S 1245 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF. IT NO
BUILDING DIVISION APPLICATION/PERMITPLUMBING•MECHANICAL 1245
BUILDING PROJECT IDILN'I'IPICATION
BUILDING ADDRESS: SANIINRY NO. APPLICAI[ON SUBMITTAL DAII
10131 Pharlap Drive $-29 9Fr
OWNER'SNAME: PHONE, CON'IIUoCFOR'S NAME: LIC NO:
y1_''11 44 — N/C CONTROL Of
•
ARCO 1171Y1%IYTIIfCE�.mP e� LIC NO; ADDRESS: ❑
— 70690A
r-orvraLT: PHONE: BUILDING P13RMIT INFO
31�-J 5 oo ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELHCP PLUMB MECH
❑ ❑ ❑ �
LICENSED CONTRACTOR;S DIiCLARA'1'ION Q'IY ELECfRICPERMIT FEE
I thicat afrmt that I am licensed ander provision,of chapter 9 armtmemins JOB DESCRIPTION
WCZ with Section 70013yof DIvIon. lofthe Bunce sand ProfesciamsCde,and my license is RESIDENTIAL:
I� nfull forcer, BwE PERMI'I'ISSUANCE
r �^ _ I'f �O� OSFDWL ❑PLUMBIINREMODEL
QUO Lae�y Ci %-I--- CarLic APPLIANCES-RFSIDCNTIAL ❑ADDITION PLUMBING RCPIPF.
N 6 ad Ua Con,mnor
E.itm ARCIII'I'EM'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O r Z 1 oodeccmnd my plans shall M aced as public records MODIFICATION
OZ�O IIP T021NIAMPS LIMP ERIOR O CHIMNEY REPAIR
I=W Licensed Pralcesional 201-1000AMPS IMPROVEMENT E]SWIMMING PDOLS
-� OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors Liceme law for the OVER "AMPS [I BATH REMODCIIREPAIR [I DEMOLITIONPgSOLU following reeson.(Section 70315.Business and Professions C'de:Any city or county SIGNS ELECTRICAL. ❑OTHER
W 31+�fme' which ruryirc o permit to conswn,alar,improve,demolish,or repair any tincture
F'�OJ prior to its issuance,also requites theapplicam for such permit to file a signed statement SPIECIAL.Cl RCUIT/MISC.
�y thinheslicencedpursuamminepmviciaoeifNeCmrmcnfsLicenselaw(Chapter9
C'aQ� oememencing with Section 7001)of Division 3af the Business and I'mfccsfar,Code)or 'IBM P.MCI HR OR POLI;INSP. COMMERCIAL
o yO� III.,he is esempl therefrom unit the basis for Ne alleged esemWon.A^y violation of O NEW BLDG/ADDITION O DEMOLITION
-^'„4
Seen...171315 hyo Iyapplicant fant permit subjects the applicant to a civil penaby of POWER DEVICES El TENANT ❑FOODSHRVICIi
W m Bol mote than five hundred dollars($5081. IMPROVEMENT
F�Q I,us owner of the norm employees with woes as theirsole contaminator. SWIMMING POOL131.ECfHIC
pMQ ❑ property, YemP Y 6 ❑OTHER .
willdn the wnrk,a^dthes..ocre is not in andcdoroffered for sale(See70aa,Busincvs /,
L 3 m
and Professions Code:The Cortisone,License Lor,docs not apply m an treater of OUTLET'S-SWI FC14ES-FIXTURF_S
Property who builds or improves thereon,and who des such work himself or through
his own antp]oyeas,provided that vrich improvements aro not Intended.r offered for NEW RESIDENTIAL[3LI?CE'N S
sale.IL however,the building or impmvemem is sold within one year oferanderin^,the SQ,FT.FLOOR AREA S/SQ.IT.
er-builder will have the burden of proving Nm he did not build or improve far pr-
pis a of sal..).
[3 o
1,as wner,of]he property,am cadu.cively contracting with licensed comment,to IOTA
construct the project(Sec.]BLt,Business and Professions Code:)The Commences Li-
ncLaw docs nm apply to an owner(if properly who builds or improves therein,and QTY PLUMBING PERMIT FEE
whocontract,forsuch projectswithacommnar(s)licensed purmammthe Canner is
License Law. PERMIT'ISSUANCE
I ant exempt under Sm. .B 5 P C for this reason
A[1PER-GRAIN At VENT-WAIER(BA) VALUATION
Owner Das V
WORKER'S COMPENSA'['ION D17CLARAI'(ON HACK FLOW PROTECT.DEVICE �J
I hereby affirm under penally of perjury one of the following decimation.,: ✓I / OJ
Q [have and will maintain a Certificate of Consent to off-insum for Workers Cnmpcn- DRAINS-FLOOR.ROOEARGA,COND. STORIES 'I'YPI?CONSTRUCTION
salian,as provided for by Section 3708 of the Labor Code,for the performance of the
work far which Nis penial is issued. FI X1IJR17S-PER TRAP
❑[have and will maintain Worker's Compensation Insurance,ac required M1y Section
3700 of be Labor Code.lin lire perfarmanceat the work fm which this permil is issued. GAS-EA.SYS 1'[EM.I INC.O CUP LhfS OCC.GROUP APN
My Woy.cey.ComJJ''�� Inwmr{� .Bier and Policy t a y" GAS-EA.SYSTEM OVER A(EA)
Carrier:�YNP UlA�O�LA� \1*-ynldy No.: `-
CER'I'IFICA'I'EOFISXEMPI'IO FROM WORKERS' GREAS"IN
DUSTEP WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION F13f'S
('this section need not he completed ifthe lamtil is for one hundred dollan($10d) GREASE'I'RAI'
or Icss.) I PLANCUECK FEE
I certify than in me perfommmce ofthe work forwhich this Permit is ianed,]shall SEWER-SANITARY-SMRM EA,200 IT.
not employ any Person in any manner sons to besama mubjen to he Workers Compete- ENERGY FEE
.cation laws of CaLforne.Date WATER IIEA1'ER W/VEWI'/ELECI'R
z Applicant GRADING 103E
y N11GCIE TO APPLICANT.If,after making Nis Certificate of Exemption,you should WATER SYSl1iM/1'RI?ATING SO[I S FEF
a ? become subject in the Workers Compensation provisions of the fadbr Code,you must
forthwith comply with such provisions or this Permit shall be deemed revoked WATER SERVICE
iQ
r7z CONS ION LENDINGAGENCY NEW RESIDENTIAL 'LMDSQ.PP. PAI
O 0 IhercM1ynRrm that them is.atmsn0mion r #
lending agency Rothe peAnnnnnse of
4.F the work for which this Permit is issued(Sec.3119].Co.C.)
0 L) Lender'.,Name OPAL'
Leadue,AddaL:ms 'TOTAv
0. 1 certify that I have fund this application and mum Nat the above information is BUILDING FEE
4 f7A correct.I agree to comply with all city and emmy^rsimancem and some law.felting If QTY. MECHANICAL PERMIT FEE
U G building ears0uc0on,and hereby:nnhnrizc rcprcscn0mives of this city,.cmcrnpon the SEISMIC FEE
aMwe-mentioned property far incpec,ion purposes. PERMITISSUANCE 5 2
(We)agree n save,indemnify send keep harmless the City of C-Puf ino.,mmvl ELECTRIC GEE
liabilities,judgment,costs and expenses wbichmay in any way amme a gain.,,and City AUfER OR ADD TO MECH,
PLUMBING ITE
in consequence of the firming of this Parent.
APPLICANT UNDERS'['ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 110.00(CPM) 9y
MIECI IANICAI,FTE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONS'fRUCT1ON'fAX
Sigrorre of ApplicanuComovaor Dam EXHAUST I IOOD IW/DUCT) HOUSING MITIGATION HE
HAZARDOUS MATERIALS DISCLOSURE
Will t he applicant or future building dmcupain store or handle hazanlous material PI[3A'I'INOUNI'P(TolIN1,1NN1HTU)
as defined by the Cupeninn Municipal Code,Chapter 9.12.and the Healm and Safety
Code,Section 25532(0)? HI?ATING UNIT(OVER 1040100 WIG)
❑Yee iVn VIENTIIATIONPAN(SINGLEItF.SID) PAID Z9 &- 0f
Will the spPlicaor fmurc building occupantse ucquipmcm or devices which Date Receipt M
m
emit hvwdous air oonuminnnts as defined by the Bay Area Air Quality Management ' BOILER COMP 3HP ORI X)000 RTU)
District? `� TOTAL: �j w
❑Yes IF&I BOILER-COME RNkgO BIM)
AIR CONDITIONER
have read the hvmdnuc tion,ds regairemcros artaU I and understand
of the Cali. ISSUANCE DATE? S
fnmia gdocs no Safety nyha ea tina 25505.25533 and 25531.1 undcrsund ishan if,nc NIiW RI?SIIIENTIAI.MSCII. SQ.FI'. /3
building docs not cumnlly have a tenant,Na it is my responsibility to msdfy the sMcupnnt
d111 reruirc0 bwhich nmq he ter Pisau 0 nl'a Ceniieac of Omapaney.
Thor..n n5 0 .�aas(u 5'2w-yCZ
Owner or are,east ager
Date TOTAL: ISSUED ItY. L /9LJ75ya.t,C C.
OFFICE