S 0364 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF,CI'RICA L 11191IT NO, O
364
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL .�
BUILDING PROJECT IDENTIFICATION
SANI'T'ARY NO. APPLICATION SUBMITTAL PA'Th
BUILDING ADDRESS:
acx��-I LAD(flnL'oL lid ua re� ?V
ry4ryyN 5 NAME ` ., I'H 9' CONTRACTOR'S NA�M6uM _LIC NO:
ngQ /may .�.y� Tlcna /� + NIC CONTROL,
AR.CRITTLUTENNEGkI.NNEER. •v LIC NO: ID� O/ rJl-IrI1� e?45f/� ❑
t BUILDING PERMIT INTO
CONTACT: PHONE:
❑ Consultant Fees Paid by Applicant(Initial) BI.DG ELECT' PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
T hereby affirm that 1 am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
Z wonsean,n7(NNn of Divishnt 39nnc BudneN.and rnafe...i9n>csde.and my neense iN RESIDENTIAL
W O PERMIT ISSUANCH
F,�O� in lull lima a5n�d-cI-T��I.�r-G -I.iaa 5Scl14(,22 ❑SFDWI, ❑KI'1'Cl WN REMODEL
�UU Licens`)J_s dl-`9n APPLIANCES ❑ADDITION ❑PLUMIIING RE-I'll'li
Q a Data CC Cnmmc-.
ARCHITECT'S DECLARATION PANIBS ❑MULTI-UNIT EJ STRUCTURAL
F H Z I understand my plana shall be used a.public moose. h10DIPICATION
ZOy— UP TO 21X0 AMPS ❑1NTERIOk C1 CHIMNEY RI7PAIR
OZ-�
LiccmWl'nsf xiunul 201WHNXIAMPS IMPROVEMENT ElSWIMMII OPOOLS
KY�aa , OWNER-,xo.,tifo. he Contractors
-4 OVER 1(NN)AMPS ❑RATII RIiMOI3E1lRli1'AIR DF.MOhI'1]ON
tY Q 1 ...I amend tnm I am esempl from the Contra,Co License taw for the
�s�(0 a U following mason.(Section 7031.5,Business and Pmfeasinns Cede:Any city or county SIGNS ELECTRICAL
❑OTHIiR
1i131LO y which requires a permit m construct,altar,improve,demolish,or repair any xtractu,e
priann its is,arr.,mw,mgmm,,hc applicant for such pemdt m rile a signed statement SPECIAL CIRCUIT/MISC.
�,y.•..11 that he is licensed pursuant the provisions of the Car...or,Liccroc Luw(Chapter 9 COMMERCIAL;
e[Q� (commencing with Section 70010)of Division 3 ofthe Business and Professions Code)or TEMP,METER ON IY)LIi IN$T,
a a e K the he is esempt therefrom and the Iasis for th<alleged exemptionAny violationof [],NEW BLUE/AUDITION L1 DF:M01,1'1'ION
-,m
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
I more than five hundred doll...1$500). IMPROVEMENT
C, O [:] I,osnwnemdlhc pn4nny,nr my empinyocx with wugesac ThursuleaamPemmion, SWIMMINGPOOLELUCfRIC
2p. ❑OI'Hlik
will do the work.and thestrm
icreis not mended or offered tit sale(Sce.70,4,B,,roos
Tal.
a m and Emfessions Code 'Die Conuactora License Law does not apply in an owner of OUTLETS-SWITCHES-FIXTURES
propeny,who builds or impmves thereon and who Joos such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECI'R SQ FT.
sale.IL however,the buildingarimpmvenf
nnt is sold within one ycurucomploom,the _ SQI'T.FLOOR ARRA $ISQ.FT.
.
owncrbuldcr will have the human ulproving that he did not build or improve for par. PA p
posse if"Ic.). TOTAL: 1_ A I D
n 1,as owner of the proPany,am exdusively cammeting with Iiceowil contractors In
construct the project(Sec.]ULT,Business and Professions Code:)The Contractors Li- ^
c se Law dons not np,l,,. a ownefof pmpeny wno builds or impmves thereon,and QTY. UMBING PER IT FEE ,Cap An
who common forsucn Projects with acnmmo7oas)licenced pmmonnome Courteaor. �/ Yvr ^9 Li(`A�
License low. PERMI'TISSUA q�I
I
O 1 am exempt under Sec. .B&1'C for this reason
AhTIiR-DRAIN&VEX ATER .A) L`M/�y11Y0S1.UAT10N
Owner Dmc
. M1WORKERSCOMPENSATION ECON
BACK FLOW PNOTCT. 'V I
I herebyn nada penalty of Perjury one or theiollo declarations:
❑Iava and will maintain aCenifeme ofConent lnmlf-nsure for Worker's ompcn-
BRAINS-FLOOR.ROOKANBA,GOND. STORIES TVI'13 CONSTRUCTION
cation,m'provided for by Section 3700of the Luber Code,for the performance of the
work far which this pemtit is I...oil FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,ax merited by Scctinn
3700ofdm Lahar Code,for the performance of The work liar wphidimis permit is issued GAS-ITA.SYSTEM-I INC.4 OUTOCCGROUP APN
CyrierGACompeQ.saCnnurLc' rricPolcyNo.: la�f`atre74Q�II GAS-IiA.SYSTEM-OVER4(BAT
C ISCERRTTIFICATE OF CX12MVf10N FROM WORKERS' GRF,ASF%INDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed ifthepermit is fornne hundred dollars(SI00) GREASE TRAP
PLANCHECK FEF.
or
less)
Loy any that int he any
m)a%tohe
whichtoxho W isi.aucd.INhall SEWIiR-SANITARY-S'IORM IiA.201IFT. ENERGY Igili
hat employ any penin in any manner su na to hecome whjecuo the Wnden'Compen-
Z moon laws of Califoram.Date WATER HEATER W/VEN/ELECTN GRADING Fl
0 0 Applicant s
� � NOTICE TO APPLICANTif.aftenmakingIM16 Ccnifaatc of Excarniun.you should WA'T 17R SYSTE vVTRHATING SOILS 1:1717Ft Leanne mbrcrrt m the Wnrkce,,Compensation pnIvisions IT tba Lubar Code,you mmxt
�+ > fndhwilh comply with .on Provisions or this permit shall M dccmeloo,sfol, WATER S17RVICE
D
W
t1
CONSTRUCTION LENDING AGENCY UQTYMECHANICAL
MB. SQ.FL PAID
7 Z Dam Ncccipt a
1 hereby affirm that there is a construction lending agency for the performance of
{UIo the work forwhich this permit i,.,,.cd(Sec.3097.Ci¢C.) TOTAL:
0 Lomlcr's Name 'DOTAL.
C) G Lender's Address BUILDING PEE
Q. 1 total,Thai I have read this application and e,am that the-Those m ormainn is
FN correct.l agree to comply%an all city and county ordinances and slate laws relaing'a ICAL PERMIT FEE SEISMICITE
U Z building ennatrection.and hereby autmove representatives of this city uI enter upon thenaive ncntarod Lanny lir mslcedon purposes. 1?hEC'1'kIC I ?I?(We)agree to%ave.indemnityand keep harmless the City of Cupcnino against
ladilities.jdgmmmc.as and cape..which may in any wayacemeiquinatsaidCityECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI"1'(TO 10.(00 CFM) MECHANICAL FEE
SO ZBREGULATIONS
AIN HANDLING UNIT fOVI?k 10.000 CFM) CONS'TEDICT'ION TAX
Sig of ApplicavJCnmr set Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FIT
I{ ZAP, OUS MATERIALS DISCLOSURE
Willtheapplicant or stare buildingmcupern smmor handle hawrdnux material I HEA'T'ING UNIT(1010.000 BTU)
is deflued by the Cupmin t Municipal Code,Chapter 9.12,and the Health and Safety BLEATING UNIT(OVER IaFddB 11',G)
Code.Section 25532(.)'1 �[
[]Yes Ill N. VENILIAT10N FAN(SINGLE RLSID) PAID
AN.
Dae ua�eipt a
t Will the applicant or future building occupant use equipment or devices which BDll.lik-COMP OLE'pR IlX1,I1fXl BTU)
Want Imorom us air contaminants as deincd by the Bay Arca Air Quality Management TOTAL:
'DwralI BO ILER-COMP(OVER 100,0X011'1'(3)
' ❑Yes VII No _
�C AIR CONDITIONER ISSUANCE DATE
1 have read the ha inkax materials requiren on%umler Chapmr 6.95 of the Cali-
ronin Ilsabh&Safety CWe.Sections 25505,25533 and 25534.1 undcrswnd that unit, NI?W RESIDENTIAL.SUCH. SQ.14.
building does nut cun,olly have a Roma.that a my responsibility m nntify the occupmn
of the r.quiremcnts which mus be mat prior m Issuance of a Ccnificate of 0ecup.ncy.
Owner or mitamsed e,cut
Doc TOTAL: ISSUED BY,
OFFICE