S 1994 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BDu.utnc..ELECTRICAL 1'It1W\FIND
BUILDING DIVISION APPLICATION/PERMIT PIALMUIING—MECHANICAL V 1994
WILDING PROJECT IDEN1'IF'ICA'1'ION
SANITARY NO. AI'PLICATION SUBMITTAL.DA'I'1?
BUILDING ADDRESS:
I
017q
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ARCIII'I'17CIDENGINBBR: LIC NOADDRESSCJ� ❑
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BUILDING PERMIT INFO
❑ CnnsuRant Fees Paid by Applicant(Initial) RLDG ELECT PLUMB MECH
111:1 ❑ ❑
LICENSE I CONTRACTOR'S DECLARATIONELECTRIC 1'EQIi
I herchy alum that I ant faenea order prnviaiama mr ebapmr 9(atmmencang JOB DESCRIPTION
awon with Sectinn7IXp)of DlvisionJof the Business anA L'rnfessions Gum,and my license is RESIDENTIAL,
won PERMIT ISSUANCE
�UD in full force andcBC C 36 93a`�C ❑SPuWL ❑KITCHIiN REMODEL
et. License Class Lich APPLIANCES-RESIDENT EAL C1 ADDITION ❑I'LUMBING RR-PIPE
F W Dale Common,
`al A' ARCIII'1'F.CFSDECI.AItAHON ❑MULTI-UNIT ❑S'IRUC'FURAL
— PANELS MODIFICATION
OZ-01+Z underrt yplan�y�J1#1gbeused ma puhlicrecdMs
4y / UP'f02t1(IAMPS ❑INTERIOR ❑CEIIMN17Y REPAIR
—Wconal -I IDI-HXIOAMPS IMPROVFMENT E]SWIMMING POOLS
JJ OWNRR-BUILDER DECLARATION
Q 1 nosh affirm Nat I mr,n cm t Ront the Cmdramor's Liccme Law for the OVER 1(XXI,MPS ❑BAITl REMODEIl1tIiPA1R DIih101.ITION
y� Y P ❑O'I'lllil2
111 6 (Scat(Scamm,711115 B.,ma,,and1 f.. Cd Any Oliver cnunY SIGNS IiLI:CTRICAI.
LL13LLy
'Id'h l "art1 a- r .lr l' J FI -I' - y.l,rar,
priono t,'swance,al+n requ ru the o,pl atiu.mch permit Ideas mad,mmrcm SPECIAL.CIRCUITIMISC.
� that he is licensed pursuarfto the provislonaef the CmunrOr's License Law(Chapmr 9 MA 1,V
.R�1pC) (commencing with Section 7fin of Division 3 of the Businessand Non,tra,Cada)or TEM P.MITER OR POLI!INS P COMMERCIAL'
a e Nat he is cscmpt therefrom and the basis for the alleged eaemplio t.Any vidialm of C]NEW BLDG/ADDITION ❑DEMOLITION
^ Sced 7031.5 by any applicant for a permit subjects the applicant in a civil mai of POWER DEVICES El TENANT ❑FOOD SERVICE
un
Q not more if Iiia madrmldollar,(&5W). IMPROVEMENT
~ ] 1,us owner of the Pomitry,or my empmyeev with wage,ae lhuir xnle mmpenwryon, SWIMMING.-OL, PCI'RI
F will do the work,and the sau®ore is not intended or offered for sale(Sec.70sLL
Business ❑O'ff11iR
3 m and Profe„ions Code:The Conlmemr's Liccns law does not apply to an owner of 011l'LI!I'S-SWITCH'S-PI URI'
progeny who builds or improve,thereon,and who does such work hiandf ornhrough
his an ctnpinyrm,Provided ihn such improvements an or intended nr offered it,, NEW RESIDENTIAL ELECT
sale.It,however,thalmd,ing of in"no tnenllssrdJ within nna yntr of cnmpluion,thr SQ,PI'.FLOOR AREA VSQ.FF.
ownehrikk,will have We a lerofpmvlmgthatbe did not build or itnpmreforpur-
pa e n'a1a.)L 'TOTAL' +
❑ I.as owner of the progeny,am exclusively contracting with licensed contractors w
onswet the project(Sec.7114.Bmioess and Professinn Cale;)'Fw Contractor)Li- -
erna law d«snot apply In ad owner ofpmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT PEE
whocananetsfo...an projrctswithucdntradm(n)lirunsed pirsmtnOil the Ctuarroa''s -
Liconsclmw PERMIT ISSUANCE v
❑I am exempt node,Sec. It&P C for this reason ` ^
Owner Data AMER-DRAIN&VENT-WAIER(EA) V 'VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE V
• I hereby offtmt under Pcnally of perjury one of time following declarations: Ix `�51`'.QYC
I have marl willmmmain a CertiflataofCunwaao,,elf-insure Nr Workers Cnmpen DRAINS-FLOOR,ROOF.AREA,COND. q S TYPE CONSTRUCTION
tylion,trs p,ovidal rorby Sind, 37W of the Lubar Code far dte perlitnnadsc of the
work for which this permit Is issued. FIX FIJR17S-PER'I'RAP a
El 1 have and will maintain Worker's Compensation Insurance,as required by Section v`at y
3700rfthe ratan Gale,fortheperformanttoffle work for which this Permit is ic,nd GAS-IiA.SYSTEM I INC.4 OUT[.-- fR APN
My Workers Compensation Insurance carrier and Policy number are:
Caviar: Policy No, GAS-PA.SYSTEM OVER 4(PA)
CERTIFICATE OY EXEMPT ION FROM WORKERS' GRIinSI%INDUSTRI.WAS Pit INTERCxI'101t
COMPENSATION INSURANCE BUILDING DIVISION FEES
U'llsscdicn meednolltecompleled iflhepennit is bi,mahundmddollars($I00) GREASETRAP
or less.) PLANCI{EEK FEE
Ioyany that Nc anyPerformanceo a, work Bit which this Permit isisowdLpan-shall SEWER-SANITARY-STORM EA.2W FE
oat employ ony person in any m s t t con d to the Workers'Contpett. ENERGY PEE
ant Aar
Z a ^I WAnilt DIATER WOVEN PFLEC R 0 V
y�yQ Applicant snrCol �� �/�_�� t GRADING FP,B
NOTICE 1Y)AP .CAH'':Ir {e eking this Certificate of lixentprion.you should WATER SYSTEM/IRFAI ING
(-' become suhjecuo the Workers Comgensalion provisions of the Lafax Code you nme SOUS PIiR
Wfonhwilh aontply wall such Provisions.,,his gamut shall be dcatned revoked. WATER SERVICE
Q
�'
CONS UCfIONLENDING AGENCY NEW RESIDENTIAL I'LMI4. SQ.IT. PAIU
UO Ibercby aflinn thatlre Nnx isnconstntdinn lauding agency to the lcrfnrmm
me of Uate It eipl#
the work for which this permit is i.csned(See.3097,Civ.CJ
C)U Lander',Natna TOTAL:
lenders Address T- M
W BUILDING PER
1 amity that l have mad this application and surae do the... infovration i+
rn armed.l remain comply wins Lal city add crony ordinance,and n,am laws nebula,to QTY, MECHANICAL.PERM]I' FEE
U ,7�. huild'mgcanntmtinn,are horuby nwhnri..e rupmsummivw of Otic airy roamer rpm,the SEISMIC PTE
above-mmninned progeny lit,m is,au r punpnms_ PFRMI'IISSUANCE
(We)unce to save,indemnify and keep harmless the City of Cupanino again, EhECfILIC I'EE
liabilities,judgments.Olsband aapenses which may in any way accrue against slid City AUF iR OR ADD TO NIECE].
PLUMBING IrCE
in nmscyncnce of Nc granting of(his permit.
APPLICANT UND RSTANDS AND WILL COMPLY WITH ALL.NON-POINT AIR HANDLING UNITUO E).OW CFM) MSCI IANICAI.FBE
SOUIM' ll IONS. i AIR 11
AIR UNI'I'fOVEN'0,000Cl'M) CONS'1'RIICTL'
N TAX
Si m u Plicara conlmatn, Data EXIIAUS'r HOOD(WIDUCT) HOUSING MITIGATION FEE
I IAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oceupanl.uore rr handle hamrdnu,macrid HIIAI'ING UNIT(TO I NONX)BTU)
as def dd by the Cupertino Municipal Cnde,Chapter 9.12,and the Ilddlh conA Safely
Code,Section 2.5.532(a)'I HEATING UNIT(OVEIt I(XI,O(Xl RI'U)
E]Y's Fl No YEN'I ILKI'[ON FAN(SINGLE RES]D) PAID
. Dam Receipt
Will the applicant or future building occupant use equipment or devices which #
emit hrmNnus air conmms iner as defined by the Bay Area Air Quality Management NOILIiH—COMP(JIIP Ok 1 W.OT(1 e'fU)
TO'
Disaic,' BOILHR—COMP(OVER IMOW BTO)
❑Ye, 0N
I have tad the hazanlnn materials requirements under Chapter 6.95 of the Call AIR CONDI I IONLR 'I ISSUANCE DATE:
fomia Health&Safety Calc,Sections 25505,25513 and 25534.1 understand that if @c NEW RISIDENTIAL MIiCH. SQ.IT.
building o,,rodc 51fly have a tenant.that it Is ra,at, nsibililytonotifyme....pant a
ofth a toe ofa Ccnifietncof Occupancy.
Ow rant) dagcm Dole 'T(YfAL Issuluo I{Y; R
OFFICE