S 2018 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-EhEcrRICAL Lqp 1 N ^O,a p
BUILDING DIVISION APPLICATION/PF,RM IT PLUMBING. MRCIArvICAh J L 1 0
Is W LDINf:I'HOJeCT IDb:NTIPIG'f10N
BIBLDINGADDRESS'. SANITARY NO. APPI.ICA'I'ION SUBMI'I•I'AL DAPI?
lonv;5 !V - 2 0 "
WNER'S NAME: Lj*I NT'RACPOR'S NAMH: LIC NO:
41 —66 O �I N/C C9ON'IR/OLX
AARC411'1'EC'fIHNGINP.R: LIC Nla,,1 IIJJ AUD ISS: =l ❑ ( /_
1n' C-9
CONTACT. PHONE. BUILDING PERMIT INFO
P,,,� r( �. 1 C � `` ❑ Consultant Fees Paid by Applicant(Initial) BLIIC ELEC1 PLUMB MP.CI
LICENSED CONTRACTORS DECL"ACRA'T'[ON"•J QTY. ELECTRIC PERMIT FEE L—VJ/ LrJ�
1 hereby action that 1 oro licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
ne Z with Section 900)af Division 3(it the Businessand Professions Cade.endmy license is RpSIDENTIAI.:
Op in force otos off PERMIT ISSUANCE
PUC) i ❑SED ❑KITCHEN R17PI E
UV License lass hick APPLIANCES-RESIDEN'I'1Al. DITION El PLUMBING RIiPII'li
Hoot nate TSDEor
AR IfITF.CT'S DECLARATION ❑MUhTI-UNIT' ❑MODIE[CATIO
..;D res4- le-o
PANELS MODII9CATION
Ozmy plan allUP TO flN1AMPs ❑INTERIOR ❑CHIMN17Y REPAIR
F+'�u'E'.t�i Lica 201-1001AMP5 IMPROVEMENT E]SWIMMING POOLS
g�ENER-BUILDERDECLARATION OVERI(NNIAMI'S �BATHREMODEIJRI?PAIR [D DEMOLITION
C C d I hereby affirm that I mo exempt from the Comoumr's License Law fill the
���dd O ell U following reason.(Section 90315,Bmincas and Professions Code:An,city Or county SIGNS L'LECfRICAI- ❑OTHER
It]�WO y which requires a,moil to marr u,other,improve,demolish,Or repair any mornme
of, prior to is issuance,also requires the applicant(orsuch permit m file a signed statement SPECI AL Cl RCUrf/M ISC.
y
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter9
�00 (commencing with Section]INN)ofDividon 3afthe Business and Professions Code)or '1'IMP.MITER OR POLE INST.
d �d that he is exempt therefrom and the basis for the alleged exemption.Any violation of NP,W BL LD)ITION ❑DEMOLITION
i mtk, Section 9031.5 by any applicant for a permit subjects the upplicamtO a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
m more Nen five hundred dollar(550).
.F.Z Y• IMPROVIiMf:NT
❑Lasowner k,the moome or my employees with wagesBred f astheir(ode e0mL Envious.,
SWIMMING POOL EhECfRIC
X65.0 will dans.work,and Ne srvmureis not intended omllered for sale bloc.91004,Business El OTHER s
L 3 m and Prnfessions Cade:no Contractors Liceme Law does not up m an owner of l3TLRf5-SWITCIIF:S-FIXTURES 7
progeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEWRL )ENTIAL FLECTR SQ FT.
sale.If,however.Ne building or improvement is sold within one yearuf completion,the SQ.PC FLOUR AREA 5/SQ.14.
owner builder will have the burden of proving that he did not build or improve for pur-
pnse of sale.,. 7 D
E]1,m owner of the progeny,nm exclusively contracting with licensed comrucmrs m T AL: C� )((J,
constract the project(See.70W,Business and Professions Code:)The Contractor's Li- 0 /
se Law Jtes not apply to an owner of Employ who builds or improves thereon,and QTY. BING PERMIT FEE
who contacts for such projects with v eontaemgs)licensed pursuant n the Connotation's
License Law. PERMIT ISS NCE Jf of,10
❑1 am exempt under Sec. .R&P C for This mason
AUI ER-DRAIN&VENT-WATIiR(IiAI VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE -'/(,to BD(7
• I hereby affirm under penalty of perjury one of the following declarations:
❑ I haveand will mainaina Certificate of Comennoself-insure for Worker's Compen- 'y DRAINS-FLOOR,ROOF,ARHA,COND. STORKS TYPE CONST'RUCI']ON
saint,as provided for by Section 37W of the LoMe Code,for the performance of the
work for which his permit is issued. PIXTURRS-I'FIt TRAP is
❑ I have and will maintain Washers Compensation Insurance,a required by Suction /
39Wof the labor Code,fonhe perflmoreeof the work for which
'this
s/pcoadisis issued. GAS-EA.SYSTEM4 INC.4 OUTLETS a OCC.GROUP APN
My W. Co
sCo rend li°gier and Pol cY Noy �1Q+�ry�-� GAS-EA.SYS'rliM-OVERAIG)
C RTIFICATE OP EXEMPTION FROM WORKI?RS
COMPENSATION INSURANCE. GREASEIINDUSTRL WASTE INE-HR .IT'OR
I ' .DING DIVISION IT:IS
or less)This section need not he compincsl ifthe Permit is for one hundred dollars 151 WI GREASETRAP y ISP
Icrnifythm in the Performance of work for whichthispermit is issued,lshut] SEWER-SANITARY-SIDRM ISA.200IT. r 20
nor employ any person in any manner so as m become subject to the Workers'Compen- F.NF.RG Z
Z sation Laws of California.Done WATER HEATER WNENT/FLECPR
GRAD EE
NOTICETO APPLICANT:If,afar making this Certificate of Exemption,you should WATER SYSI II(TREATING
Z Applicant
h Femme subject to the Workers Compensation provisions of the labor Cooke.you must
>,a forthwith comply with such provisions or this permit shall be seemed revoked. WA'ITR SERVICE
a
5 Z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLAIH. SQ,IL PAID
Dam Heccigt p
LJ I hereby effort that isacomSm.constructionlendingagency for performance of
the work for which this permit is issued(Sec.309"/,Civ.CJ
IL L.T. TOTAL:
f Leaders Name
{UL1 Lenders Address OTAI11 L
FL 1 certify that 1 have read this application and shite but the aMwe information is BUILD] 'E
0 exa eeL 1 agree 1.comply with all city and county and inanso,and s,am laws relating 1" QTY. MECHANICAL PERMIT FI?lip
V Z building consumerism.and hereby authorise mpresentmlves of this city to enter upon the S61. T ly . �V
aMve-mentioned progeny for inspection puq.rses. PERMIT ISSUANCE
(We)agree to save,indemnify and keep homeless the City of Cupertino against EL I 'EE O
habilities,judgmems,costs and expenses which may in any way accrue against said City ALTER OR AUDIT)MUCH. P B GI•TH
in mmegoenm of the granting of this germit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE REGULATIONS. ME I NICAL FEE
AIR HANDLING UNIT(OVER 111,000 CIM) CONITRUCTIONTAX
Signature of ApplicanVContacmr Date EXHAUST HOOD(W/DUCT} If SING MITIGATION PER
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplieni future building am,simsme or handle hamNoms material HEATING UNIT GO 100.000 B1'U)
m defined by the Cupenim Mu "NI Code,Chaprar 9.12,and the Hcahh and Safety
Code,Section 2553'Ed? /�J1 HEATING UNIT(OVER 100,001 BTU)
❑Yes LI]No VENTILATION FAN SINGLERFSID) PAID
Umc Rmcipl a
Will the applicant or future building occupant use equipment Or devices Nhleh
,to emit hazardous air commonant defined BOILER-
by the Bay Area Air Quality Management COMP OHP OR 100,000 H'IL) TOTAL:
District? BOILER-COMP(OVER 100.000 BTU)
E]Yes Nso
I have mots the hazaNnus mamrials requirementsunderChapter 6.95 of the Cali- AIR CONDITIONER ISSUANCIi DATE
fomia Health&Safely Cale,Sections 25505,25533 and 25534.1 mmleataml thm if the NEW REST DENFIAL MUCH. SQ.FT. tty�
huiliingdoesms tlyhavl a teoonLth tismy beraaibiloym ramify the mvpant
ad imine abs mel pr eaance ofa Comfiv of Ocmualu8 V o✓g
(45K,or au�azW agent 4'D'me TOTAL: ISSUED BY.
OFFICE l