S 1225 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUl[,HNG-ELECTRICAL Pe IT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 1225
BUILDING PROJECT IDENTIFICATION
LDING ADDR[.SS: 11- SANITARY IS APPLICATION SUBMITTAL DATE
0055 MtIIE� 14-1 St,►14.- 101 /� Off] 2�6
O NA
Sap_AjC1 PHONE: NnAC�TOo'S NAME: LIC V�ID���
11LL7•�A1�^r NAC CONTROL
:HITECTIENGINEER: LIC NO: A DRESS: ❑
I - t L . (S,p(+Gp'► -4704 JCba+Sors�
CONTACT:/► ,u PHONE:l�S q BUILDING PERMIT INFO
Z_%4�Ln(.'1 ❑ Consultant Fees Paid by Applicant(Initial) ILUG ELECT PLUMB M17CH
-..IGJI45. � I-t IT
LICENSED CONTRACTOR'S DECLARATION QTY L'LECTRICPERMIT FEE
I hereby dura that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
oaZ with Seenon 7DXB or Division 3°flhe Business and Professions Cale.and my license is RESIDENTIAL:
ADO in PERMIT ISSUANCE
f-�F License
Class
effect. ❑SPDWI, ❑KITCHIiN RIeMODEI.
�V(, Liccnsc Class Lich APPLIANCES-BESIDES!I'[Al. CADDITION ❑PLUMBING R -PIPI',
aDare Committee
F,o rn ❑MU:fl-UNIT ❑STRUCTURAL DECLARATION PANUS MODIFICATION
N Z I understand my plans shall iv used az ec
public rords
pF-4t:a UP'T02W AMPS ❑INTERION El CHIMNEY REPAIR
�FW Liveried!Professional 201-IOIIOAMPS IMPROVEMENT ❑SWIMMING POOLS
CY -4 OWNER-BUILDER DECLARATION OVER IOW AMPS [I HATH REMODEUIiCPA1R ❑DEMOLITION
C W Q 1 hereby caf nn that I am esempt from the Conwcmr's License law for the
X�0y5(,O6 U following reason.(Senna.7031.5.Business and Proleasiom Cask:Any city or county SIGNS F:LF.CfRICAL 0OTIIER
YJ 3 LL ya which requires a permit to construct,alter,improve,demolish,or repair any structure
prior it)its issuance,also requires the afflicted for such pemtirso file a signed statement SPECIAL CIRCUITIMISC.
ythat he is licensed pursuant o the provisions of the Comr ler.License Law(Chapmr9
GC (commencing with Seainn7W0)of Division 3nfthe Business and l4olassinnsCare)or TEMP.Mfffl?R OR POLF.INST COMMERCIAL,HmS(c C that he is exempt therefrom and the basis for the alleged exnnplinn.Any viclation of ❑NEW BLDG/ADDITION ❑DEMOLITION
WI flection 7131.5 by any applicant for a permit subjects the applies,ut a civil penalty of POWER DEVICBS -
�' not nunadum live hundred did .. TENAN9' ❑FOODSERVICE.
p❑❑.,yy�5�. IMPROVIiMENT
O ❑Las ownernlthe maddlopengarmYemntended m.fivolradRur their sake compensation, SWIM MIN, iLliC9'RIC
3Fwill do the work,unJ tlm struemreis nm iniendedomlTercJ forstle 15m.71H4,liunina" ❑O'I'HCR
m and 11..Nation,Cale:The Contractors Lincoln Law docs not apply m ua°caner of OUTLETS WI " FIX'1'Unis
property who build,oT improves thereon,and who dons such work himself or through
his own employees,provided that such improvements can nm intended or ofTcred for NEW RESIDENTIAL.L.I. SQ FT.
wide.ILhnwse,the buddirElmiam
provcent hsold wiminm
oneyenfenmplomen,the SQ.FT.FLUOR AREA $/SQ.FT.
owner builder will have the burden of proving that he did not build or improve for pur- A
po� ml") `Jo
as owner of the property,am exclusively contracting with licensed contractors to A
cit
ea the pmjesn(Sec.7f .Businessland Professions Careq The Contmdurs Li- A p
c suLaw diva not apply to an owner ofpsol who builds m improves thereon,and QTY PLUMBIN T FEE M / 0
who contracts for such projects with acontraetor(s)licensed pursuant In the Commuter FF
License law. PERMIT ISSUANCIi � 7
❑ I am exempt under Sm. .B&1'C far Nix reason " d
- ALTER-DRAIN&VENT-WATER(EAI ,,II VALU
Clear, Dina
WORKER'S COMPENSATION DECI.ARxrRN BACK FLOW PROIIiUT DEVICE
Iinanity affirm under penalty of parjury one of the following declamfianx:
❑ Ihav and will maintain a Certificate of Cortuu to self-Insure fur Workers Compe.- DRAINS-FLOOR,ROOFAREA,COND. YPB CONSTRUCTION
.ration prnvical for by Section 3700 of the Luau Code,ler the pema
rfornce of the
STORIES
work file which this permit is issued. ' FIXTURES-PER TRAP
I �y,�/h-uvc and will muinmin Worker,Compensation Ireumnee,e,required by Section
971XI,rthe Uttar Gxle, rthe perfartnance of Ne work far�wyh�i�cyh rtyhis tenant in issued. GAS-RNSYSTIiM.I INC.40UfLETS OCC,GROUP APN
My Work cmrie PodYNnynIVP IpAi GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/LNDUS'I'RL WAS'1'H INTERCEPTOR 'D SIO_N FEES section need not be completed if the permit is for one hundred dollars(S 100) GREASE TRAP
ar less.) PLAN C FEE X I Qt-)I
Icmify that in the performa,veof the workf°rwhich this permit is issued,lshall SEWER-SANITARY-Si'ORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workeri Cooper- GN G iii
Z station Laws of California.Date WATER HEATER WNENI'/ELF.0 R Applicant GRADING P.
C)
r~Ni NOTCHTO APPLICANT:If,after making this Cer ilicate of Exemption,rite should WATER SYSTEM/TRIiAHNG 5011.$I'E
(~ beam.,subject to the Workers Compensation provisions of the IaMr Cala you must
Wllsk
funhwith comply withauch provisions or this permit Shull IM deemed revoked. WATER SERVICE
Q
CONSTRUCT ION LENDING AGENCY NEW RESIDEN'T'IAL PLMII. SQ.IT.. PAID _
I luersbyuflinn tb°ulmre is eronametion lendowtispncy for dmperfnrmunce of _ Dt° °iptN "`t
fO~-t the work for which listener,is issued(Sec.3097,Civ:C.)
pLender's Name I z ICTAL:
Leader.Addre,,
Q. I cradled...I have read this application and.ante that the drove iefurn lim is BUILDING FF. r
rn cared.l agree tommply with all city and county°thinness and state lows winning to QTY. •MECHANICAL PERMIT FEE
V Z building construction.and hereby memorim representatives of this city m enter upon the SEISM IC FEF
grove-mentioned proper for inspection purines. PERMIT ISS UANCH
(We)agree m save,indemnify and keep harmless the City of Cupertino against EL.IICTRIC
Iiabilme,judgments,costsis it uses whiahmaYin any way accmc against said City ,TER OR ADD TO ME CH. evA
in consequence ofthe grand this Permit PLUMBI PEE
APPLICANT LENDERS S AND WILL COMPLY WE III ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CIM)
SOURC� �GULATI MECH NICAL PEE
'^ .f AIR HANDLING ON['1'(OVER IQIXp0id) CO IRUCTION'TAX
1
Nagm`,`�
roofmimamr EXHAUST HOOD(W/DUCqto AZARUOUS MATERIALS DISChOSflRii HOLES GMI'I'IGATION FEE
WII e' )I icam or future building oeeupatn store or handle huesnloucaderial MEATI NO ON I'FEE 0 l ml.m)d ll1'U)
Acfe a Cupenlno Municipal Code,Chapter 9,12,anti the Hedhh and Safety
tun 25592(tHP ORATING UNIT(OVER 101)Fax)11'I'U)
71 Yea; ❑No ' VENTILATION FAN(SINGLE RIiSID) AAHI
R t
Will the applimna or future building oeeupml.,a equipment or devices which
mail froodods d,,rorai.ands as defined bythe Bay Arca Air Quality Management BOILER-COMP 13HPOR I(X)fX3RTU) TO AL
Duarie4 BOILER-COMP(OVER 100,000 BTU)
❑Yes Fl No
I have rand the haraNtms materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER SUANCE DATE
forma lis It&Safety Care,Sections 25505,2.5533 arta 25534.I undersand that if Ole NEW RFSIDENTIAI.MECH. SQ.FT.
buildingdwx notmne.0ybare atenant.Nati,ismymsplmsibilitymnse the normae
4 of the requirements which must M met prior m romnee of o Cenifcam of Occupancy.
1
Owner or authonned agent Date AL :
OFFICE