S 0065 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO LU MING.MECHAL CAll[CAL EL+MIT rva ,.,nr-
RUILDINGDIVISION APPLICATION/PERMIT i'IAMBING�MP:CIIANICAI. �`(7 ��'�
BUILDING PROJECT IDEN'DPICAHON
BUILDING ADDRESS: SANITARY NO, APPI.ICA'I'ION SUBMITTAL DATE
Oe3.75 5AW FE2rlA�1 �r� r4✓� S�sU
OWNER'S NAME: PHONE: CON'TRACTOR'S NAME: LIC NO:
NIC COST ROLp
RCHHECGENGINEER: I.ICNO: ADDRESS: El SL�GZ
�/ tCS R C2t3
CON'T'ACT: PHONE: BUILDING PHRMITINFO
D�� t O i f0`O6!`382 ❑ Consuhant Fees Paid by Applicant(initial) G f;1�8C(r PLUMB M[CH
1.- J 1 10 ICI ❑
LICLNSEDCONTRA ORNDECLARATION TY ELECTRIC PERMIT FEE
I lamb,affirm that 1 oat licensed under provisions of Chapter 9(commencing _ JOB DESCRIPTION
! OWOOZZ with Seen..700r1 of Division 3ofthe Businayeand Professions Cedc,and my license is p[RMI'1'ISSUANCB RESIDENTIAL'
Fcc_ i^full force and effect. ❑SFDWL ❑KITCHEN RT:MODHL
t—u License Class Lic.M APPLIANCES-RESIDENTIALPOP[ON El PLUMBING RE-PIPE
F-Zn1 rum Comru lm
ARCHITECTS DECLARATION El PANELS ❑STRUCTURAL
ZOyZ IC
I understand my plans shall he used os public records PANELS MODIFATION
O'Z4O UP TO 200 AMT'S ❑INTERIOR El CHIMNEY REPAIR
F.Fac Licensed Palestinian 201-IMIAMPS Q IMPROVEMENT Alt❑SWIMMING POOLS
OWNER-BUILDITR DECLARATION as
I Touchy off tin that I am exempt frna the Comma...',License Law far the OVER Ig10 AMPS ❑BATH BE Yi W F. I E]UIiMOLI'll(IN
O y u following reawn.(Section 703 1,5,Rosined and Professions Gude:Any city or county SIGNS ELECTRICAL ❑OTHER
4 O F which requires a permit m at caroict,alter,improve,demolish,or repair uny a rucame
V0a prior It is Varince,also requires the applicant for such Parini,in fila^signed statement SPECIAL CIRCDIDMISC. '1 � � eCAIA
y that he is licensed parsnaatto the p..visioo,mime Contractors License Law(Chapter 9 -RIi-�_-o—RED'
W L'�Q Icommencingwah Section 7")of Division 3 ofthe Business and Professions Cab,)or TEMP.MRift OR POLE ENST. I
d ¢ that he is aempt brief min and the basic for The alleged aomption.Any violmlon of ❑N�(IyIq1B1�V)((''IIpppIJ art DEMOLITION
+ cols- Section 7031.5 by any applicant for a permit subjects the applicant a civil Penalty of POWER DEVICES OTFAAfVI_Vr_ H DSERVICE,
t mare than five hundred dollars(SSW).
hZP IMPROVEMENT'
6 [7 Las owner of Tooad pmpmaalmnon,employteswith wred I.. .ltheir sd.7044,rumor msearn, SWIMMING POOL F.LIiC'I'R1C
O will norm work.a^de, per eamiators Licdnsei-ae does .,aplytoan Business El Or
3 end Prnfexsians Gxk:'fhe contractors License Iyw Jtcs nm apply to an owner of OUTLETS-SWITCH -EXT,
property who builds or improves Thereon,and who Joey such work himself or Through
npl
his awemuyecs,provided NU
that such improvements are not intended or offered for NEW'E"Tar AL ELECTR lel'
sale.IL however.the building or improvement is sold within one year ofcomplmlmn,Ne SQ.Fr.FLUOR AREA S/SQ.IT.
ser builder will have The burden of pursing that he did not build or improve for put-
Dew ol'.eale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors bu
umswn the printer(Sec.7041.Ilusiness and Pond ssims,Code:)no Gm unler's Li.
cause Law does not apply to as owner of property who builds or improves thereon,and PLUMBING PERMIT FEE
who cnntrat for such projects with a comreamr(s)licensed pnrsuanuo the Contractors
risatsc w PERMIT ISSUANCE
Ianander Sec. &P C burns reason
ALTER-DRAIN&VENT-WATER IEA) VALUATION
Date
WORKER COMPENSATION 101CLARAT(ON BACK PLOW PROTECT.DEVICE dacni
1 hereby o1Rrur under Penalty of perjury one of the fullwwing declamtionr, 4=7�J
I have and will maintain a Certificate of Consentto self-incase for Workees Coupon- DRAINS-FLOOR,ROOF,AREA,COND. S'ioItl 'TYPE CONSrll ION
smioa,as provided for by Section 3900 of the Lahor Code,Torre Perlinmanm or the
work for which this permit is issued. I FIXTURES-PER TRAP
I leave and will maintain Workers Compensation Insurance,as required by Section
3700of the Lahnr Code forthe Peerfonaraw,ofthe work for whichthis permit DT Issued GAS 17,A SYS'1'LM-I INCA OU'1'LETS OCC.OROUI' AI'N
My Workers Compensation Insurance tamer and Policy number am:
Carrier; Policy Noo GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION 17IZOM WORKERS' GREA51%INDUS'I RL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION
(This section need not To completed ifthe center is forams hundred dollars'(SK(ff GREASETRAP
or loss.) PLANCHECK FEE _
I cenifythat m de performance of the work for which this permit is movii,lsholl SEWER-SANITARY-STORM LA.2N)FT.
not employ any person in any manner so as to become subject m the Workers'Camper- ENERGY FTE
Q z patios Laws of Cubforma.Data WATER HEA'rpB WNENT/ELF.CTR GRADING PEEis
Z O Applicant
ti NOTICE TO APPLICANT:If,after making this Cardfucme of Esemption,you should WATER SYSTEMTRF.A'1'ING SOILS I li s
a , Tacoma subject T9 the Workers C ral ensmion provisions of The[-shot Code,you must
Ra forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
a QAll
CONSTRUCTION LENDING AGENCY NIiW ItESIDF.N'I'IAL PLMII. SQ.FI'.
` z I herehynn that is a construction lending agency for the Performance of rte Receipr
U P affrg
V he work for which this permit is issued(Sec.3097,Civ.C.)
0 V. � [.enders Name TO'IAI:
V Lemli Address 'TOTAL:
1 eerily that 1 have read this application and slate them rhe abuse information is - BUILT
correct.I agree m comply with all city and county m&mnces and state laws relating us QTY, MECHANICAL PERMIT FEE
U �' building maswninn.and herehyuuthorize represenearives ofthis<itymemerupon the SEISM CFEIi
nbnve-memitneJ property for inspection purposes. " PERMIT ISSUANCE
(We)agrw m save,indennnily nnJ Acap harmless the Ciry of Cupartin^nguinst ELECTMl
Iiubilincajudgments.costs and expanses which may in any way inertia against said City AITERORADDTOMECIL
inconsequence of the granting m bis permit. INGI G
AP NT UNDERS'T'ANDS AND WILL COMPLY WI' 1,1,NON-POINT AIR HANDLING ON IT(TO 10.(rdUCrVU
SOUR ' CULATION, ME. CA FEEq 6-16 p AIR HANDLING UNIT(OVER M.MECIM) COb' RUMHO TAX
Signatureo pplicantlCoulon V Data P,XHAUS'P HOOD(W/DUCT) HOUSING MIT IGA ION FEE
HAZARDOUS MATERIALlit DISCLOSURE
Will the up,,licam or future building tmcupant mora or handle huzallous material I HATING UNIT(TO 100PM RTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Gde,Section 255320)'! HEATING UNIT(OVER 1110,030 B"rU)
El Yes Fl No PAID -
VHN'fILAI'ION PAN(SINGLERBSID) putt RccciptM
Will the applicant or future building occupant use equipment or devices which� BOILER-COMP(3HP OR 100,000 BTU)
cast hazarlous air contaminants as defined by the Buy Area Air Quality Management 'TOTAL:
Uismmft
❑Yes E]No [TOILER-COMP(OVER 100,000 BTU)
Ihave read the howardnms ntamrluls requiremmnK under Chapter 6.95 of the Call- AIR CONDITIONER
ISSUANCE DKI'li
Runs Health&Safety C.M.Sections 8505.25533 and 85 rL 1 understand tha if the NEW RF_SIDENTIAL MECIL SQ.Fr
building does not cunantly Imve a mman,that it is my rape sihili,m notify the rccupaat
of rhe requirements which umst bl met prior in Issuance of o Certificate of Oceupmmy.
zi
Owner or authorized agent Date T :3, ISSUED BY:
OFFICE