S 2074 APPLICANTTO FILL IN INFORMATION VATHIN RED LINES-USE BALL POINT PEN ONLY
CITY'OF CUPERTINO BUILDING-ELECTRICAL Pe ITNO.
BUILDING DIVISION APPI.ICATIONIPERMIT PLUMBINGMECHANICAL 2074
BUILDING PROBRCI'IDENTIF'ICA'TION
BUILDINGADDRECS: SANITARY NO. AI'P1.ICA'110N SIIBMI7TAL DA'I'H
1059k T b � 2-7- ��
O N[?R'S NAME: PIIONG' C RACTO 'S NAM IC NO:
1 _'1 N/C CONTROI.p
RCHITECTANGINEER: O EJC N`07,Y qDl ji{IS, r.. I IJ ❑
ONTACE PHONE: I/5 �(( BUIhUING PERMIT INTO
O
El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PI.UMq.. MITCCH
SS-� 71
El
LICENSED COME RACTOR'S DECLARATION/Y QTY. ELECTRIC PERMIT Fr:E
1 hereby affirm dial I am licensed under provioms of Chapter 9(commencing JOB DESCRIPTION
Owith Section Tll(10)of Division Sof die Business and 4nfessiom CmR.lnJmylicem,is RESIDENTIAL:
Z r� PERMIT ISSUANCfi
WO in fulVforam �tic� /1 w ❑SFDWI. ❑KITCHEN RIiM00E1.
aZE Pam isLxC�'. C_3�Contrunr jrA APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPIT
rn6a /'W— ❑MULTI.UNIT El STRUCTURAL
ARCHITECT'S DECLARAI'[ N
Zpr7AZ IundersmnJ my pleas shallbeused as public records PANELS MODIFICATION
OZ_O UPTO 200 AMPS L3 INTERIOR El CHIMNEY REPAIR
wI Licenced Professional 2B1.1n00AMPS IMPROVIEMENT SWIMMING POOLS
eigOWNER-BUILDER DECLARATION
hh 1 hereby affirm me,I am ea,,np,from the Contract Liana Law 4a the OVER IBBIIAMPS ❑BATH REh10UEURGPAIR DEMOLITION
ad O6 UF following reason.(Section 7031.5.Busies and Povivoion,Code:Any city in I malt SIGNS F;LI!C'1'RICAI, ❑OfflfiR Z
LL'3 LL N which requite a Permit to consent,alcor,improve,demolish,or repair any structure
F'y•LL,OS prior to its issuance,also requires theupplicam for.such permit file.signed statement SPECIALCIHCUIT/M ISC.
y y that he is liciumedpunuannn the provisions of the Contractor'%License Law(Chapter 9
uI�OO cc anneneing with Sordint l(gXDof Douint3ofthe Business and Prnfessieam Crde)ar TEMP,METER OR POLE INST. COMMERCIAL.
d ea than he N cxcmpt tberefrma and the husix for the alleged cwmpuon.Any violatlmn of ❑NEW BLDG/ADDITION ❑DFMOLITION
W^N Section 7031.5 by any applicant fora permb,abjese,the applicant On a civil penalty of POWVR DEVICES ❑TENANT ❑FOODSERVICE
not muse than five hundred dollars(3500). IMPROVEMENT
F d I,asow..er of ohc Tn cn
q O � I p y,nnny employees with wages as their sole wmpunsvtion, SWIMMING POOL I!LECfRIC OTHER
AF- will do the work,and the Totemic is Out intended oruffered for wile(Sce.'BLL4,Business
13
and Professions Code:The Contractors License Law does not apply to an owner of OIJTLL•TS-SWITCHES-IBX'I'URfS
p,,,,oy who builds o,nannies thc,am,and elm dee,such work himself or mmagh
his men ermploya,,provided that such improvements are not imenJed or rffnnd for NEW RESIDENTIAL ELIiCI'R SQ F1'.
aale.If,ImI the building orimptvement is sold within one year of conopI I d the SQ RAREA LSQ.FT.
cr-builder will have dial harden of pmving than he did nut build nr imprnvu Ins pur-
pose of sale.).
[:] 1,as owner of the property,am exclusively contracting with licensed enmradoes t TOTAL:
correct Out project(Sec.704,0,Business and Prdevsions CoiN:)'1Le Contractors Li.
u Lawdoes nm apply m an ownre
owner of property who builds or improves me.... it QTY. PLUMBING PERMIT FEE
who amuoms forsuch a,j,,,with n nmemor(O hetnord punmmno the Contmctrs
License Lew. PERMIT ISSIIANCIi
I am rise Ed under Sec. .B&1'C for this reason
ALI'PR-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby Talon under penalty of factory one of the fallowing decla rations:
j l have and will maintain a Certificate of Comennn self-ineme for W'orkds Compen- DRAINS-FLOOR,ROOF.AREA,GOND. STORIES 'I'YP17 CONS'I'RUC'1'ION
tion,as provided for by Section TIM of die Labor Code,fm die performance of die
work for which thio permit ix issveJ.
FIX'I'URF.S-PER'['IIAP
1 have and will maintain Worker's Compensation Insurance,as inquire t by Section
37110of the Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.J OUMETS (>CC.GROUP AI'N
My Wark r')Compyrsalinsn lns�umnnnecartierand l'oliw xuuJxriBp'mp�21 Lf� GAS_EA SYS'fl'.M-OVER t Cartier.�( � CI✓�� -pnlicyN VJ 1G 00
HRTIFIG'1l?OI'❑%EMYf10N PROM WORKIiHS GRHASEIINDUS'I'RE.WAS 117 INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION In!NS
(7ltis awlionaced net becom,hainjiftim pmmi,is feature,huMreddollan(5100 GREASETRAP
or Its.) PLANCHIICK FEE
leemr,that in rhe peraraanceofrhe work l-.1huch lhispennk i,isued,Iahall SBWIiR-SANITARY-STORM I?A.2M PrP.
not employ any person in any manner so as m become subject to the Worker'Compcn- ENERGY ITE
CZ smion Ltwa.f Cullfntiu.Dane WATER 1117AT17R WIVEMPELECI'R GRADING FEE
Applicant
azo y N(TfICF.'I'0 APPLICANT.IL after making this Certificate of Exemption,you should WATER SYST E-NU REATING SOBS FEET
become mbjwt tea oho Wo Let's Compensation p,.,I..om of the Labor Cal.,you mast
Lakl ferns ioh tamely with such provisions or this permit shall he deemed rooked WATHR SERVICE
I1. Q
CONS'fRUC'LION LIiNDING AGENCY' NIiW RF.SIUGNT'IAI,PLMIt. SR,FI', PAID
Receiptk
UO that I hereby affirm hem is construction lending agency for the performance of 1
the work fm which chis permau
it is wcd(S.309"7,Civ.Cd
OLender's Num, TA TOTAL:
Let.] Lt ndcr',Address
1 card fy tbnt 1 have tad diis nppllmaion and sante that the above infotmtion is BUILDING F E
W c .1.In,,.to comply with al)city did county romeance,and sane law,m1mng e, QTY. 'MECI IANICAL PER MIT FEE
L) Z, building correction.and hercbyame
herize mpresnatives of this city to concretion the SI]SMICf .
'-" Those man inneJ property forinspoution parponw.
(We)agreet se,indemnify and keep families,the City ul'Cupertino against I'IiItMIT ISSl1ANGI! PLUMBIN FEL?
save,
liabilities,judgments,costs and expenses which mayinany way acemeagainsr said City AMER OR ADD TO MECIL
in comeof the granting mf this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNIT(ft'10,000 CFM)
MECIIANICAI.FHE
AIR IIANDI.INC.ONE'P(OVER 10.001 CFM) CONSTRUCHONT'AX
Sig a Appirant Conrrantnr !/��bbCCC etc EXHAUST 11001)(W/DUCT71 HOUSING MITIGATION FF.E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant score or handle hazadous maternal HEAPING UNIT(10 100,000 BTU)
as defined by the Cuperi no Municipal Code,Chapter 9.12,and tine Health and Safer,
Code,Section 25592m)? 1117ATING UNI'[(GVHR 100,000 If I U)
[3 Y. LI No VENTILATION PAN(SINGLE RESIO) PAID Dire R,ceiptp
Will the app omm it entre building by theoB use equipment nr dEst'ian which
nio haznrdnus air commitments as okfneA by the stay Arca Air Quality Estrangement BOILER-COMPf1HPOR If10,0X0 BTU) TOTAL.
istdmEl Yes [I No BOILER-COMP(OVER I SLOW 137'U)
Ih:ve read the h,,ardous materials roquircluus under Chapter 6,95 of the Col i- AIR CONDITIONER ISSUA,,,NNCC!!lE.DATE,
folie Health&Safety Code,Sections 25505,25537 and 25534.I understand that if he NIiW RF_ti1DEMf1AL MECH. Sly FT.
building Joca not currently have a tnnent that it is my respumihility to notify the occupant
ollhe requirements which most theme,prim In issuance mf a Ccalikam at 0ecupancy.
Owner nr uuthoriecJ agent Date TOTAL: ISSUEDB tfe' �O
OFFICE