FLOW I'HOTIiCI'.DEVICE
1 hereby affirm under penalty of perjury one of the following dulamtions:
❑Ihave and will maintain nCenificatenf Conmmtn self-inmre for tenrkrQ Cnmpen- DRAINS-FLWR,ROLE.AREA,COS'IURIgS 'I'YI'IiCONSI'HUCI'101
sation,as previded for by Sutton 37M of the Labor Code,for performance of the
work for which this permit is issued. II XTURE4-PER TRAP -
❑I have and will maintain Workers Compensation Insurance,m required tio
by Seen().
37M of the labor Code.for the Performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.i OOI'LErti OCC GROUP APNI
My Workers Compensation Insurance career and Policy number are: GAS-EA.SYSTEM-OVER J(EA)
Cu Policy No.:
11
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE4SFJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION Ig3iS
(Tats etionneed not Na completed ifthe permit is for arm hundred Jolla,Spla GREASETRAY
1'LANCIIECK IIJi
nr le".)
I ecarfdam gero the any....as'hewalkfor which this he
is issued.lshdl SEWER-SANITARY-STORM En.210 FT. ENERGY ITT
not employ any palm^in any manna m as ns become subject nh the WnderA Cnmpen-
Z sation laws of Caltfomia.Doe WATER HEATER WNEN'1'/ELI:CfR GRADING I'lili
z Applicant
NOTICE TO APPLICANT:If,after making this Ccnifca¢of Eaemptinn,you should Wq'IT:R SYSI'CM/fREATING SOILSE
14i1i
F ^ become subjest m the Workd.,Compensation Provisions of the LaFur Code,you must
forthwith comply absorb pmvisi......his .it shall W deemed revoked. WATER SERVICE
U.1 0
L
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. I•AID
Doe Receipt a
UOI hereby affirmthat mem is a contraction lending agency for the performance of
me work ter which this Fund i.issued(sec.3W7.CO.C.) 'TOTAL:
.0 Tenders Name ITITAU
U Lender's Address I BUILDING FEE
1 ccnify that I have mad this application and umm chronic abuse inforwaram is
UCI,ri c rrect.I agree m comply wLb all city and cowry ordinances and state law.relating to QTY. MECHANICAL PERMIT FEE SEISMIC Fns
Z building construction.and hereby aummire representatives of this city to enter upon me
above-mentioned property for inspection par lows. PERMIT ISSUANCE LLECIRIC FI3B
(We)agree Io save,indemnify and keep harmless the City of Casnafte against
habilities.judgenems,costs and expenses which may in any way accrue against said City ALTL'RORADDTOMECH, PLUMBING FIA;
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) MECHANICAL ITE
SOURCE REGULA IONS. A 1 / a /J I �Q
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAS
Signature of ApplicanJComracwr Doc EXHAUST HOOD IWIDUC ) HOUSING NO I IGATION ITE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicanwrfuwre building mcupwtstore-,handle harardou.mmetial HEATING UNITe'f0100.000 BTU)
as.defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety BEATING UNIT(OVER 100.000 BTU)
Code,Sutton 255321st)?
❑Yef ❑No VEN RATION FAN ISINGLERESIDI PAID
Dae NeceipM
Will me apVbcant or future Wilding overland use equipment of devices which BOILER-COMP(THP OR Harlot BTU)
Lhave
uus air com arinants as defined by the Bay Area Air Quality Management TOTAL:
BOILER-COMP(OVER I(XLIXXIuru)
e., ONO
AIR CONDITIONER ISSUANC17 DAT'Ii
ve rtad the avath&Safety Coda.Seetlons 25505.25533 and 25534.1 understand Lha if the NEW RESIDENTIAL MECB. SQ.Fr.
s not currently have a tnmL ma it is my responsibility ho notify the vocationalmmwets which must be met prior to issuance of a Certificate Of OccupancyumodzcJ agcm
Dec TOIAI.: ISSUIiD BY.
OFFICE