S 1401 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINQ BUILDING-EI,EC'I RICAL 1'17RMI'I'No.
BUILDING DIVISION APPLICATION/PERMIT 1'hI1MIIING�MHCIIANICAI' S 1401
IlUILDING PBOJEC I'IDENTIFICATION V
ILDING ADURP_SS SANITARY NO. AI'I'hICAI'ION SIJItMI'I'I'A I,D61'li
ash tors e 2
NAM PHONE: CON'I'kAC'I OR'S NAME: LIC N(1:
O NIU CONT 1L®
jll� 'AR'HIFECT/ENGINEER: LIC NO ADDRESS: ❑
CONTACT: - PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Iniljal) HLUG LIr�C' PLUMB MIL:H
ED /� E:1 C1LICENSED CON'TRACTOR'S LHICLARAI]ON QTY. ELECTRIC PERMIT PSB 1
1 hereby ancon that I am rinsed miner pen o,ions of Cruise,9 femrttnencing JOB DFSCRI PTION
0
with Section 9(Nq)uf Dmvtsmn let be Busincvsnnd Pm2aimts Codeand my license is RESIDENTIAL:
W 0 '
FW full forceanJ ulfit. 1117RMII ISSUANCE
❑S19)WI, ❑KI'fCl{IiN REMODEL
aUU Gcensc Class Lie# APPLIANCES-REMDEN'I'I Al, ❑ADDITION ❑I'L(1MIHNG Rl:-PIPE
F Z W Date Cmm.cea
wQy ❑MUI:H-UNff OSTRUCI'URAI. -
ARCHITECTS' DECLARATION
E„Dm PANELS _ CHIM7CA'IION
'ZOy� Iundensh
understand my plans shall be e'ucas puhlic records UI"1021X1 rAML'S
O Z.-.O ❑IN'1'IikION ❑CIIIMNIiY REPAIR
�4LW Licenced Professional 291-IIXNIAMPS IMPROVIiMIiNI' SWIMMING POOLS
OWNER-BUILDER DECLARATIONOVER IIXNJAMPR O BATH REM '. 2�1' 1)- 1C I
C C Q 1 hereby affirm that 1.,it exempt from Inc Comcroon's Lmensc Law for the
dO d U following reason.(Section 9031.5,Business and professions Cuolc:Any city or csmmY SIGNS ELECTRICAL. ❑(YI'HEk
W 3 W� which requires a From,to ma1
to ,altar.improm
ve,deolish.or repaistructurer any structure
prior to its.. I:o requires the apple,an,f In maint fl g Jal moot SPECIAL CIRCUI UMISC.
In.,he is 1 Ip a the p at he Comourcon,License 1' (Chapter 9
W (enmmemngwth Serfion 7000),flu—ion 3oftne Rmomss andP f. lam Ced.)or TEMP M ITER OR DOLE I NS L COMMERCIAL:
Q.d e that he is exempt therefrom and the basis for the alleged tscmpuao.Any vonation of "PERMIT
❑NEW BhOG/AUUI'I'ION ❑OIiA101,ITION
Semon"031.5 by any applicantfora,enot,objects theapplicanuaanvil pcwltyof DEVICES [-1 TENANT ❑FOODSERVICE
m more in,.live hundred dollar,(5500LIMPROVEMENT
Sp ❑ I,as owner(if the prapeny,nr my employees with wages as theirselecompensation. [,ELECTRIC
�F'm wiildmhewnrk and thesmaure is not lnlenJe iofiered far wle lSec9fW4,BusinessOQTHIiR
W 3— and Profession.Code:The Contractors Licence,Law does not apply to an owner ofTCHES-FIXTURES
property who builds or improves thereon,and who does such work hicOe f or though
his own employee',provided that such improvmnenis are nut intended or olrere forIAL ELEC'R Sp 11'.
sale.IL lmwncr,the building or improvement is sold within one year of completion,the SQA-[ FLOORAREA $ISQ.IT.
unner-builder will have the burden of proving that he did not build oe improve for per
Fuse of salt). v
I,us oxm r of the propcny,am radusivdy uimracting with IiccnacJ contmcton nm ']I' 1,: P A IDcense Law dons not apply m an owner of property who Wild%or improves thereon,and PLUMBING PPERMIT FEF,
who enmmets for such fencers with a commetor(.p license .,.art to the Co muctoes ,
License Low. PERMIT ISSUANCE 4 a
lamexe mpronde See. .B&PC for this reason MAR ti2l
AIXER-DRAIN&VENT-WAI I7R tl!AI VALWCI ION
Dam
WORKI:R'SCOMPBN5Y1110t DLCLAHATIIN PACK PLOWI'ROfECr.UEVICIi VIII VY NVYCtIIINO
. 1 hereby affirm under penalty of perjury one of the following declarations:
❑I have and wil l maintain a Certificate of Consent mself-insure for Workers Compo- DRAINS-FLOOR.ROOR AS F.A.COND. S-IORBIS 'I Yl 17,CONSTRUCTION
nation,as provided for by Section 37W of the Labor Code.for the Is rfoomance of the
week fee which this permit is issued FIXTURES-NCR TRAP
❑1 have and will maintain Workers Compensation Insurance,as sequined by Section
3700ofthe Labor QNe.for the performance of the work for which this .it is i...Id. GAS-EA.SYSTEM-I INC.4 OUTLETS
OCC.GHOUL' nl'N
My Worker's Carl mosiun Insurance carrier and Policy numtcrare:
Carrier. Policy No.: GAS-Fk.SYS"I'EM-OVER 4(HA)
CERTIFICATE OF EXEMITION MOM WORKERS' GREASEBNUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FENS
(This section need net M complenrl Ban,Permit is forme hundred dollars(S Ign GREASE TRAP
,r Iesxl I'LANCIIECK ITE.
I certify this in the perfrrmanccof the work for which this permit is issued.I shall SEWER-SAN]LARY-ST ORM F.A.200 FE
crado,any person in any manner so av to becomccdjcO m the Wodcn Compcn- ENERGY 142E
ZZ nation Laws of California.Dote WATER HEATER W/VINT/ELECTR GRADING FEE
Applicant )
NOTICE TO APPLICANT:If,after making this Cerificane of Esmnptlon,you sWmId WATER SYSTENITREA'1'ING
SOILS PEE
a > funhwi subject y the Workers Comps or thin pmvit sha of the Labor Code you maw
forthwith comply with such provisions or this Permit shall rte deemed revoked. WATER SERVICE
Q *PAIZCONS'1'RUCf10N LENDING AGENCY NF:W RLSIDEN'IIAf.PIMP. SQ.PC Eta' #
U O lhereb"fifimt thatthem is a comwction lending agency for the performance ofki. F^ the work tar which this permit is issued(Sec.309].Civ.C.)Lender's Name T(YIAL:
ULenders Address 1(TfAL1 certify ohm I have neadthis application and sure that the above information is
F' to correctA agree to comply with all city and county ordinances and state laws relating to Ql'Y. MECHANICAL PERM IT FELE VMECTIANICALIT-
SGURCE
(.J Z building construction,and hereby aathorin:representatives of city to enter upon the
above mentioned properly for irO,v inn purposes. PERMIT ISSUANCE li
(We)agree to save,indemnify and keep harmless the City of Cupertino against
I Minkel.judgments,costs sad expenses which may in any way inicue against said City ALTER OR ADD TO MSCI 1. :
consequencein of the granting of this permit.
APLICAN'UNDERSTANDS AND WILLC PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFs11 ILSOURCE HI }ULATIO
AIR HANDLING UNIT(OVER IU,IXpCPM) ONT %Si trno Applicant/Contmnor Dam EXfIAUST HODU(W/DUCO IGR ION PELT
HAZARDOUS MATERIALS DISCLOSURE
Willthenpplicam nr farm building icupant store or handle W Osnus material HEATING UNIT(TO 100.000 BTU)
as defines)by the Caperton,Municipal CWe.Chapter 9,12,and the Health and Safety
Code,Section 25532nd! HEATING UNIT(OV T:R 100.000 BTU)
Cl Ye, 0 N VENTILATION PAN(SINGLE RGSID) PAID
Dam Kc«opt p
Will the applicant or future Wilding acceptant use equipment or devices which POLI EH_COMP(3HP OR 100.000 BTU)
emit hazardous air inuminants as defined by the Nay Area Air Quality Management 'IDIAL:
District' BOILER-COMP(OVER IWhat BTU)
❑Yes ❑No
I have mend the hazardous materials pmrU95 of the Cali- AIR CONDITIONER ISSUANCE DA'1'IE
"comments 25533 uta realer Ch.
,c,
Health Code.Stations .noti 25533and255U.I to notsandthatif the NEW RESIDENTIAL MECII. $Q.IT.
buildingdivnot currently have atenant,not it ismyce of a ertifamminify the occupant
of Ire requirement-which mint be met poor m issuance of a Certificate of Ocaipaticy
Owner or authorized agent Dam TOTAL: ISSUED RY:
OFFICE