S 1144 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OE CUPERTINO BUILDING.EI ECTRICA1, PFTIT NO
BUII,DING DIVISION APPLICATION/PERMITr PI.UhIBING-MECHANICAL J 1144
BUILDING PROJECT IDBNT'IF'ICA'I'ION
SANITARY NO. APPLICXHON SUBMITTAL.DATE
BUILDING ADDRESS:
�11
O NER'S AMR: PRO I' C N RAC'1'OR'S NAME: LIC NO:
D NIC CONTROL#
ARCHITECT/ENGINE LIC NO: Ap2�n'
4,4
CONTACT': 'J-6 A/ st p(2Ty 1'IIDNE: (�d�' BUILDING PERMIT INFO
❑ RELE(-FRIC
es Paid by Applicant(Initial) BLDG ELECT I J ntcCy
Y4� LICENSED CONTRACTOR'S DECLARATION QTY PERMIT FEE
1 hereby sante mat I am licensed coder provisions of chapter 9(ammmendng JOB DESCRIPTION
OC with Section 0000)of Division 3 of the Business and Professions Code,and my licause is NCE. RESIDENTIAL:YFin full Innocent cBcd. ! ❑SFDWL �I'I'CI IFN REMODEL
-ul Licene Clas LIC.# RESIDEN'IpAL ❑ADDITION 1'I,UMBING RE-PIPH
W Data Connoted
S ARCHITECTS UE ATION ❑h1ULT1UN1T' ❑STRUCTURAL
PANIi1S MODIFICATION
I.
ZOZt2 Z 1 understand my plans shall be u.d as he records
-C GET021x1 AMPS [I INTERIOR El CHIMNEY REPAIR
r,�FW Licensed Proielimnal 201-10MAMPS IMPROVEMENT E]SWIMMING POOLS
h �; OWNER-BUILDER DECLARATION
'a 1 herehy nfMn dont I ten exempt from the Ctinna,on"l.lcense Law I'nr iho OVER Itx10 AMPS C3 BATH RI?MODF:LIRI:PAIR DEMOLITION
YyS O y U following on (flection 9031.5,lhosineas and Professions Code:Any city or nonny SIGNS ELECTRICAL. ❑OTHER
ywhich reyubes a penoit m uonsuvct,.]ter.improve,den u�lish,m repairany�.wcmro
og prior to its issuance.also deputies he applicant for such Permit to file a signednmemcnt SPECIAL CIRCUITIMISC.
.j that he is licensed pursuant m the provisions ofthe CommonA License hw(Chaplet 9
X00 (commencing with Section 9000)of Division 3 ofthe Busineesand Professions Cnde)o, TEMP.MEIERORPOLE INST COMMERCIAL:
d y m y that he is exempt therefrom and the basis for the alleged exemption.Any violation of C1 NEW BLDG/ADDITION ❑DIiM01.ITION
�YC7 4•
Section 70315byanyappllcam forapermit subjects thenppllennttoacivil pennhyof POWER DEVICES ❑TENANT C1 17001)SERVICE
2q not room man five hundred dollar'(G$500).
SD IMI'ROVIiMIiN'I'
E]1,asnwnerofthe propeny,many emnml
employees with wages as their sole cx'nxLECI
ndon, SWIMMING POOL E 'It IC
(.., wth
Ill doe work,and fleormice is not intended or offered Rowle(See.)044.Business ❑OTHER
63 and Professions Code:The Coumnatnex License law does not apply man mono-of ^01 OU'ILF.'LS-SWITCHIS-F;cTURES
property who builds or improves thereon,and who does such work him If or through
his own employees,provided that such improvements art not intended or offered for NEW RESIDENTIAL.ELECB SQ lel'.
sale.IL hnweveq the nnildng or improvcmem is sold within one year of wmNletimn.lhe SQ.Ff.PL00R AREA 5/SQ.IT.
owner,hadder,xill Breathe harden of proving that he did not heild or improve for Far-
paeofmlc.), - TOTAL
I,as owner of the property,am exclusively contracting with licensed contractus to
construct the project(Sec.7044,Business and Professions Cmle:)The Contramor's Li-
u Law ares not apply to an owner of property who builds or improves themon,andQTY. PLU r PERMIT PFEE n A '
who contracts for such projects with a contractors)licensed pursuant m the Controls P M D
License Law, PIIRMI'I'ISSUANCE
Elm I aexempt under Sec. ,B&P C for this reason '
AIA ER-DRAIN&VII "-WATP, ) ,q�BO�'RON
•
Owner Data }� AZT
WORKER'S COMPENSATION DECLARAi'ION BACK FLOW PRO)RC'1, !Ihereby aW,.under Penalty of perjury one mile,fallowing cremation- '1 I
I have and will maintain a Cardu
ifcum ofConseno self-insure for Witrkds Camped DRAINS-FLOOR.ROOF.AR N .OSTO It IUSV TYPE CONSTRUCTION
soden,as provided for by Section PRO)of the Labor Code,for the perfmrmuncc of the
I ave and will maintain Worker's Compensation In.sunmeo,as required by Section
work for which this permit is issued 1)XI URES-PER TRAP
'
TIDO ofthe Lauhnr Coda,for the perfornmace ofthe work for which this permit is Issued. GAS-1A.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
My Workey:uEf�peysatinn Lnprani'c ria poli Policyn jjlm: q
Contac 1'�"� f Policy Na:-�/�—y./- GAS-IiA.SYSTEM OVER 4(EA)
CERTIFICATE OF HXEMPTION FROM WORKERS' GREASE%INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION FEIS
('this section need not Mmi
completed ifthe pert is fornnchundred dollars(SIM) GRRASETRAP
or IessJ 1'LANCHECK PIiH
Icnfil'y that in the performance of the work for which this permit is wood,l sholl SHWCR-SANITARY-S'H)ItM EA.200 FT.
not employ any person in any manner so as to become abject n the Workers'Qmnpcm ENERGY FEE
Z artium laws of Culifomia.Data WATER IfLOTER WIVENE&LECTR
GRADING P
Z Applicant tFEE
y NOTICE TO APPLICANT.IL cher raking suis Cenifcaeof Exemption,you should WAT IRI SYSTEMn BEATING SOILS ME
F' become subject to the Workers Compensation provisions of the labor Code,you must
forthwith comply with such provisions or this permit shall bedeemed revoked WA'I'ERSERVICE
Q
GONSTRUC11ONLENDINGAGENCY NEW ItESIDBNT1Al.1'LMIL SQ.PI', 1'AIU
p
U O I hereby affirm that them is a construction lending agency fnnm
he performance of )°¢ Recetpl
Els r the work for which his panni,is issued(Sec.3097,Civ.C.) TOTAL:
O 'he
Name
U Lendels Address TOI'A1.:
I ceni fy that 1 have read this application and state that the stove information is BUILDL PEE
Tao correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAI,PERMIT FEE
U 7buildingcomxumetiun.and French,anthmiz.e mpecanbalvcs of this city to rear upon the SHISMICF E
F4 above-merlin ad property for imptelmn purposes. PIItM'1'ISSUANCE
(Wed agree to.save,indemnify and keep harmless he City of Cuper ino against ELECTRIC IN',
limilitics,judgmams,costs and capsnses which may in any way rccrve against said City ALIERORADDTOMECIf.
PLUMBING IIT
in oarrAPPLICANT
Nthe STANranding of thisFront.WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CFO 10,000 CFM) '
MECHANICAL F'Ii
SOC CE REGULATIONS.
t / AIR HANDLING UNIT(OVF:R Itl,ll(p CPM) CONSTRUCTION AS
tg sure of ApplitenJVContredar ( me EXHA US'IHWU(W/Ul1C'D HOUSING MIp'IGA ION FF,F.
HAZ RDDIJS MATERIALS DISCLOSURE
Will maripplicant or future huilding oactIantsmreor handle havandomsmarurirl HEATING UNIT TO HALM BTU)
as defined by the Cupertino
of
Code.Chapter 9.12,and the Health and Safety
Cook.Section 255321x)9 1117ATINC UNIT(OVER IM."BTU)
❑Yes C]No PAID -
VI:MI'l1.KCIONFAN(SINGLERESID) Dat, Receipt#
Will the upplicam or future building occupant ase uympment or devices which
•emit hfroo mus air contaminants as refined by the Bay Arco Air Quality Management BOILER-COMP(3HP OR 100,00)BTU)
TOTAL:
District? BOII.HR-COMP(OVER 100.000 BTU)
F1 Yes C]No
I have real the hazvdom materials muniremems ruder Chapter(195 of the Cali- AIR CONDITIONER ISSUANCE DATE
forIF still&,a ty Code,Seclions 25505,25537 and 25534.1 understand that it list NEW RES IDENT1AL ME11. SQ,Pit
but in dors ten amenralyh atemlm.that it is my respmisihirny to notify the occulaa
one nemswItjch .I ba met P of r Ccntrate ix r nay.
r author".,a., OFFICE
TOTAL: ISSUED BY:
OFFICE