B 0418 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY "firLoot OL
CITY OF CUPERTINO PIIILDING ELECTRICAL PERMIT NO. ,� ,., r— �.,
BUILDING DIVISION APPLICATION/PERMIT 1'LUMHING-MECHANICAL �popy �� '26@145,yLj81
RI111,DING PROJECT IDENTIFICATION J�VVI
BUILDING ADDRESS: SANITARY NO. APPI.ICAI'ION sunmiTTALHAT
103 , 7 G1JFS;4ee<< S n
2OWN3R.'NAME PHONE: CON'IKACIhKS NAME: LIC N(1 N/C TROL#
413 - I S O til,\R'llI HEC`PENGINIiIiR: LIC NO'. ADDRESS: ❑ OSS n 3(.e 61 a
CON ACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fee.Pail by Applicant(Initial) BhD _ 131 Jird PIAMI+ MECH
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51C.I�„ rwrbg.'� l/9_ IJ CJ-T
LICENSED CONI'RACIORR DIiCLARAI'[ON QTY ELECTRIC PI'.RMIT FEB Jpl3 DESCRIP"PION
1 hereby animal that 1 am licensed under provisions of Chapter 9(commencing
pd'Zp with Section TlXXB of Division3ofthe Business and Professionscode.and my license is .r11 RESIDENTIAL,,
Iup7 V
CVF- in toll lim<c and ellccL PERMIT ISSUANCE ❑SFDWh ❑KI'1'CIIEN REMODEL
CVV License Class Lia# APPLIANCES-RISIDENTIAL GAT56il'ION ❑PLUMBING R&PIPE
ya a Date Commcmr
D. ARCHI"IECI'S DECLARATION 1'ANI3LS / MULTI-UNIT ❑STI"RUCTURAL
F,AZ I unersmad l
my pan.sshull he used aspubb"card,
% � h10D11'ICAf10K
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d
UP TO 200 AMPS ZC/ E)INTERIOR [I CHIMNEY REPAIR
Licensed Professional r 201-1(1X)AMPS IMPROVI:MEN'I' [2SWIMNIING pools
OWNER-BUILDER DECLARATION OVER RXX)AMPS ❑HAIH REMODEUREPAIR ❑DEMGl.1'IION
C C Q I hall!.mnm em
totally alliat I expt faint the ContrnemLs License Law for the
a p a V fallowing reason.(Section 91131 5,Business and Professions Code:Any city m county SIGNS ELECTRICAL ❑OTHER
1+1 a
0 w which infinite,o Pon.,[m-omtrad,oiler,improv-,d-malisb,of repeal any emtaurc
Prior o its issuance.also requires the applicant for such Permit o file a signa,bacro d SPECIAL CIRCUIT/AS
S' y ma lickfictmedp.Faanna the proviai(,naanne c-mmaor's ueense haw lChanter9 COMMERCIAL:
1125 QC (c°nanencingwim Scocti 191XX1)of Divisiun9nfthelbisina%sand Profassinns Codc)or 'I'IiMC MIdTER OR POLE INS"I fz4o
S 6 o that he is eaempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW Ii LDGIA DDI NON ❑GEM01.1'I'ION
x� Sstion90J LS by any applicant fmapemtit sublects the applir nuoacivil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
son oa n...re than live hundred dollen ISAXq. IMPROVEMENT
=Q 01.ax owner of the property.or employees with wages as their.usl-vompemation, SWIMMING POOL 17LECI'ItIG
F• will do the work.and the stmcture is not intended or olrcred hoastile(Sce.T(XW.Business � ❑GTHIiR
W 3 m and Protcssiom Cod,'the Cmtranor's License Law does not apply to an owner of OUTLETS-SWITCHES-IOS'I'URES
propmy who builds or improves Ihercen,and who dtws such work hintmlf m through
his own employees,provided that such improvements aR not intended m sabered for NEW RESIDENTIAL ELEC'1'R SQ 1'I.
sale.IL however.the building or improvement is sold within one year ofcompletion.the SQ,FC FLOOR AREA PSQ.IT.
erbuildcr will have the burdmr of proving mut he did not build or improve for par-
ptn Isom.). YA: � ��
[.71,m owner of the prnpeny,am exclusively contracting with licensed comrecmn to f
msama Abe,cleo[See 7044.liminess and Prefc"111-s Coate:)The Cammemrb Li-
censeLaw does nestop,]yut an owncraf property who bond,,,,improve,thereon.and QTY PLUMBING PERMIT FEE
who contracts for such projects wall.conueemgs)licensed pursuant m the Contractors
License Law. H&ITC lite this rcuson PERMIT ISSUANCEM
Ivrea fpl un crStt. ALTER-DRAIN K VIEW-WAVALUATION
Owner Mato ORKI: )MPF.N'ATIONDECLARATION RACK FLOW PROTECT DEVICr�operVI have and will maintain a Certificate ofConsennosclf-asurc forWorkersCompen- DRAINS-FLOOR,ROOK ARES-TORB: TYPE CONSTROCTIO
Noon,us provided for by Section 3900of We Lahnr Code,for the pmfnnancrof the work for whichdbi,permit is issued. FIXTURES-PERT RAPI have and will maintain Wnrkcr's Compensation Insurance,as required by Station3700ot the l.ahm Code,for the performance offe work fr which mix pemtit is issued. GAS-EA.SYSTEM-I INC.40ICC.GROUP �.�-S A�
My Workers Compensation Insurance currier and Policy number am: GAS-F.A.SYSTEM-OVER 4(EA) J "�
Cameo Policy Na.: 2 C
CERI'IPICATE OIr 17XEMIMON FROM WOR KERS' GREASIJIN DUST RI,WAS'1'E l N rERcEPT012
COMPENSATION INSURANCP. BUILDING DIVISION PERS
(This section need not be completed if the permit is foams hundred dollemCd O) GREASETRAP �i� O
nr lexs.) PLANCHI3CK Igt.E �D
I really that in the ivrfor armacof the work far which his ,act is issued,Is hall SHOALS-SANITARY-S'IORM HA.200 FI'.
not employ any person in any manner w as m become subject to the Workers.Compen- ]ENERGY FEF
Z sntion laws of California.Dam WATER HEATER WNEN'f/171TCfR GRADING FEE
zQ Appllcval +
t, NOTICE TO APPLICANT:If,after making suis Certifcxm of E amino n,you shauld WATER SYSTEM/TREATING SOILS ITE
(•-' bcnnne subject to the Wufkers Compensation provisions of the Labor Code,you must
d Q forthwith scantily wore such p o,kion,(,,this pefntit shall be decmml rue(,ked. WATCH SERVICE
P
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.f.. PAID
I Imah union Ohm then ix ncnnemction lmcan forthe rfmmuncv of Recetptp
y a g ugeney pc s
F the work for which this permit isissud(Sec.3097.Civ.C.) TOTAL:
Q lender's Name
U T
U Lender's Address BBI ING .E
1 certify that I have read this application and emm that the above information is
sF. N corma6l agree as comply with all city and county ordinances and sate laws miming la QTY. \ NICAI.PERMIT Plast SEISMI ITE
U Z building construction.and hmebyaumadee aepresenmd esof this city 1.corer aeon the
cMrve mentioned prnpeny,for inspection pmlwscs. FERMI .DANCE, 131.E NIC hili S
(We)agree m sur,indemnify and kmp harmless the City of Cupertino against
liabilities,judgment,colas andcxpcnses which may in any wary income against said City AL OR ADD TO MECli P MRING FEE! O f O
in consequence of the granting lot this farm"[.
APPA.CA UNDERSTANDS AND W WITH ALL NON-POINT ANDL� ON T(TO 10.000CFM) ;CHANICALPHE
SOl <'ER�IULAI'10' e n
A1j fIANULIN0l1NIP/{)VER InO,(XNI CPM) CO. S'IlB1Cf1(IN FAX
igna�i le NApplican error Date IST HOOP(W/DUCT s7 VIOU.ING MITIGATION FEE
I IAZARDUUS MAI IIRIAI,S DISCLOSURE
Will[be applicant oafuture building occupant ,one nr handlcM1vanNnlu material IIEAI'IN , "I fl'O IlN1.111X1RTO]
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety .(p,00(1 BTU)
Code,Stadol.2553200P HEATING UNIT
E3 Yes Qxl� VENTILA'1"ION PAN(SING ESID) PAID
Date Receipt#
Will the nPFlicant or faun building m:eu,na use am,ar eat o,devicm which BOILER-COMP CHP OR IflMjXNI R Ill
coal Falmdou,air cnnmminann as defined by the Bay Ara cAir Quality Management, I'
District? — MOILER-COMP(OVER 100,000(ITU)
C1 Yes el/
I have read the hmmm
andous materials luircmes under Chillier 6,95 of me Cali
AIR CONU1LONI.N ISSUANCHLATE
Iola liealth K Safety Cade,Smionn 25505,25533 and 25514.I under, vi that tithe NEW RESIDENTIAL MECH. SQ.FT. /
bull ding of re nut car-any hvvvammnh that it i"ayruponxihil'nywnrnify the occupant (Q ( C
s t •mqt emcnts which t can,of Occupancy.
TOTAL: ISSUiill HY
1)or
OFFICE