99110018 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 101 ' l Q O lia 4
CITY OF CUPERTINO BUILDING-FLEC'TRICAI, PERMIT NO
Isl11LDWG DI VISION APPLICATION/PERMIT I IBING-MECHANICAL
BU11,111N(:PROJECT IDENTIFICATION
IfU1LUING ADDRISS: SAN]I'ARY NO, APPLICATION SUBMI'I'IAL DAPI
OWER:S NAMIi; D/aeX PHONIi: CONTRACTORS NAMIi: LIC NO:PEI Vn tf' - ir.w;4• -37 NIC CONTROLp
HTECL'HENGINECR: LIC NO'. ADDRESS: # /.r lel C/Lt✓9' ❑
-4 VIG$'U
CON ACP. PHONE: BUILDING PERMIT INFO
n/ 9c, ❑ Consultant Fees Nail By'Applicant(Initial) BLITRITDG , L1ECT PLUMB MECH
/ ❑ ❑ ❑
LICENSED CONTRAC'LOH:S Df:CLARN'ION I—
�x
E1_FC'I'RIC PERMIT FEE JOB DESCRIPTION
I reach,nation that I um limuld under pro,kians of"Coupler 9(commencing
paZ with Smlioll700)of UlvLion S afthe Business and Professions Code,and Illy l imuse is RESIDENTIAL'
W p p PERMIT ISSUANCI?
in all fines and dLirt. ❑SPUWI, El KITCHEN REhl0Dli1.
O Urala Cluss Lice— APPLIANCES-RESIDENTIAL []ADDITION D PLUMBING RE PIPE
irsi= Date—!e - - �� T'S.11r
ARCI{ITECTS DECLAR TION PANE ❑h1U1.T1-UNIT ❑STRUCTURAL
F n Z 1 understand m l shall be used a,Public records CHIMNMODIFICATION
oZ plans UPT02IX AMPS [I INTERIOR ❑GHIh1NEY REPAIR
F Mil Licensed Professional 201-100DAMPS IMPROVEMENT L]SWIMMINGPOOIS
OWNER"BUILDER DECLARATION OVER 1(X10 AMPS OBATH RHMOIDEE/ EPAIR ❑DEAIOLITI N
ce Q I hereby after that 1 am exempt from the Contractor's Liccme Law far the
R a U fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHL'R
F LL p y which requires a Permit to common.alter,improve,demolish or repair any structure Q V
prior et itx iem:meq also regmres The applicant for such permit o file a signedxmtemem SPECIAL CIRCUI'VMISC.
�Y mut he is licensed Pursuant to the Provisions of the Connector',License law Chapter COMMERCIAL: O Q�
(commencing wish Section]IX)p of Division 3 of the Business and Professions Code)or TEMP.MCIER OR POLLEE INST. ❑
0.as o eG tow he is exempt tharefmm and the basis far me alleged exemption Any violation of O NI?W BLDGIADDH ION DBMOLITIO
DC_W sectio 9031.5 hyany applicant fora permit subjects the aldicmn to a civil penalty or POWER UI?VICIIS ❑'1'I:NAN'f C1 FOOD SERVICE
oat nmra than live hundred dollars($500t IMPROVEMIN'I
L
2 ❑ as owner of the property,or my employees with wages as their mdc mmPenxution. SWIMM INC,POOL HLECI'R IC frill 117R
d2 will do the work.and the%m uml.s not intended oroffcred Ila ole(See. ,puniness ❑
totZCm
not aPPIY m
W 3.2 and I'ralessians Code: Ile Cmarrecoul Lima-Law does un owner of OUTLETS-SWITCIIIiS-hIXT RI?S
property who builds or improves immou,and who doer such work himwlf or through
his own anplayems,provided that such improvements arc not installed or offered for NEW RESIDENTIAL ELECTR S
sale.IL however.the building or improvement is sold within one year ofmalpleion.the SO.I'1'.I1.00R AREA $/SUFI'.
ncrhellder will have the burden of proving shat he did ons build or improve for....
pose of sale.). TOTAL:
Fl E,as laws bar of the unpery,am exclusively contracting with licensed contractors to
onsWet the Project(See.7044.Business and Prefesslon.Code:)The Contracmis Lawdiesnotapplytoanownerofproper,who builds or improves thermal,and QTY. PLUMBING PERMIT FEE
wLi-
arse ho mmiu v for inch projects witha comracmr(s)licensed pursuanuo the Cunwnar's
License Law. PERMIT ISSUANCE
I am exempt under See. .B Fr P C fm this reason
ALTER-DRAIN.Pn VI?NT-WA'1'hR(EA) VALUATION
wntr
Dam 690
WORKER SCOMPENSATIODfCLAHN'ION PACK FLOW I'R(rrCCl'.DEVICE
hereby unioon undePenaltyPenaltyof Perjuryore of that xefollowing dC
❑ IhuvcanAwlll rnuinminnCenincmeaf Gmnllo sell-in.vurWorker',fur urker',kcr's nmpcn- DRAINS-PIAGR,It001'.nRIiA,COND. S'TOR1Ei5 TYPE CON S'BIICI'101
maion,as provided Ibr by Section 3700 of she L.Nsr Cdc, on(ha performance of that
work lin which this li non is issued FIXTURES-PER'I'RAI'
❑ I bast and will maintain Worker's Compensation hromine0.as required by Section GAS-EA.SYSTEM-I INC.J DUE LEIS (ICC GROUP nP
P1LXIoTtht Wd+nrCde.lin lhcpmformnncc of the work lar which rhix permit is isuad ` ��
My Worker r Compemation Insurance carrier and Policy mumm
her a : GAS-EA.SYSTI:M"OV ER (EA) (FIS••
Carrier: Policy N.,
CI?NTII'ICATEOFEXEMPr10NFROMWORKERS' GRFASEANDUSTBE.WASTE INTERCEPTOR
COMPENSATION INSURANCE HUILDING UR'ESION FIGS
(Tr,wcianncodnolhecompleted ifthepenmis u nronebudraddoilurs($BIO) GREASETRAP I'IANCIIECK IEE
or le,'.)
Eoy any matinthe say.m..... ,1.baknnwhichthis Permit ileissued.Co.,.- SEN'CR-SANITARY-ST(IRM EA.20)FT.
not employ any Person in any manner so as to become wM1ject m she Workers CompcnENERGY Itili
Z sntion Lawsof Cadfurysia.Dme NATER HEATER WNEM'IELECR GRADING ME
Z O APPlicant .L
NOTICIi It)AI' ICANT:If,after mal' us Cemficam of Exemption,you should WATER SYSTENUTREATING SOILS 19?I?
become subject to the Worker's Compensation provisions of the Luton Code,you must
Wn'7.r IEmhwiannnply win such provisions a,,his Permit shall he deemed revoked WATER SERVICE
Q CONSTRUCTION I.ENDENGAGIENCY NEW RESIDIEN'HAL PL.MB. SQ.II'. PAID
Uwc Ractipt p
UO Ilsen,"a"itrnth,Irba is arn.utmsion luodingagea"hn tine pofonounce of
fL the wnfk Ill,11,111,mil pontis Is issued(Sce.aN7,civ.C.) 'r TAI.
I- .
. U I<
nder'e Name TOTAL:
.0 U lander',Address BUILDING FETE
E ccrlfy ohm I have mad In,.,heoeon and.rola that the allor admi airm is
Ftiost.l agreecomply with all city and county ordinances and state laws rcle6ngto QTY. MECHANICAL PERMIT FEE
um 1IC FEE
U Z building eonnamaion,omd hembyamhodmmine.nm...,ufthi,ca,loenterurym the
abm'omentionedPmrany for inspection pull PERMIT ISSUANCE 1 TRIC "C
(We)ngma ut save,indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmenn.Costs and expenses which may in any way became against said City ALTER OR ADD TO MECIL M t"E _
in consequence of the granting of this ponies
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO I().(XX)CFM) ECHANICAL FEE
SOURCE REGULATIONS.
� AIR HANDLING UNIT(OVIiR IB.IXXI CFM) NSTRUCI'ION TAX
.S.001mmor A,pticanUC ntr. Ilam EXHAUST HOLD(WIDUCr1 .H(> Q's[:N 9HArLOA.Fnr
HAZ,MG)OUS MATERIALS DISCLOSURE
Willthc n,pli,am on fulme btiildingaact unset or handle Naardousmwand HEATING LINE x(10100,000 B"IH
as defined by the Cnpctino Municipal Code,Chapter 9,12,and the Health and Safety HEATING UNE"r(OVER IIXIdXX)B"rU)
Codc,Section 25532004
❑Yes C]No VE?N'G LATIONFAN(SENGLIE RIESID7 PAID
Date Barry,A
Will dm applicant(it future building occupant use eyri,orm or device,which BOILER-COMP(3111'OR BASS)B'LU)
anvil Im'umdoa,air contaminant,as defind by be Ifay Arta Air Quality Management TOTAL
E,is srict'! BOILER-COMP(OVER 100,001 111 Or
❑Yes ❑Nn
AIR CONUITIONIiR ISSUANCE DATE
I havehealth
read the Code.oi Similar,
I S.25533 an under Chapter rwri of the Cali-
fsnnia glike,m Safety tlyhoS ation 25505.25533 and 25534.1 umleumd that If the NEW RESIUIiNTIAI.A11iCH. SQ.Ff. 9
buildingokes not curmntlY haveaTenant.ohm oia,nyleamo arti htnotify the occupant
of the rtquim nu whic n and pnortoissuunce afaCenihcwe of Occupamy.
/• ,�vd
aumoriecJ ugen
Data TOTAL: ISSUED BY..
OFFICE v