S 0138 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING.-ELECTRICAL P17RMI'I NO. /�
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-.'s1I!CIIANICAI. C 0138
BUILDING Lotom.Cr IDENTIFICATION J V
;SANIIARY NO. APPLICATION SUBMITTAL UAL BUILDING ADDRESS:
] D10/ D � Cri(ZKT _-0/j--
3
oWNER'SN M I'IIONE: CONTRAC'IDH'5 NAME.: LIC NO. CONIROLA
IfeJbdARCHITECT/ENGINF,ER: LIC No ADDY SS: w
O S T f
CONTACT: PHONE: - BUILDING PERMIT INFO
V4,11 q �8� ad—�� 3 ❑ Consultant Fees Paid by Applicant(initial) BLDG FLECr PLUMB MIiCH
❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I am licensed u d ponvixtiare of Ch pl 9(Ourno.eir,
Jaz with Section 7000)idfD,o4,am Y i the Imorro,andPrfs,ion,Code.and my license, R IIAL;
1-oc= Clot] I Rett /� I'I'RM111)ISSUANCE ,FDWI, ❑KI'ICI IHN REMODE:h
U use CI :�pi. 1'c.ir g�elloabT/
It-a Da¢ Contract,
mt tAI'IIIANCBS RESIUEN'I'IAI. ❑AUDITION ❑I'hUMBING Rh PIPE:
RCHITECTS DECLARATION PANI15 ❑MULTI-UNIT ❑STRUCI'UR•ll.
F-n Z I understand my pl...hall he used as public rtcnrds CHIMMODINEY
CN ION
OZ-0 UP T02W Ab1P5 [I INTERIOR ❑CH1h1NEY RIiI'AIR
W Licensed Professional 201-1000AMPS IMPROVEMENT ElSWIMMING Pi
Q6,s1f; OWNER-BUILDER DECLARATION OVER 11X0 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C C Q 1 hereby affirm that I am exempt from the Contractor's License Law for the ❑OTHER
'Wo
k! following mason,(Section 7031.5.Business and Professions Cede'.Any city or county SIGNS ELECIUCAL �("'
'3 W y which b,aim,a rcaui, ,,eumuun.neer,improve,denudi%h,- repair any mmcmrc r
B-.u+�Q prtn I I. I hetl such D a IIsignedLot Hent SPECIAL CIRCUIT MISC.
} Bare sedPursuant l the p Ito C I I .1 I (Chapter9 - COMMERCIAL
00 Ittm caning withSccl alto 7gXBalOvlx.1 a 3oflhe Bui nus and to nn'Cde)ur ]NM P METER OR POLE INS']'.
66.0
That he is exempt thcrcfom and the basis far Bore alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑UEh10L1'HON
Xm $cction7W LS by any applicom fnrapermit svbj«t the npplicannoacivil p.nahy of I"WER DEVICES []TENANT ❑FOOD SERVICE
I more than five hundred dollars(SSn). IMPROVEMENT
Sp ❑I,mowner of the pmpeny.car my employees with wages as their sole compcnvlinn. SWIMMINGPODLELECTRIC ❑OTHP.R
t- will du the wmk.and lhest etum is not inlcndW or offered for-1,(Scc.7044,Business
i3 m and Pmfesxions Coale:The Contractors License Lou does not apply to an owner of OUTLETS-SWITCHES-I:XTURES
prop[ny who build,or improve,thereon,and who docs such work bmsclf or though NEW RF_SID-NTIAL ELECI'R SQ FT.
his own employees,provided tool such improvements are not intended cr offcod for SQ.Pr.FLOOR AREA Ii/SQ 17C
sal..IL however,the huilding or impovemenl is sold within one year it cora pletion.the
owncr-hudlder will have the burden of proving that be did not build or improve torpor-
Pro,
orpar-Hro,of sale.). TOTAL:
1,as owner of the property,am exclusively contracting with licensed contraclurs to
construct the project(Sec.71,14,Businc%s and Profession,ue,i one Contractors Li-
censeLaw does not apply to an owner of popery who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracis for such projects with a contractions)licensed pursoanl In the Co moremr's
Liccnw Lies, -., PERMIT ISSUANCE:
I oin exempt uner Sox. .B&E'C fonb'rc
ALTER-DRAIN&VEM'-W'A'1'IER BEA) VALUATION
Dm
Owner o
WORKEN:SCOMI'llNSATION DECI,ARAITON RACK FLOW PROTIiCI'.DEVICE! �L O
1 firmby amnn under penalty of perjury one of the Johouvirg declarations:
I have and will muinainaC[ndiaat.ofComenuu%elf-inure un Worker's Compen- DRAINS-FLOOR,ROOF,AREA.COND. S'IORHiS TYPE CONSI RIICI'ION
'inion,as Provided for by Section 3710 of the Labor Cade,fir the performance of the
work for which this permit is!sued. FIXTURES-PER'I'RAI'
1 have and will maintain Worker's Compensation Insurance,us required by Section
37M.Nhelal,or Cesdo for lbeperfmmanceiftheworkfnr which this permit is issued. GAS-IIA.SYSTEM-I INC.4 OUTLETS C(:C.GROUP APN
My Workers Compensation Insurance c:vrier and Policy number are: GAS-FA.SYSTEM.OVER 4 LEA)
Cartier. - Policy No.:
^j - CERTIFICATE OF EXF,MPTION FROM WORKERS' GRRASEJINDUSTRLWAS'IH 1NTERCEPT(DR
40.1c COMPENSATION INSURANCEBl11LDING DIV STUN FEES(Thowc n nccdear hcco idro,difth,permil is for nnbvindroddillcan BLI00), GREPhANCI IIiCK hI!H
ASII'TRAP �ped0
or 1c,0
cenify that in the rcriornounceof the work for which this ponoit is issued,I%hall SEWER-SANITARY-STORM IA.20t1 FE ENLrFF
not employ any pesos in unY munm ''ydrt rye nu I th Workers"Com Z cation laws of CaliB,mia.ll� r%
t` oA/I Tf�I�� �n WATER HEATER WNEN'I/ELECTRZ Q Applicant 1 1 GRA'z' NOTICETOAPPLICA .ofter making this Certificate ofExemption,you should WATER SYSTE dnBEATING SOILbecome subject In the Worker,Compensation provisions of thelabor Cede,you must
forthwith comply with such pus isions or Ibis permit shall he deemed revoked. WAITR SERVICE
LIJ
PAID
CUNSTRUCIION LENDINGAGIlNCY NEW RIi.SIDEMIAI.PhMB, SQ.FL
.1.)0 thereby affirm that len construction lending agency lin the performance of
r Its work four which this too is isand(See.30199.Civ,C.) TOTAL:
O Lenders Name _ TOTAL.
r lender',Address BUILDING Ili
9L I certify ohm 1 have read this application and sale that the above information is
�r N correct l agree to comply with all city and county ordinances and,tate laws relatingto QTY. MECHANICAL PERMIT Ir SEISMIC FEE
V Z building cnmtmcliin,and hereby authnriss representatives oflhis city to enter upon the
ab w-mentioned Emotively for inspection purposes. I'EiRMIT ISSUANCE ELECTRIC Flip
(We)agree to.save,indemnify and keep harmless the City of Cupertino against
hahilities.judgmenB.costs and expenses which may in any way acme against said City ALTER OR ADD TOs iCD. PLUMBING PEI!
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WH'11 ALL NON-POINT AIR HANDLING UNIT(TO I(),(XXICI'M) MIlCHANICALPEI!
SOURCE REGULATIONS.
AIR HANDLING UNI1'ROVER 10,000 CFM) CONSTRUC'I'ION']AN
Signature of ApplicaoVCiotractor Date EXHAUST HOOD BW/DUCT) HOUSIN MITIGSHONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ecupanl stare or handle bmsNate
ous material [BEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code.Chaffer 9.12.and the Health and Safety EEArING UNIT(OVER I00,000 BTU)
Cade.Section 255326)'
❑Yes ❑NaVENTILATION FAN(SINGLE!RESIDE PAID Doe Receipt
Will the applicant or Tatum building occupant use equippmm or devices which 1{plLllR-COMP 13HP OR I0r,mXI BTU)
mil hnmrdous air coo annuans to oufneal by the Bay Arco Air Quality Monagemcnt L'. Q
Daon,, ''M' BAILER-COMP(OVER 100.BX))B'IVI
❑Yes No
1 bave read'be
bmaNnm mmerials Trimness under C I pars.."of rbc Call- AIR CONDITIONER �/ g^IJA NICE LAI F,
R,min Heald,&Safely Cede,Sections 255115.25533 and 35531 I una&rstand thou if the NEW RESIDENTIAL.MiCII, SQ.Ff. / 3
building does not currently have a moral,that it is my re%pm,ihilay to notify the escaped
of the t«,c immorm.,which must be tel Fri.,to isman[c ofd Crmi&are of Occupancy. - ,-r'D
Owner or aulbon'eed agent Dote TOTAL: ISSUED BY: 1�
OFFICE
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