S 1171 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
RUILDING-KI,ISC'1'RICAL PERMIT NO.
CITY OF CUPF,RTINO
BUILDING DIVISION - APPLICATION/PERMIT TING PROJECT ICDANIF[C S 1171
BUILDING I'R(IJEL9'IDISNI'IFICA'f10N
SANITARY NO. APPLICATION SLIHMI'I'TAI.DATE
�(jIjI1.DING ADDRESS:
OWNERS NAME: PHONE: CONE CI'O 'g NAME: `I ..r�� NICCONTROL��
J /
- CHITECf/ENGINEER: LIC NO: ADDRESS! ❑
y �- -
CONTACT: - PHONE: BUILDING PERMIT INFO
371"// ❑ Consultant Fees Paid by Applicant(initial) BLDG ELHCT PLUME MHCII
LICENSED COWRACORIS DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby anions that 1 an licensed under provisions of Chapter 9(commencing
O�Z with Sectio 700,,Division 3ofthe Rosiness and Professions Cmde,vnd my license i. RESIDENTIAL:
W O PERMIT ISSUANCE.
�,_ in fullfnme and eR ZQ �iy �r ❑SIDWL C3 KITCHEN RIiMODIiI.
f..U Littnu Class Lick APPLIANCES-RESIDENT IAL ❑ADDITION [I PLUMBING RE:PIPE
tgZW Date Contractor, V44 -
F❑m •ARCHITECTS DECLARATION PANEIS ❑MUI:I'I-UNIT ❑STRUCI'URAI.
MODIFICATION
O
zp ZZ Iandeoloolary plansshall heated ns public records:] UI (x)
"102AMPS El INTERIOR ❑CHIMNIiY REPAIR
Fz G Licensed finfe....not 201-1000AMPS IMPROVEMENT (]SWIMMINGPOOI.S
<,l OWNER-BUILDER DECLARATION OVER IO )AMPS ❑BAI'II REMODEUREPAIR ❑DEMOLI I ION
PG U 1 bcrn chy uhrnthat I am exempl font the Cnnmtemr's License Law for 0m OI'I IIIR
LYS$O c.U following rnemo (Semina 7031.5,Business iced Professions Code:Any city or colony SIGNS ELECTRICAL 0
u+3 W F which..quires a permit to construct,alter,improve,demolish,or repair any snucmre
.0O./� piiormits issuance,also requires the applivunt fm.urhpermit lnlilessignedamemeni SPECIALCIRCUI'TtMISC.
„yy chat he is licensed pumu.nuo theprovislmnsof the Cnmmemr's License Law(Chapter 9
W C) (commenci as with Section 7")of Division 3 of the Business and Pmfesslons Code)ur TEMR.METER OR POLE INST COMMERCIAL
=a:e that he is exempt therefrom and the basis for the allcgN exemption.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
^w Section 7()31.5 by myapplicam fore permit subjects theopplicam m a civil penalty of POWER DEVICES [I TENANT C3 0001)SERVICE
are than Five hundred dollars(150o. all ROVE
F=CLmnwner mf the prnpeny,ur my employees with wages as their sole cmmpensminn, SWIMMING POOL ELECTRIC
will Jo the work,antl theswaure is nm imcnJeJ nr oflcrcdfnrule(Sec,704i,Business C1 OTHER
3
add Probes sions Code:The Contractors License Law Atcs ern apply m an Owner of 001—
OUTI-I fS-SWITCHES-PIX'I'URI
property who builds or improves thereon,and who does such work himself or through
t his own employees,provided that such Improvements are not intended or offend for NI?W RESIDENTIAL ELECT R .Q
Rule.It,however,the building or Lnprovententis sold withinune yearafcompledon,the SQ,FP.FLOOR AREA SOSO,Fr
tcrhadder will have 0e hunlen of proving that he did not build or improve her at- 5n A D
p ste of stdc.). T f
I,us owner or the pmpeny,am exclusively cnmmating with licensed commctnrs m
,em....n the project(Seo.9044,Rosiness mad I'ndcseions @Mc:)The Contracnsr'n Li-
onow, aw, does not appy 10 an owner of Property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE rrr
fon AII�fD
who contracts rsiehprojects with arommemr(.$)licensed pursuant nm
othe Commrn V HII
I.icende Low. PERM]f ISSUANCE 'iTy
I um exempt under Sec. ,B&PC fnr this—'an f !
ALTUR-DRAIN&VENT-WATER U?A)
weer Date
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
I hereby.hfirm under penalty of perjury one of the following dvelamtimr:
I have and will maintain a Certificate of Consent to selbinsure for Worker's Compun- DRAINS-FLOOR.ROOF,AREA,COND. S'IORIFS TYPE CONST RUCTION
,anion,as Provided for by Section 3700 of the labor Cale.Ends,perfmwooer mf the
work for which this permit is issued FIXTURES-PER TRAP
flLl hove.and will maintain Wallace.,Cmnpen.vulinn Insnrnnce,as required by Section
1191X1 of the Lolaa Code,for the performance of The work bar which this permit is issnud, GAS-PA.SYSTEM-1 INC.40il I'IA?'I'S (ICC.GROUP MIN
My Work.' Cnmpematum in...ance cur"'nmd Policy
Camen. YAl s Pokey No.: 60_"+`P GAS-EA.SYSTEM-OVI?R 4IRA)
CERTIFICATE OF EXEMPI]ON FROM WORKERS' GRI3ASFJINUUSTRI,WASTE INTI?RCEITOR
COMPENSATION INSURANCE BUILDING DIVISION THUS
(This section need not becompleted lithe pennon is formic hundred dollar,(SIlk) GRGASETRAP
or less.) PLANCHECK THE
Icendythat in the perfmmantt of the work forwbich thispermitisiseued.l shall SEWER-SANITARY-STORM HA.200 FT.
not employ any person in any manner so as ht become actio to the Workers cn-CompENERGY FEE
,Z Rasion laws dClih o rm.Date WATER HEATER WNENT/ELECTR
O GRADING F
Applicant ' IiIi
rA NOTICH TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMITREATING
become.subject to the Workers Compensation provisions of the Lubar Cale,you must SOILS 1117r,
lYi forthwith comply with such pmvisionn or this permit shall he Jecmed revoked WAdUK SERVICE
Q
z CONS]RUCTIONisLT10NLENDING
roduni CY NFiW RES IUF.NT'IAI.FLY It SQ.FC PAID
I hereby affirm that there ism"'wwednn lending agency for the petfmrmance of Dwm Remlpk
the work her which this permit is issued(See.3007,Civ.C.)
C1nU TOTAL:
Landers Name
1<nders Address TOTAL:
C I rinify That I have read this app irmian and tame that the above information in BUILDING ITE:
h "'noel.I ugrcem comply wilh.)[city and raunty nMiami.and dote laws Marc ut QTY. MECHANICAL PI?RMlt FEE
U z hui)dingconsracton.ondherehy anthome¢precentmivex ofthis city to p
enterum the SIi15MICF
u es.-Ou itloned properly for inspection purposes. PERMIT ISSUANCE.
I?LI?CI'RI f£E
(Ws.)agree ns save,indemnify and keep hawlcss the City of Cupertino again"'
liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER OR ADDTO MECH. PLU NC FE
1. equnn e,of the granting of this permit
APPLIC T NDERSTAN S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI['(TO 10.1X0 CFM) MEC A C ,FEE
SOLI F ULATIONS/JJ
w� ���9a���_ 4.� AIR HANDLING UNIT(OVER It1,11011CPM) C(lN5'IRUC' ION TAX
Eirk-mcit pplemitcmadctcr Umc EXHAUST HOOD(W/DUCT') HOUSING JITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre building occupont store nr handle to rordous material 11ENrING UNIT Oro dio,IXXI RTO)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Calc,Section 25532nd? / HEATING UNIT(OVER 10,000 BTU)
C]Yr,, I�,f9 VI?NTILATION FAN SINGLE HP_SIDI PAID Dole Receiptp
r - Will the applicant orfumre building acallem me equipment or devices xhich BOILER-COMP(3HP OR 1(X).(00 BTU)
Oil limamous air comaminams as defined by the Illy Arca Air Quality Meakicuunt T L:
'District? - 1301LER-COMER(OVER 100,000[THE
I]Yes `1; j
I have read the elmMon,materials rcquitemm�ts trader Chapter 6.95 or the Cali- AIR CONDITIONER ISS CE DA E
humin Health&Safety Code,Serious 25505,25533 and 25534.1 understood that if the N17W RESIDENTIAL MECIL SQ.Irl'.
building does not wrren0y have.tea a%tbnl h k my mnpmtsihibty,,mdfy lhenratmmt
of the mquiremrms which must be tact pdnr to isstamre of a Ccnmcate of Occupuney.
(Iwner nr authorized a gent Date ) ISSUED BY:
OFFICE