S 1631 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BNI
UU.DG.ELECTRICAL Pc IT NO
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT
ICIIANIFIC 1631
IIf111,DINC I'RO.I F.CT IURNTIFILA'I'ION
HUILDINGADDRESS: (UUI N 7jf4e_ 1eI } Q sTE,L1SANITARY NO. APPLICATION SUBIT
MTAI.DATE
S
t R'S NAME: PI UNE: CONI RACTOR'S NAME,: hIC NU:
C( Vllp/� L IV S7U N/C CONTROL Is
! ARCIIITEC111iNGINIiIN: LIC NO'. ADDRESS:
7143 Aor SvZo"w f?cQ s1 ❑
• £5799
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fces Paid by Applicant(Initial) HI.DO ELECT I.UMH ME CH
SI 'D swIs '-7 .17-31-71 E-] ❑ 2�_
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby atnmt that 1 am mown ander Imevixiena of chapter v(emnmencong JOB DESCRIPTION
OaZwith Sedof nivlsi
ien 70 n 03afthe nudne.smN Prorcasiuns code.onA myllecn.c iv RP.SIDP.NTIAI:
W 00 I'IiRM111T ISSUANCE
W• in full force and�T< ,,,,,
4'U~ License Claw_CI—L.-L�L Licp 12-1 (015 70 �SPDWL ❑KITCHIiN HE\90DIi1,
Q U �. �_� APPLIANCES-RESIDENTIAL. ❑ADDI'T'ION ❑PLUMBING R6PIPE
yzw One--.4-gj Co."
AItCHIT1iC1"S DECI.AR PION ❑MULT1-UNIT ❑STRIICPURAL
F D N PANELS
Z0,AZ I turnaround my plans shall be used as public records MODIFICATION
OZEn-M UPTO20OAMPS ❑INTERIOR ❑CHIMN17Y REPAIR
F t3.E-t•�a I.irenoed l'nticsland 201-I0IXIAMPS IMPROVEM17NT El SWININING POOLS
sat,n,...I1I OWNER-BUILDER DI!CI.ARATION OVER Intro AMPS El PAS I<P.MODI?IIREPAIk (]DEMOLITION
C C Q 1 hereby affirm that I am so On front the Contractor's License Low for the
d 0 W U Itsllon in remoa Section N3 LS.If winos and Professions Code.An t aunt ❑OTIipht
g ( Y any or Y SIGNS HL HI RICAI. �^
which requires a permit rt cnnstruco,alter,improve,demolish,or repair any stricture ��` L�
prior to its isammce,nlau mgain,thenpplicnm lit.math ormi(to file aslgnedsmaaOm SPECS AL C I RCUI'1'/MISC.
>, that he is licensedpammantotheprwisionsorIliaContractor'sLiceraeLow(Chapwr)
u1S,00 (commencing with Section A(ND of Division 3 of the Business and Professions Cde)o, :MR-MIrZ ER OR POLE INST. COMMERCIAL:
d q a C that he is exempt therefrom and the basis for the alleged eaenmpoion.Any viol miI n of ❑NEW BLDG/ADDIi'ION ❑DEMOLITION
iC V. Section 703 Li by any uppli,am Cora Ynrit nah',at,the tmplicant to a civil penalty al POWER DEVICES W• y ❑T17NANT ❑FOOD SERVICE
neo nmre aunt five hundred dollars($5110).
F Z>' IMPROVEMENT
Q ❑ Lmowner k,and Pestruct re is employees mothered
for their sole 0-FE,
linen, SWIMMING POOL ELECTRIC
will do the work.and the ate Cont a norfor intended ontw do hx of rally ,,an Business ❑OTHER
lW R m and Professions Gxle:The Conrtuuart's License Law does not apply In an owner or OU'ThPTS-SWITClIHS-FIXTURES
property who builds of improves thereon,and who does such work hlnmulfnr through
his own employees,provided that such improvements are not intended or offered Im NEW RESIDENTIAL Ii1.ECfR SQ F .
mle.If,however the building or impmvemcm issold withinore ycarofcompleoion.the SQ.IT.FLOOR AREA snag in
owner-badder will monde hander of,roving that he did not builder improve for purr
pose al'mle.J.
I,as owner ad the property,nm exclmively cou rumin,with licensed contractors In )TAI
c meuva the project(Scat III4A,Business and professions Coval The Commmoru
sense Low docs not apply m n,
an owner of property who builds or improves thereoand QTY, PLUMBING PERMIT F
who contmclx for melt pnijcem with a amvicetnrfs)IlcemW @iruvm Sort,Comnulnr'x
License Law. PERMIT ISSUANCE
❑ I am exanpo under Sea. ,B&I'C for this reason
Owner Doc
ALTER-DRAIN&VI?NT-WATER(EA) VALUATION
_ 0
WORKER'SCOMPENSATIONd, per.,
DECLARATION BACK PLOW PROI'I?CT.DEVICE J�
�r5 I nand w affirm maintain
title,Certify of of
enc of mf-invure ung decWorker',
W Ihmaandwi11 ist bit by Se Certificate 700 of he LahrnCode,l tthere Wnrkar..Out er-She DRAINS-MOOR.ROOK AREA,GOND. STO IIS TYI'Ii CONSTRUCTION
smith,us hick his
for by Section 3]nll of he Lunn.Code,for the perfnmmnce Out the
work forwhich chispermit is.,kcl. PIX rUl<I3-PF.R'1'ItAl'
❑I have and will ado,fon Workers Compensation rkfor hi h required by Section
My of the""', Code,for the peraxmanect I work for whichthispemnit is iauen, Gqs-EA.SYSTEM-I INC.JOUTLG TS OCC.GROUP APN
C Wor re Com 'a Inuurancc,nrzie Pon Policy numhcr are',
Currie. � � Pnllry No.: OAS-I?A.SVSTEM-oV HRG H'.AI
f7FRTTFICATV or EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIIINDUSTRI-WASTE INTERCEPIDR
BUILDING DIVISION FliliS
(Thule«tion had not bcennnplmN if that lwrmit in fornnu hundred dollar is 100) GREASE'[RAP
nr less.) PLANCIIIeC Pli
Loy any meson in perfimramanyinannca rof as
o,k for Is,omewhichthis pe the Workers'
Coam hall SHWER-SANITARY-STORM EA,2W FE
not employ any person in any manner so as m become subjen m the Workers'Cotnpem F.NF.RG E
ZZ cation LawaofCitif..ora Data WATER HEATER W/VHN'rIF:L11CrR
Applicerl GRA N( C
NOTICG TO APPLICANT:If.after making this Cenifcmc of Exemption,you should WATER SYSMMU1117ATING
a > harem,subject m the Workers Compenuation provisions of the labor Code,you must S S 13
fIJ t,
forthwith comply with such provisions or this Permit shall he deemed revoked. WATER SERVICE
1 Q
�
CONSTRUCTIONLENDINGAGENCY NEW RESIDENTIAL,I'Ln1B. SQ.IT Z U Dom Hacipt p
U O Inereny arum that mere i>aa,mwennn lending agency for the Perlmmoan,e of
the work(or which this permit is issued(Sec.DPA.Civ,C.)
0 tUendo',Ni a TOTAL:
lender's Address 'I'OI'AL�
1 certify that L have read this application and note that the abswe information is H ILDING FEE
fA cormet.I agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL PERMIT FEE
UZ trading eonshnctlon,and batch,t In....a rcprescrtaivwuflhis oily mento.n,rnnthc .ISMIC LEE
uhnvementioned property for impu'ISon pm,coas. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Culcrtino against EL-CIItIC FEE
liabilities,judgnmms.cosuandespenses which may in anywayaceme against said City ALTER OR ADD TO MECH.in mnscquenee of the gorming of This permit, PLU.IDING FHL(
APPLICANT UNLESS'TANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'('PO 10,000 CFM)
MSCI NICAL FEE
F UL O'S. �
AIR HANDLING UNIT(OVEH 10.000 CFM1D CONS'TRUCE'[ON TAX
Signa ora fAiguIE116i rector Date`1[ EXHAUST HOOD(W/DOCT) HOUSING MII'IGA'I'SON FEE
RDOUS MATERIALS DISCLOSURE
Will the applicant.,future holdingoccupantstoreor handle homiloe mncn.) HEATING UNIT(TO 100,000 IITO)
as defined by the Cupertino Municipal Code,Chapter 0.12,and the Webb and Saba, So t2
Cale Section 2553200? 1]RATING UNIT(OVER IOQ(Sisl BTU)
❑Yes �Nn VEMI'ILATION PANS INGLE HIS ID) PAID -
Dam Receipt M
Will the applicant or Pour building by tiro B use ea Air Qu nr devices which
cInil hneunhms trir enntuminon0 ux JaEncd by mho❑try Arca Air Quality Mnnugmncnt BOILER-COMP(AIIP OR 100,000 BTU)
TOTAL:District?
❑Yes DENo BOILI3R-COMP(OVIiR IIXlxI B'N
gJ
G� AIR CONDITIONER
Ih:nc read the hmnnlnm nntmrivlo ruluirements honor Chnpmr[95 of the Gili- 1A' ISSUANCE DAT(?
Enron Health&Safety Code,Sections 25505,25533 and 25534.1 understand that it The NEW Rf SIDENTIA.MECH. .Q.FT.
Or docs no¢u 1 roul,thm'�is my msrymsibility at notify the warrant
rte,mpurct (s hich n. IE t�rt prior to txsrnna a'a c,nnrcac e Oce an
owner. ImoiA,11 a � Date v '1'O'1'AL: ISSUEDRY. 'TOP �Ton.:cGf
OFFICE