S 0349 APPLICANT49,FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BDILDING C
-ELEIHICAI. PERMIT N(1.
BUILDING DIVISION APPLICATION/PF,RMIT 1'LUh1111N1:-MECHANICAL S 0349
BUIUDING PROJECT IDENTIFICATION
SANHARY NU. APPLICNIION SUBMI"I-AI,DATI
BUILDING ADDRESS:
SCK) d rete, 7`?-8'97
O IiR'SNAME: / I'H(1NI:: NTRACTOR'S NAME: LIC NO.
MGl.xi�cl 725 —05.x- / N/C CON'I'ROI.p
1RCIII'I'ECC/11JGINIiIiR: LIC NO: ADD ISS: Sf /FI�1_^/ h ❑
[ilh
N(ACI': PHONE: BUILDING PERMIT INFO
❑ Consultant Fetes Paid by Applicant(Initial) BLDG ELECT' PLUMB Mi
LICENSED CONTRACTOR'S DECLARATION QTY (ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
CaZteeonXN)).l .tvirum 3 of ltuoue—ad profci..ionx Code.andnry l(cense lx RFSIUENTIAL:
X00Section]IXXI)oID" I'ERMI'I ISSUANCE
KGF- n ull for ❑SFDWI. ❑KI'I'CHEN REMODE
aVU Liccnm Class Lica APPLIANCES-RESIDENTIAL ❑ADDITION .UXINING RE-PIPE
N Q 6 Dale Cnnaucar
pRCHITECPS DECIARATION PANELS ❑MHIII'1-UNIT' ❑MODIFICAT16
~=Z I understand my pl....hall be used a•public reands MODIIgCAT1ON
OZ-� UP TO 200 AMPS [I INTERIOR [I CHIMNEY REPAIR
P nLZLicensed Rafessional 2UI-IINXIAMPS IMPROVEMI;N'F 0SWIMMING POOLS
<sj E; OWNER-BUILDER DECIARATION OVER I"AMPS E3 BATH REMODEL/REPAM ❑DEMOLITION
C C a I hereby nffinn that 1 sen cnempt from the Contractors Liters.I.uw I the
�a(�d V following reason.(Section]031 S,Business and Ymfessions Cde:Any city nr umnlY SIGNS ELI!CCRICA]. ❑OTHEk
W 3 LL v~i which requires a permit to constmct,alter,improve.demolish,or repair any structure
prior to its issmmac,also requires the applicant for such permit to file a signed savemcat SPECIAL CIRCUITIMISC.
Eby that he is lami,ed pursuant to[lie provisions of the Connector's License Law(Chapter 9 COMMERCIAL(commencing with Section]")of Division 3 ofthe Business and Profession,Code)or TEMP.METER OR W11.Ii(NST.
C.G ey� that he is exempt therefrom and the basis for the alleged exemption.Any violmion of C1 NEW SLUG/AUDITION ❑DEMOLITION
Xm la. Section]031.5 by any applicant for n permit .bjcets the applicant m n civil pe mhy of POWER DEVICES ❑TENANT ❑FOOD SIiRVICE
W N not more than five hunJmd dollar,($50d.
IMPROVFh11iNT
F.
❑ Las othe w.owner of the propeny. maintended
with mads stheir ic(.comlsen7144,Bmtlon, SWIMMING('001,ELECTRIC []OTHER
p., and Professions
and t, The Corc awan's License Law do is not apply to an owner
of
Y 3 and property
whiob Cade:The CUmtacmd License law drcn not apply to if owner of OUT'LIffS-:WITCH13-FIXTURES
property whooyeW.or improves thereon,and who mass re n work deed or or through
his own employcu,prnviJd tM1m such Inmrovenumts are not intended rn offered for NF.W )IiNTlp1.ELIiCTR SQ PI'.
SU I'('.FLOOR AItITA gISQ.IZ
sale.If.however.the building or improvement is sold within one year ocount..lion,the
owner-builder will have the burden of Proving that he did not build or improve for pur-
1 Ince ofsnlcJ. IC I'AI:
O L as owner of the proper,am exclusively enmmcting with licensed contrwmth m P pi 1 D
comuuct the Project(Sec.1044.easiness and Pndcssions Cde:7 The Cnnmactors hi- M
c se Law does not apply to owner nl'property who balldsor improves thelco,and QTY. PLUMBI IT FEE
who contracts for such pmjeas with a wmawor(.$)licensed pursuatd to the Connectors
License Law. PERMIT ISSUANCE L R{�•101
I am exempt under Sec. .B&I'C for tbisrcaxnn
ALTER-DRAIN&VENT-WATER(GA) gLI� d1
Owner Dam VVCC
yy El
WORKER-SCo MP17NSATSON DECLARATION BACK FLOW PROITCL DEVICE Elly Vt
I hereby affirm under penalty d perjury one addle following declarations:
❑I hmcend will mainaina Ccniftca¢nf Conxcmmself-insure far Worker's Compen- DRAINS-FLOOR.RUDE AREA.CONI(, STORIES TYPE CONSTRUC IOP
samno,ax provided toe.by Section 311X1 ot'the lanhon CnJq far the pcafrnmonce of Ibe
wad for which this Icrmit is i.asud. FIX'(URES-1'LR l'IIAI'
❑ 1 have and will maintain Workers Compensation Insurance,as required by Section
37mOdme latb-Cade,fonheperfuranancenf the work li+t which this permit is issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCC.GROUP APN
My Wor Cnmp n lion II ran er and Policy nutire
Comer: PcllCy No.: m71�925 GAS-FA.SYS TEM{)VERJ(FEA)
CUR1171CAT i OF EX EMPTION FROM WORKERS' GRBASUINDUSTRI.WASTIi I NFERCEPTOR
COMPENSATION INSURANCE HIIILDING DIVISION FEES
(Thihsectian neednnlbecompletedifthepecian is fnronehundteddollan(S10U1 GREASETRAY
I'LANCHIiCK hili
of lull
Ioy.,that in the any rrmanceofthework has,..c,pcl,thisc,m theIscrinitWr6sad.Ishnll SIiW1iR-SANITARY-SIOHM EA.21x1FT.
not employ any person in any mann<r so as m become zubjmt to the Workcri Cnmpcn- IiN[RGY 19TH
0 Z ration Lawn of Califomia.Date WATER HEATER WNENT/ELECfR (TRADING FEE
Z Applicant
N. NOTICE TO APPLICANT:If,after making this Cenificme of Excmptinn,you should WATIiR SYS'CEM/TRIi1TING SOI(S PER
become suhjcet to the Workers Compensation provisions of the Labor Code,you must
1r fimhwiN cumay with such pmskimoon lhis prnnitshull he deconed revoked. WR'I'ER SERVICE
PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ FT. Dae Recein
VQ I hereby affirm that there'isacouloonfion lending ugcney for the pcdurtoance of
LL.2 the wpe
ork foe.whichthis rmit is ismed(Sw.3091,Civ.CJ 'TOTAL:
� Leader,Name TOTAL:
U
_erdcr's Address BUILDING FEE
r UJ
0. I certify that I have mad this opdiemma and slam that the above information k
F' N
correct.I.'aeeto comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC IRE
U Z Wildmi,cmnshuction,and broth,aummir renresumodvcs ofthis city wutnar upon the
tW e.mentinned Property Toa inspection pmlx+ms. PERMIT ISSUANCEELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
iahilitie,judgmcros,costs and expenses whichmuy in any way incme aguinasaid City ALI'17R OR ADD TO MECH. I'LUMBING FEE
in consequence of the' n6 of thi+pc
APPLICANT ANDSA L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.OIXI CPM( MECHANICALIRE
SOURCE NS. �r Q
AIR IIANDLING UNfC(QVI',R IQIHNICFM( CONSTRUCTION LAX
Sig re of pllcan/Commcbsr G Data EXHAUST HOOD(W/DUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lheapithearnor tutu.buildingoceupamsmmorhandle hazallous mamrial HEATING UNITOO IW.NXI M)
its dcrind by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
Code.Section 25532(e)1 HFX1 ING ONIT(OVER I00,om)I1'1'UI
❑Yen ❑NuVENTILATION FAN(SINGLE RESIIA PATO
Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP OHP OR HXI.000 Is'1'U)
emit Wordous air conmminams a defined bna
IN,the Bay Area Air Quality Magttmm TOTAL:
District? BOILER-COMP(OVER 100.000 H"I'U1
❑Ych ❑No
AIR CONDITIONER ISSUANCE DATE
I have lead the haeamous materials nequiremcros ander Chapmr 6.95 of the Cab-
' Want Health&Safety Coda Sections 255(15,25533 and 25534.I understand that d the NEW RESIDENTIAL MECIL SQ.Irl'.
building does not currently have a tenant,that it is my responsibility to witty theaccupant
of the nquircrooV which mute rte mel prior In isomace of a CcniRca c of Occupancy.
Owner or authorial agent Date TOTAL: ISSUED IIY:
OFFICE