B 0412APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - MECITRICAL PERMIT NO.
APPLICATION/PERMIT rLumnmcntecnnmcnh •�J LIIj}�l�k�..Y�
n OOODIN1, DIVISION f uvu mfr: mall]NIT HIVNIOFICATIIA' `"""'• ILLJ 1!�
1 ,333 V
0-224,
p I hereby alarm that I am licensed under provisions of Chapter 9 (commencing
tri apz with Section 9(X0.1) of Division lot he Business and Professions Core. and my license is
1- in t a lllinceandencel.
QU U License Class Lie. p
h G L Ilam Contractor
•^ARCII ES. .ARATION
F H Z IA dclsmnd my pla'�blie records
n0tA= LL
❑ Coremllant Fees Paid by Applicant (Initial)
C.1 DILDER DECLARATION
C ❑W`. Q I hereby allirm mat 1 am exempt from the Commerce s e Law for rhe
ig(O y U following teas..n. (Scctinn ]8315, Btonieva and Profc,aion, Cr my
W i LL N which mi,or,, a permit In canavoa, tomo, improve, demolish, repair any
O Q, prior to its issuance, also requires the applicant far such permit v e a signed sat
�y,bar hcislicemalparsuam1.heItvn:an,ofthe Commeloe, (Ch'
yrp0 (commencing with Section](XX)) it Division 3rfthe Future, PnolexlousCor
c a e �a mar he is exempt therdr
rom and the basis for the alleged exe on. Any
it `t"y f l
m Section 703 1.5 by any applicant for a permit subjects the appli ). a civil malty` f
not more rhnn five hundrW dnllurx(551X1). `'�
O p h as owner of me pmPerY, may empinyms with wages as ]heir sole C.mpenvfio6"
F will do the work. and the amcmrc is not intended or offered forsele(See. 16X. Business
tail m
..it Professions CJe: The Contractor's L'ee.w, Luw due mol apply to un owner of
m' 3 .. 111 who builds or improves the on. and who does such work hinamlf or through
his own employees, provided that such improvements are not intended or offered for
sale. 11, howcvea the building or ilnpnrvceirm is sold within one year ofclairdi inn, the
coin ilder will have the burden of proving that he did not build or improve tar pur-
pose of wlcd.
❑ I, n., owner of be pnryeny, alt excluxivcly contracting whn licensed convene, an
onMmm the project (Sec. 90H4. ]business and Prdc,sions C(A0 The Commeba's Li.
u law does nor apply to an owner of pmpcny who builds or improves thereon, and QTY.
who corbuatx for such project, with a corbacma,) licensed pursuanuo he Contmemfs
Licemc Law.
I am exempt under Sm. . B & P C for this reason
mer Date
x WORKERS COMPENSATION DECLARATION
I hereby allifm under Penalty of perjury one of the following declmmion,
❑ I have and will maintain a Curti licam 0 Consele m selDinsurc for Wnrkcr s Compm-
satinn, as pmvidJ far by Section 37M of the LaMn CJc, for me performance of the
work for which this permit is issued.
❑ 1 have u nd will co'd'a uin Worker's Cnnlpens cion Insurun , as required by So tit e
311X1 of the labor CJs. for the performance of the work for which this pencil is issued.
My Workers Compensation Insurance carrier and Policy number a2:
Caraicr: Policy No.:
CERI'IFICATF, OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be compared If the permit is f.ronc hundred dollars 0100)
or I"'.)
1cenify that int he
performancece of the work forwhithis Permit.l Ihall
nm enploy anyptnn in an,annumeaxm necamexanjem 1. he wa,Ierr,'C.m,n-
O Z sation Laws of California. Dom
O Applicant I
Z N NOTICE TO APPLICANT: IL after making this Cenifietac of Exemption, you mould
a; occnnm sahjul as the Wafkcf, Compensation pmvisinns of the lahnr Code, you moa
Wfoahwlm comply with such pmvisl...... his permit shall he deemed revoked.
utaa CONSTRUCTION LENDING AGENCY
V C) I hereby affmr that ry
hem is a constcrinn pending agency lin the performance of
LL —the work for which this permit is issued (Sec. 3037. Ci,, C.)
C) U Lander', Name
}L[1 Lenders Address
L I minify that 1 have read this application and state that me above information Is
LF. H correct. 1 agree m comply with all city:uW county ordinances and store pawn relating It, QTY
L) Z building creamed., and hereby truth ..rim m,mscr nne,olthis city uta enter upon lire
above-mentioned prnpeny, an inspection parlous.
(We) agree m save, intle rify and keep harmless the Cay of Cra,mro.,am,l
habildics,j idgment,, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICAN'p' UN Dr:os;Tnv DS ANI) WILL COMPLY WITH ALL NON -POI N'1'
...e..___ _.
HAZARDOUS MAE g ERIALS DISCLOSUREhandl
Will the applicant ter forum building occupantsmrcor handleHeard, and
ax Jdined by the Cup+eninn Municipal Code, ChaHc
ger 9.12, and the Head, pand Sulnly
�1Ne. Section 25532fa1' .� Yi
/%^af�'
❑Will me applicant or Iulam M1uilding occupant use equipmmnt or devices whkh
emir haeardous air contaminants as defined by the Bay Area Air Quality Management
District'!
❑ Yes
1 have rend the naearloua materials requirements under Chapter 6.95 of the Culi-
former Health & Sal 255(15, 25533 and 25530. 1 undemand that if the
buddine does nm currently have tons tis my ressmsibility to utility the ocmrym
ELECTRIC PERMIT'
PERMITISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TO 200 AMPS
]ELECTRICAL
POWER
(Il1TLIi FS - $WTFCHEN - RGWS
NEW RISIDENTIAL I:I.I:CFR SQ FF.
W,
INFO
SQ. Fr.
SISQ. FT.
PLUMBING PERMIT FH
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�% D
C
I'li I' "'DAN",..
FEE
JOB DESCRIPTION
RESIDENTIAL
❑SPDWI. ❑ KITCHEN REMODEI,
❑ ADDITION ❑ PLUMBING RE PIPE.
[I MULTI -UNIT ❑STRUCTURAI,
MODIFICATI(IN
❑ NT17RIOR ❑CHIMNEYREPAIR
IMPROVEMENT ❑SWIMMING POOLS
nBAI'11 KEMODEUREPAIR ❑DP.MOLITION
W OTHER
DRAINS-ThOOR, '. ARCA. COND,
HIS
OC`GROUp
7
FIXTURES - PER TRAP
GAS-EA.SYS'FIiM-1 INC.40U'I'I.ETS
GASB- EA. SYSTTM-OVFR 4 (EA)
GREASEANDUSTRL WASTE INTERCEPTOR
COMMERCIAL:
❑ 'W BLDGIADDIT'ION ❑DEYIOI.I'TION
' ANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
GREASE TRAP
PLANCHECK EF
SEWER-SANITARY-STORM EA. 20b IT.
ENERGY IEE
SQ. Fr.
SISQ. FT.
PLUMBING PERMIT FH
L/"Z, I 1
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�% D
C
I'li I' "'DAN",..
ALTER RAI &VF.M'-WATIiR (EAI
BACK PLOW 'CT. 1 EVICIi
DRAINS-ThOOR, '. ARCA. COND,
HIS
OC`GROUp
TYPE CON:
I
AI
6'1
FIXTURES - PER TRAP
GAS-EA.SYS'FIiM-1 INC.40U'I'I.ETS
GASB- EA. SYSTTM-OVFR 4 (EA)
GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIV)SION PEES
GREASE TRAP
PLANCHECK EF
SEWER-SANITARY-STORM EA. 20b IT.
ENERGY IEE
WATER I WAS UR WIVENl9ELECTR
GRADING FEE
WATER SYSTENEC'REATING
SOILS FEE
WATER SERVICE
PAID
NEW RESIDENTIAL PLMU SQ, EL
Date R",E1as
TOTAL.
BUILDING 14?E?
MECHANICAL PERMIT FTE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC 19ili
ALTER OR ADD 10 MECH.
PLUMBING I'lil
AIR HANDLING UNIT(FO I0.000 CFM)
MECHANICAL -F
AIR HANDLING UNIT (OVER 1(1.010 CPM)
CON STRUC'I'II TAX
EXHAUST HOOD OVIDUCT)
L IGUSING MITIGATION
HEATING UNIT (TO 1(10.0(10 BTU)
HE'AT'ING UNIT (OVER 1 00,000 BTU)
PAID
VENTB.ATION[AN (SINGLE RMID)
Date Rceei t
BOILER -COMP (3HP f )R 100.00a BTU)
BOILER -COMP (OVI:R 1(0.(X0 BTU)
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY.
NEW RES]DEN'1'[AL MECH. SQ. Irl'.
TUTAL:
OFFICE