S 2250 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY r^
CITY OF CUPERTINO BUILDING-ELECTRICAL IIE81TNO. ZZ V O
BUILDING DIVISION APPLICATION/PERMIT PLUMB N; MECHANICAL l`l
BUILDING PROJECT'II)EN'l'IF'ICATION
RUILDINGADDRESS: SANITARY NO. Ali'[,]]CA'IIONSUBMI,TALUAIIE
OWN '.'NAME: PHONE: CONTRACTOR'S NAME: V LIC No:
NIC CONTRDLN
40
�pltClll'1'ISCT/F.NGINFiI?R: hIC NO. ADDRESS:( ID ❑
CONTACT: PHONE: BUILDING PERMIT INTO
❑ Consultant Fees Paid by Applicant Initial) BI.DG ELECT PLUM( MECH
AAoquo O ^ — cid ❑ ❑ P, ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby mfirm mat 1 mm licensed order pmvisicrs of chapter 9(camnteneirg JOB DESCRIPTION
WDaZ with Semion9000)of Division 3nflhe Bysinesxond PmfeomasCtme.andmylieeneei, RESIDENTIAL'
F'O O In full Brce and cit PERMIT ISSUANCE.
e_U OSFDWL OPLUM INREMODCL
HzW Littnse lax, Lic.p ;APPLIANCF-S—R[SIDI?N'f1Al. ❑ADDITION ❑PLUMBING RE-PIPC
F2aora cSDFC ARAIO. lFFO,. ARCHITECf'S UIiCLAItA'I'ION • ❑MULTI-UNIT 05TRl1CPI1RAL
ZOyZlunderstand myplans,hall ecused m,Pyblie records MODIFICATION
Z4-M PS 0INTERIOR ❑CHIMNEY REPAIR
r4t:w Licensed Professional S IMPµOVF,MENT SWIMMING POOLS
�.gSOWNERRUILDER DECLARATION 1'S ❑BATH R&MODEIJRF.PAIR ❑DEMOLITIO1''a 1 hereby affirm that Iam exempt rue n Om Contractor's License Law fr me6 U following reason(Section TW 5,Business and Pmfeasinns Cole:Any city or county RICAL OTHER
i�+B a y wmeh require,a per�nh to c:�rsuum,suer,bnprave,ae:nolLh,ar repair ymy,,ranula
R.
Prior to its issuance,also requires me applicant for such permit to file a signd statement SPECIAL CIRCUI'UMISC.oh
L
r�r•.l foahe i.,licmtsedpunwmun the prnvisiom nrthe Camracmrs License Law(Chapter 9
Eat (commencing with Section I"X))of Division 3 of the Business and Pmfes,ions Cnde)or TEM P.M 13'1ER OR POLIS INS'f. 1
6
that he is exempt therefrom and the basis far the alleged exemption.Any violation of <T17NAW
/ADDITION ❑DEMOLITION
Section 7031.5 by any uppl'mum tarn permit suhjnathy:gq+licant macivll Pendry nr POWER DEVICES OFOODSERVICE
ITION
not more than five hundred dollars($500).
0 Lmuwnerol'the p(peny,or my anployces with wages as their sole cnmpensatlon, SWIMMING POOL ELECTRIC ENTp. will retiework,andtheswctmentatiracribdolerel bnsnle(See.7ND,Burials,
L d,m ntal Pndexsinm Cole:The Connector's License Law dues oat apply u+an owner of DOMETS—SWITCHES—FI%I'ORES
pmpeny who - ark him,elf or hamgh
his own crept pmvidal/ntah impm e Is mended or o8'ercd for NEW RESIDENTIAL IiLIiCTR
sole.IL hawev buildi •muni IdwiO A h year of cmnpleion,the .(7y100R &SQ.FF..
mer-builder -I vc the s� len+jf�mvi g he diJ talk fid or improve for pur. 5-�
muaLme.). 1111i
0 1,as myna e p t 1 t tLt WI{I li"tived eomrudnts lo TO'fAl.:
construct let(SIM UN,BhUneyan s :)'Me Court oors Li.
c
tseLuwda, rnnpply to an ownerot Dop,ny w o hrldh impmve,thereon and QTY. PLUMBING PERMIT FEE
v,momruct suchpmjects withacontmnor(s)licenc'd Warr.the Contractor,
License I.uw, pp PERMIT ISSUANCE
❑ lam exec Imgf+r See. It C tat this mason
ALTER—DRAIN&VENT—WATER UEAI VALUATION
owner Uma,
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(TTELT.DEVICE
I hereby affirm under penalty of perjury,one of the following decimation,:
❑I have and will maintain a Certificate of Consent n selbinsmn for Worker's Cnmpen- DRAINS—FLOOR,ROORAREA,GOND.
scion,an Pnwided for by Section 3110 of the Labor Cnde,for the Pchmmance of the S'I R TYPE CONS'IRUCI'ION
work]or which this permit In Issued. PI%'I'11RH5—PIIR TRAP jq '
��•q1 have and will maintain WoRers Compensation Insurance,as required by Section
19110 of t he Labor Cada,for the performance of the work fn bica this permit is i.¢yed, GAS—EA.SYSTEM-1 INC.J OUTLETS OCC. IP APN
My Worker's Cowm +IJ afire y nJ I'nlicy num�e(ye Ld(CIS
Curtier:E 's.r �Ll,t(eR,ll` cpolicy No.:O{B6OI O GAS—EA.SYS'IVMOVL'Ri(I?A)
CERI'IFICAI'Ii OI'EXEM PITON PROM WORKERS'
COMPENSATION INSURANCE GRIiASI%INUUS'I'RL WASI'li(NTT?RCEPI➢ ,DING DIVISION FEES
P11f,,seaion coednm Ivemapletetl i0hepoanit is forma hundred dollarsSI010 GREASHIRAl'
or less.) PLANCHECK ITP.
I certify that in theperfarmunccafnhe work lbrwhich thispermin is issued l shall SEWER—SANI'T'ARY—STORM F.A.210 FI'.
not employ any person in any manner so us I ythc WorkeN Cnmpmr ENERGY FLIT
z ,mien ha s t Cali_.t O Liz 70 WATER HEAL HR W/VENT/ELECfR
fizz C) Appkcut �v ({J/(✓ L ' GRADING ITE
NOTICII TO A Pi(CANT.If,after making this Certificate of Exemption.you should WAI HR SYSTENUTREAUNG SOILS FEE becameaun)ecua be Workars Compematian provision,of the Labor Code,you must
fnnhwim comply winhsuch provisions on his pe...install M decarainvuked. WA'I'FR SERVICE
Q
z CONS'lRUCTION LENDING
AGENCY NIiW RESIDENTIAL I'I,MSQ.F. (AID
V (herebya0nn thauherrej,.conametinn lendim,mrimcy frthe pHnnanceof
a
e walk far which tis pemi,s
tit is tmd(Site.TP)1,Civ.C.)
{L thlender',Nanta TOTAL:
�-t W Lenders Addri IT '
6. 1 certify that I have teal his appllcmieI and cram fare me aMwe infonnu0et 11BUILDING FF.
F � co <ct.nI,give to comply with all city and county oNinaneesand state laws relating on QT'Y. MECHANICAL PERMIT rFEE
CJ Z huilding commando.,and hembyanthoriaerepowamlivesuf this city mcmerupon to SEE MIC Ff':'
above mentioned property far inspection purposes. PT:RMIT ISSUANCB
(We)agree to save,indemnify and keep harmless the City of Cupertma aommh 1?LECI'RIC EEE
Iiabllllies,judgmontx. trv15:mJ expenses which nmyln any way acerae ngninst said City AI:I'BR DR ADD'ro MECH.
perml PLUMBING P E
in nuquencc oft 6rep)yy�s jf this t.
APPLICANT tl - 1?R CN S Ay1] II, .COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT lIkIXO CFM) MECHANICAL 4':
SOURCE HC A'fl :S. /
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
11! 16 MOM
Sig aLAppRc YCW ate li
IIAZARDOUS MATERIA(S DISCLOSURE %IIAUST HOOD(W/DUCT( HOUSING MITIGATION PEP.
Will the applicant or future Wilding accupam snore or handle haaamloux manurial 1II7ATI NO ON I'(TO 1010,0011111'U)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade,Section 25532(0).' IIEATINO UNI'('(OVER 100.000 PTU)
C]W, E3 No VENTILATION FAN(SINGLE RESIO) PAID
Date ReeeiplIf
C willus aircrnratfuture a huilding by the ifit Bay Am
ent QulitdManaementes which BOILER—COMP OUP OR IEE,q BBTO)
emit hazardous nil rnmamin:mns as tkfineA by the Bay Ama Air Quality Management TOTAL
DIsti BOILER—COM P(OVER 100,000 BI'U)
❑Yes 0 N
AIR CONDIDONER
1 have read the hamNnm mamrims .5,25533 an u2553 .1 and rsta of the Cmi. I�S.4UANC° 'D°
formic Ieullh&Safety Code.SecOnns 255[k5,2SS3J ant 255J0.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. / �p
building does not cynically have a tenant,that it lx my resptmsihility to mad"he oecrlanl V '�
of me myuircmm�a which amt be amt ptiuna issuance of a Ccnificae of(kcuryncy. �+
Owncror nallarbel agent Date TOTAL: ISSUED BY: / O
OFFICE