S 2483 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RI CAI, PERMrr NO.
RIJIIAIft DIVISION APPLICATION/PERMIT PLUS1141NG-MECHANICAL S 2 4 8 3
�. BUILDING PROJECT IDF-"IFICA'I'ION
BU)LDINGADDRFSS: SANDARYNO, APPLICATION SUBMITTAL.DATI
r/G: X� s � E31 ud t
2-- 3-92
OWN1314 SNAME: O PHONE: CII 'fRACIY)R'S NAM13: LIC NO'. _
` 05 NIC CON'180LN
III'MillCII I'rECT/F NGINEI3R: t%p LIC NO: Ah1)RF.SS.. % J �VL/J` ❑
( CONTACT: PHONE,: - DU ILDING PERMIT INFO
2 / lift,
/1 t, tel- ❑ Consultant Fees Paid by Applicant(Initial)' BLnG 1L.Ccr PLUMB MECO
f l CY C� C�7j ❑
LICENSED CONTRACTOR'S DECLARATION QTY - ELECTRIC PERMIT FEE
I hit iffimt that 1 vat licensed under provisions of Chapter 9lanmmcncing JOB DESCRIPTION
WOO with Section 70X00 mf Dittman.3nfthe Busimessand l'mfessinn,Gsde,andmy license is RESIDENTIAL
:
WOO 1'13RM111'1'ISSUANC�
�~U CU Incei OClas cli«t O ❑$FDWI. ❑KI'ICHON HRMODF.1,
UU License Clercs Lic.sslyuzill Oki APPLIANCES-REST DENTIA I. ❑ADD]'I ION El PLUMBING RE-PIPH
N6 a Dae Gruner I, -
NOH ARCHITECFS DECLARATION PANELS ❑h1ULT1-UNIT ❑S'T'RUCTURAL
ZOyZ I understand my plana shall be usedas public «ords _ MODIFICATION
OZ-o UP TO 200 AMPS ❑INTERIOR [:1 CHIMNEY REPAIR
I=�F'ul Licensed Professional 201-1003AMPS IMPROVEMENT 0SWIMMING POOLS
t OWNER-RUILDER DECLARATION OVERIOINIAMI'S G4119TI RE ODHL/REPAIR ElDFMOIAHON
at
lee 1 hereby afrrin that 1 vexempt from the Contractor's Licence Law I'nr the
a a U following reason.(Section 7031.5.Business and Professions Coca:Any city or county SIGNS ELECTRICAL (]Ol'HLR
��F' wl(l y I II ....... ' Y.Cne
1 r p I':I pwre
F+.. primu,I I: y rc ,happ! ,batsmen vionitt flea .b damenem SPECIAL CIRCUIUMISC.
EVtyl N} than licensed p tt they t fth Contractor's L 1' (Caapmr9
Coo (con eruct,w)h Secto17000) lD'vl,im 3 mfthe Business and Probatons Ctde)tr TEMP.MIi I'ER OR POLE INST. COMMERCIAL:
that be is exempt therefrom end the basis for the alleged exemption.Any cadminn of NEW BLDG/ADDITION ❑I)EMOLI'I'ION
li Section 70315 by ac,.p,li.nl for.penal,subjeax Che applicant too civil penalty of POWER DEVICES
l^m of nem than five hundred dollars($500). ❑TENANT ❑FOODSERVICE
.H. i+ IMPROVEMENT
Q Ql,mnwnnr Ol'the pmpeny,or my cmpinyceswiih wvgen us Omirsnln cumpenaaio., SWIMMING POOL FICCI RIC
S F=..O will do the wnrA.and me.amewmi.c not imm�ded nr nlereJ far wle!Sec.]014,Business ❑0VHER
a 3 and Profession,Code:The Come ants License Law rices not iii ,,an owner of OUTLETS-SWI'I CIES-FIXTURES 0
property who huilds or Intprovus 1h«eon,and who docs such work Onoodl nr lhoegh
his own mnployue%,provided that such improvements are not Intcnde0 err offered 4a NEW RESIDENTIAL BLECEN SQ Pf.
sale.U..however,,hebuilding oriniprovement is sold simianae yea of conafatiogthe SV fI'.R(%IRARIiA USQ.IT
crhmlder will have the human al socing that redid!not hnlld nrImprove kor puf-
pns1 of soled.
I,as owner of primary,ppeny.am caclmivcly contracting with licensed rommaors m
instruct the protect(Sec.7(144,Business and Profen%inns COAs:)The Cmmmnor'a LI- - -
seLaw does nmapply manowner OfPntpertywho milds nrimproves ihereon,said QTY. PLUMBING PERM I'1' FEE
who contral for such projects with a cmmmemrls)licensed pursoam to the Conmecm/s
License Law. PERMIT ISSUANCI! ro
❑ I am exntin under Sea. ,B&P C lar this reason -
Owner-� Date Arll-DRAIN&VENT-WATER IPA) VALUATION
WORKI!R'I COMPENIAIION DbCLARA'1'ION T.BACK FLOW PROI'FCDHVICE
mt I hereby Infunder penalty of Mrjury one of the following dealamtion¢
L] I hamemd will maimmna CeniGcare of Consemut self-i...refor Wnrkefs Compen- DRAINS-FLOOR,ROOF,AREA.POND. ST ES '1' PECONS'IRUCI'ION
Indian.as prnvidad for by See on 3700 of Che Labe Code,lin the peali,mare:of the
work for which this permit is issued. 1'lXTIIRES-I'ER'I'12AP �. J
1 have and will maintami
in Wude,'s Cmnpcnson Insurance,as tnyuircd by I cirri
3 Ill,I me Lahnr Cade,for the pelort tiof thew ork for whichmis permit is!,sued, GAS-EA.SYSTEM-I INC,4011T HTS mee, ROUPyPN .-•a
My W1rkcYs pcn%vlion nwmnjjacv Jy No,nmthvrar�� 135-?A
Q
Carrier�}F(II Policy Nn:W WORKERS'
ODO/uy' GAS-EA.SYSTEM-OVER4(EA) Q 2 OO O
CERT'IPIC O
O,EXE IIICOMPENSATION
INN FROM WORKER$' J
COMI'I3NSATION INSI111ANCI? 01t13AS13lINUU$'I'RI.WAS]1;1 lN'I'HRC
RI111.DIN0 DIVISION FEES
mneNs.)
(This seainmteeJ not aznnnple¢J fair pc ,is fnnmc hunJmJ JnllanYI00
( ) GREASE TRAP
F cu c 931i
I cenilythat in the pmrformm�ceml the worktewhichthi"arel lsi...a,],l Out SEWER-SANITARY-STfIRM EA.21 1'.
nmanplOy any person in any manner sn ac Int Fecnnnesubjecturthe Workers' ...died- 1!NF.RGY
z sminn laws of Cnlifeniv.Dote WATER((EATER WNEMI'A!LECIR
'
O�jQ Applicant \ GRADING FE
G = NO]ICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTENVI'RRATING
F become subject to the Worker's Compression provisions Of the Labor Code,yen matt 1711l Flili
fnnhwhh connplywim such provisionsorthispevmtit%hall hat Jeonsed revoked. WRIER SERVICE
a �
]
CONSTRUCTION f10N LENDING AGENCY NEW RESII3ENTIN,PLM11. SQ.Il'. PAID z Ihereby nfrirmllnnnhcrr lxucmnx0unionlenJing agceYforthu perfnnn,mxenf faro V NcceiptX
U O he work for which this permil is issued(Sec.3097,Civ.C.)
Lender's Name TOTAL:
V Lender's Addoe, if)
>i Q., I cenily haat 1 enc rend This application and,late mat the albse a informin a in It U I LD1 TF /
F'(A context.I.,.,a comply with rill cit and mumy orthimac,and stale laws elmilli QTY, MECHANICAL PERMIT FEE
L Z building constmetiowand hereby uutheriec representatives ofthis city to enter uptime SEISMIC . 7
above.menrmtad pmpeny for la,protio I purposes.
(we). mxave,maternityand kec bemlesame Cit fCa ulnae I I'1!RMI'f ISSUANCE 131.IiCTR .FEE g,fialbQ
gree p rat pe anis
in
O,ai,seenol the
and expenses which may in anyway accme against said City ACI'ER OR ADD TO MECH. /
in ennscquencm nl'me granting of laic at it. I'LfIMBL G FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT ITO 10.0011 CPM)
SOURCE REGO \TIONS. MIiCHANI AL IyiE
p -� � �� w-
r -L C"64A a1a79q HANDLING 11Nl'f(OVER IgfXIf)CIM) pNST'IIIIUfION'IA%
Signmu mf 0xandCOamcIaT /mate EXHAUST HOOD IW/DUCT) HOUSING MITIGATION ITE
HAZARDOUS MAI'FRIALS DISCLOSURE.
Will the applicant or future buildinge'copmustoreor handle h....cmusnmtentil HEATING UNIT I ID Fitmn B'FU)
x defined by the Cupertino Municipal Ctce.Chapter 212,and Ne Ilwlth and Safety
Ciae,Section 25532(arf HFADNG UNIT(OVER 100,00()Ill 0)
El yes )
)onVENTILATION PAN(SINGLE kESIDO PAID Dec k 1X 1
041,
Will @e vcampplior Towne building weupmd use equipmentnr device,Which
emit hazardous air smwnninants us defined bythe!lay Area Air Quality Metal BOILER-COMP(3HPOR IBQ0IN)11T11)
District? >'I'AI
❑Yes ver BOILER-COMP(OVER 1X0,00081'U)
I��{{ mad rite baN
raous mammals rcyuircmanN�unJer Chapmrfi95 of me CWAIR CONDI I ION13Ri- ISSUANCE DATE
more He{Idt&Safety Cade,Section,25505,25533 and 25534.1 understand that if,he NEW RESIDENTIAL MECII. SQ.Fr. Z
Waiting dddddd,.rot 1 cr aynEven l"n Lthin iti.my re.ponsiidityin malty the numtm
ofthe Cryo' , (wh�i�h.nest be tt pr/i�r�m,issun�ofv Cenifizv ,lO
NL� 7 PlatL 9 ISSUED TOTAL'.
b 11 V:
OFFICE