S 1540APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING . ELECTRICAL
BUILDING DIVISION APPLICATIONAERMIT PLUNIRING- MECHANICAL
BUILDING PROJECT IDENTIFICATION
PESIT NO, 1540
l`7
BUILDINGADDRESS:
c, P tote:V ll� ,�V�
SANI'I'ANY NO.
AI'I'LICAT[ON SUBMITTAL DATE
qn
OWNF.N:S NAM&�
�'��
W'I
CO ACTOR'S NAME
NIC
COWR/OII.x
-77A
`I I'I'eC NGINEI?R: NO:
kLIC
A :
_f4ye 41k D
CON ClA': PHONE:
BUILDING PERMIT II t)
`
Cf/C (n l J /7Z - _O ( n CJ
❑ Consullar l Fecs Paid by Applicant (Initial)
EC CH
I.ICITNSIi1)CONTRACToe:S(DECI,ARATION
1 hereby.eimm that 1 am licensed under previsions of chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DES RIPTION
PERMIT ISSUANCE
with Section 900!0 of Division 3 of the Businnss and Pmfesions Cede, and my license i.s
ifill farce and effect t.
RFSIUEN'TIAL:
❑S WL TCHIiN REMODEL
PPLIANCES— RESIDENTIAL
License Clan Lic,x
Dam Comrncmr
DITION PLUMBING RE -PIPE
MULTIUNIT ❑STRUCTURAL
MODIFICATION
ARCHITECTS DECLARATION
II di,,r plansshall he used as publicrecords
PANEIS
UPT02MAMPS
I [I INTERIOR 0CHIMNEY REPAIR
IMPROVEMENT C]SWIMMING POOLS
Licensed Professional
20I-1000AMPS
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Lau, far the
following reason. (Section 90315. Bmin,o tad 1'mf.,sien, Code: Any city nr county
❑(IATA REMODEUREPAIR ❑DEMOLITION
❑ O'1HER
OVER IIxIBAMPS
SIGNS ELECTRICAL
which ".in, a permit to ennslr.a,.[air, improve, demolish, or repair any smme urc
SPECIAL CIRCULUMISC.
prior in its issuance, alrn requires (he applicant forsuch pemeil to the a signed statement
that he k licensed pursuant to the provisions of me Contractors License law (Chapter 9
(commencing with Section imk) of Division 3 ofthe Business and Professions Code)or
TEMP. METER OR POI.5 INST.
R
that he is enempl Ibcrefrnm ad the hmis for the alleged uxcmpti.e. Any vw aion of
❑ NIiW A DITION ❑ DEMOLITION
POWER DEVICIS
Section 7031.5 by any applicant for o permit subjxeu the applicant to a civil penalty of
not more than Five htmdred dollars(S500),
Las owner of the pmpeny, or my employees with wagesns their sole compensmion,
will da the work, and the Nuvclure is not intended muffeed for sale (See 9044* Business
❑•tl?NANT 'Rtaa�k E7 FOOD SERVICE
1 f '1 AN
1:1 T,.
SW'IMMINGI .CTR IC
.11'mfessiuns Cede: The Contractors License Law does not apply Int an owner of
hard, or oves thereon, and who docs vel work M1imself ur mmugh
property who imW
his own employes, eprovided that such impmvemems are not intended or offered for
noneytmre inprovetiomlbe
isat
salolLhnwevell
OUTLEI:S—SWITCHE. — UES
NEW RESIDENTIAL ELECT N SQ 14.
ry
�.1 1 Uf Iin ,Ur CI INN
SQ, FT.I1W
LSQ. hI'.
Lord!
ownein side). will have the burtlen of proving that Lord! nal build or improve for pury
haveldi burden
(rose inside).
❑ I, as owner of property, nm conlmming with licensed contractors i-
ov
1[9A1;
and The Contractors Li-
ct and
construct the project (Sec. once, Business
buts
wem,LawdmrsnnwpPlyleen owner of who ds or improves
La property
wccused,amoamlIncome. and
QTY. PLUMBING PERMIT FEF.
iflu.cd'pmpery
who commas for such projects with v amtmemr@) IicenseA purswmt m the CommdoLs
PERMIT ISSUANCE
Licence Levi.
1 um csi mpt under Sec. , B se P C (,,,,his reason
Owner Dalo
WORKER'S COMPENSATION DECLARATION
Ihenchy.1inn under penalty of perjury be of the following declmalims:
AL'II7R — DRAIN & VENI'— WATER (EA)
VALUAFION
OV
BACK FLOW PROTECT DEVICE.
❑ Ihase and will maintain a Certireamof Consent mself-iaumfor Workeds Cnnlpen-
ration, as provided for by Section 7900 of the Labor Cede, for the performance of me
DRAINS— FLOOR, ROOF, AREA, CON D,
STORIES
TYPE CONS] RUCTION
work for ,Inch this pemdt k issued.
plXi'URBS-1'ER 9'kAl'
1 have and rill maintain Wneker's Compensation Insumnce, as «quimeJ by Section
370341he Lubar Core, lir the mcdonmunreol'the work forwhich this permit is isued,
OCC, CROUP
APN
GAS — EA. SYSTEM -1 INC. 4 OU'I LETS
My Worker's Cnmpenmlinn Insumnce <aaier an, Policy mheI art:
Curricc �c I'ali<y No.:�
GAS — G.SYSTEM-OVIik 41EA1
GRIiASFJINDIISTNL WASTE IN'1'IiNC1iP1'OR
'ENTIFICATIi OP I'.XI?MPTION IRO W UG. S'
COMPENSAi'[ON INSURANCE
I!ALLVGk1VTSION FEES
GRL'ASETRAP
(This scc,am need not M emnalual ifthe permit is(atone mounted dol kits (SRM)
or less.)
PLANCIiF,CK I.
(ccnify main the perfnrmanseol'lhe work liawhicM1 Ibis permit isissned,Ishull
not employ any pmam in any mann" m as to Menthe subject m the Worker' Co.,.-
SEWER—SANITARY—STORM EA. 200 FL
ENERGY Ff:h
WATER HEATER WIVENT/ELECfR
GRADING
tylion I.aws of California, Dam
Applicant
NOUCE'I'O APPLICAN'D If, after making this Certificate of Exemption. you should
became subject to the Workers Cenlp:n.eaien Provisions of the Labor Code. you must
WATER SYSTFEMrrREATING
SOILS FP'
forthwith comply with such poison or this permit shall be deemed revoked.
WATER SERVICE
NEW RESIDENTIAL PI.MB. SQ. FF.
CONSTRUCT ION LENDING AGENCY
I herebynffinn that Meru ism coalmelinn lending agency for the perfomnnceof
PAID
au Receipts
the work for which this permit is issued (Sec. 3197, Cie C.)
Lender's Name
TOTAL:
TOTAL:
Lndcrs Address
BUILDIVG ITE
1 ccnify that 1 have read this application and state that the above information is
cormol. Jul to c oply an till c'my anted coonly onlin.nces and alum law, relating m
huiku.,,satmnion,mnd herebymaheturepmsenlalivcsofthiscity mmtmupen the
goy.. MECHANICAL PERMIT FEE
SEISM J,,FTC
PERMIT ISSUANCE
E1.13 NIC PEE
above-mentioned pmly rly for inspection purposes.
(We) agree to sme, indemnify and keep hamdess the City of Cupertino against
Iiahilides,judgmmmts, costs and expenses which may in any way accrue against said City
e granting of this permit.
IAppo cUN
ALTER OR ADD TO MECH.
PLO M1 BING FEE
AIRIIANDLING UNIT(i'0111,(MNICFMI
MEC( ANICAL FEE
CA 7R. AND WILL COMPLY WITH ALL NON -POINT
URC IEGI' .r NS.
AIR HANDLING UNIT(OVIIR 10,tM0 CIM)
'oNS'N%CQ.0N'FAX
Signa mfAp candCo moor a
IIA RDOUS MA'11iR1A1.S DISCLOSURE
R51 eeapplica or(
rnedcame buddingoccupanl.more orhandle hazadous material
as daby Ihn Cu man Municipal Cale, Chapter 9. 12. and the Health and Safety
Code, Section 2553200?
HXHAUST110(ID(W/DUCT)
HOUSING MITIGATE TE
I IPATINGUNITO')FIftogIHTU7
((EATING UNIT (OVER 010,0111 BTU)
❑Ycs No
Will the applicant or future building acupmn use equipment or devises which
emit hazardous air conmminvntr m defined by the Buy Area Air Quality Management
District?
❑Yes 0 N
VENTILATION AN (SINGLE RHSID)
PAM pate ReceiplN
BOILLR—CONI' (7hIP UH Illll,lgB NIU)
TOTAL:
BOILI7R— COMP (OVER 1110.000 BTU)
AIR CONDITIONER
I have mail the hanumus materials requirements under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
forni. Iludlh & Surety Cade, Sections 25505, 25533 and 25534. 1 umdersead that it the
building does not currently have a ¢nmol, that it is my responsibility to notify the arcupirm
of the requinditems which must he at 16,111. Issuance of. Cart of (kora acy.
ISSUED BY:
TOTAL:
Owner er motharize l adin Dam
OFFICE