S 0289 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL)ING-ELECTRICAL PI:NMrr NO.
BUILDING DIVISION APPLICATIONPERMIT PLUh{nwG-MECHANICAL S 0289
BUILDING PROJECT IDEN'iTPICATION
BUILDING ADDRESS:2 ���I SANI'I'ANY NO, API'LIC61'ION SUBMI'TIAL UAI1
Ir V• aCC I-Cfly_
O NE N E: I'HONB:f TRACTE?'OR NAMLIC NO:
NIC CON'IJRO^L Ip
RCI{ITECUHN INEER: LIC NO: AU RIi55: ❑ 1
CONTACTPHONE !.J 0.bA CGf 75-//7 BUILDING PHRN INFO
Z� I —!Sq as-0 ❑ Consultant Fees Paid by Applicant(Initial) D' EL I'LlIMl1 MECH
LICENSED CONTR CfOR'5 DECLARA'T'ION QTY ELECTRIC PERMIT FEE
I hereby affimr that 1 am license under provisions of chapter 9(commencing JOB DESCRIPTION
pZ with full andtine([tmsinn 3 afore Rusinessand l'mfessinnx Crete.unJ myli¢n.m is RESIDENTIAL:
O PERMIT ISSUANCE;
CSF ❑SI'UWh ❑KI'ICHIN REMODELaVV License Clan Lieu APPLIANCES-RESIDENTIAL ❑ADDIIION ❑PLUMBING RIiI IPE
t Zn,,�ci Dore Contractor ❑MUCfI-0Nll' ON'1"RHCI'DRA1
ARCHITECTS DECLARATION PANELS ,
F V)Z I understand my plans shall be used as public record, MOUIIICAI'lON
OZ UPTO 2COAMPS ❑IN'I ER10R El CHIMNEY REPAIR
O
e"Q-i��W Licensed Pmfe,sienal 201-10XIAMPS IMI'11 RFM(IDFI 'W IMMINI I'UOLS
E: =J OWNER-BUILDER DECLARATION OVER 100 AMPS ❑BATH kGMODIi1JHI;PAl1 )IiM01.1'TIUN
C Q 1 hereby affect moll 1. exempt from me Cmnmemrs Licence Law for me
1 O�U ❑OTIIIiN
iC3d followingrcasoa(Section J er,li Businessandove.dr irons Gds:Any sty orcounty SIGNS ELECI'RICAh
ul 0 h
which rite issuance,
n permit m c mus the,aper,i for
demolish,or repair any stammers
O�' prion its ,ahafeq 'mapplicantf omepinflsignedoocnsmt SI'ECIALCIRNITIMISC.
bar he licensedpumv u m p nn fm C t tor' License LwfCM1upmrY COMMERCIAL
W�G� Irum g lh Sect 7(X1(11 fD' i,i, l fth H .-' exs dlh f:stns Gde)nr RMP.MIfI'EH OR POLH INST.
C,R o mut he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW HhUGIADDI'rIUN ❑DEMO].]]
Xm� Section 70315 by any applicant for a permit subjects the applicant n)a civil penalty of POW17R DEVICES ❑'1'17NANT ❑PODUSERVUE
rn marc man five hundred dn11an 1 SAX)). IMPROVEMI?N'E' A
VSDn 1,asowderofthe property,lir my employees with wages as their self,cmnpeaation. SWIMMING 11001.ELECT RIC A
CFo
will do the work,and thestmchare is not intended or offered for sele(See WPU Baines, OTI{IiR
aim and Dafemin b Code:The Custhere',License Law does ern apply himself or
OUTLGTS-SWITCHIiS-FIXTURIiS
progeny who builds or improves thereon,and who nta•..such work ded, nr est lot
his awn employees,provided Ibot such improvements are not intended ver offered for NEW RES IDIiNTIAI.ELECTR SQ tT. �1
OOk AH BltiQ PCsale.If,however,the building or improvement id within one year of completion,the Ln
er-builder will have the burden of proving that he did not build or improve for par- Lt
goseof mkJ. TOTAL: �n/'l
1..,owner of the property,am exclusively contracting with licensed common,or U
construct the project(Sec.7144.Business and Processions Cedoo)Tor Cnmruemr's Li-
se law does not apply it)an owner of progeny who builds or improves memon.and QTY. PLUMBIN )P IT 1$E
who contracts for such precious with a cnmrcands)Iiceri pursuant m me Commemr'x
License Law. PERMIT ISSUANCE
I do exempt under Sc. ,B&PC for thisRsnn
AUI'ER-DRAIN&VENT-WATLRP ) VAIMAI11IN
Owner Date 1 e o
• WORKER'S COMPENSATION DECLARATION RACK ROW PROTECT.DEVICE;
I haffirm under Penile of perjury one of the following declamtinm:
and w
�Inave and will maintain aCertificate nf Cnnsem w.alf-insure for Workers Cooper- DRAINS-IlOOH.ROOF,AREA.COED. SORII;g TYI'Ii CONS'IT(l1CI]ON
sound.as provided far by Section 37M of the Labor Code,for the pdourmance nine
weak for which this permit;,issued. PIX'fUHES-PIiR TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 ofahe Labor Code.for the performance ofthe work for whichthls Permit GAS-IiA.SVSTIiM-I INC i OUTLETS,issued. OCC ROUP MIN
My Workers Compensation Insurance carrier and Policy maderare: GAS-EA.SYSTIi ILOVER 4(EA)
Came, Policy No:
CERTIFICATE".OF EXEMPTION FROM WORKERS' GREASEJINDUSTRL WASTE INTENCF.ITOR
COMPENSATION INSURANCE t I ')DIVISION FRITS
(7 ewedoem,daut W completed lithe permit is boron,hundred dollars(SNO) GREASETRAP
I'LANCH' K ii
orle")I
(certify that in the any manner
work for wbichthis pe.art;,er,'Cwlandl SEWER_SANITARY-STORM EA.200 PT. ENIiHG
not employ any pc„nn in any manner m as m Forams mbjem m Inc Worker;Gsmpcn-
z scion Law,of California.Date WATER HEATER WIVE M'IELFCTR GRAD ,1,
ZO Applicant
N
NOTICE TO APPLICANT:If,afar,making this Cenipca¢of Exemption,you should WATER SYSTEM/BEATING WPAID
become subject m the Workers Compensation provision,of the Under Code,you must
forthwith comply with such provisions or this peramiddl M deaned revoked. WAT12R SERVICE
1 0 zCONSTRUCTION LENDING AGENCY NF,WRESIDENTIALPLMB. SQ.PT,L.7 0 1heaebyrifi,mthat them isocon.bumion lending agency for rte performance of
the work for whichan,permit is i„ued(Sec.7(197.Cv.C.)Leader's Name TOTAL:
C) W Lcndcr,Addres,I certify that 1 have read this applicmmn and same thatrte above Warmation is
crumN,l agree to comply with all city and county ordinances and state laws relatin&u, QTY. MECHANICAL PERMIT FEE
V z building construction.and hereby authon¢repre,enmtivcs of this city menmr upon the
above-meminned property for inspection purposes. PF.RMI'f ISSUANCE ELECTRIC FEE
(We)agree m save,indemnify and keep hamdess the City of Cupertino against
Iiabildiesjudgmenu.costs and expenses which may in any way accme against said City ALTER OR ADD TO M ECH. PLUMBING FEE
in consequence of the granting of this Permit.
APPLICA " "NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CO[0.0041CFM) MECHANICAL FEE
5 REC AA Ns
Q AIR HANDLING UNIT(OVEH 10,1110 CFM) CONSTRUCf10N"TA%
Si lire pplicanUConuacmr care EXHAUST HOOD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DILOSURE
Will the applicant or future Wilding occupant sore or handle haeardous material HEATING UNIT(TO 100.0(10 BTU)
a defined by the CePerhno Municipal Cade.Chapter 9.12,and the Health and SafetyNW2
IT(OVER 100,001 BTU)
Cock,Scctinn'_5532hd?
❑Yes ❑No FAN(SINGLE RESIDE LAID
Date Receive p
Will the applicant or future building excuumn use equipment or devices which MP CHP OR 100.00(1 BTU)
snit hazallou.s air contaminants a'defined by the Bay Area Air Quality Management 'I OPAL:
District? MP(OVER 10,(X0 BTU)
❑Yc, 0 N
I have readthe hmadeus mamrials - t undo Chaer,6.95 of me Cali- IONER ISSUANCE DALE
requart
hom
WildigaltmSauce Code.
haveatinns2thati is 533 myrepr8S3i.l understand) hat lfd¢ NTIALMECH, SQ.IT.
ofthedgpainsnmemren0y have a meant,halo ismyei'If Curefitunotify the acuWm
of the requirtments which mast be met poor m issuance of a Cenificam of IRcupanry.
Owner or authorized agent
DamTOTAL: ISSUED BY:
OFFICE