S 2001 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'RICA]. PE II NO
BUILDING DIVISION APPLICATION/PERA1IPPLUMBING—MECHANICAL 2001
BIIILDIBG PROJEC IIDENTIFICATION
HUH.DINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
io , o l Wo - d -4 y
Q ERSNAME: PHONE, CONTRACfOR'$NAMG LIC NO:
NIC CON .M
(l+pRCI l'1'F 1'/E GINI;ER: LIC NO: NIIIRESS: ❑
C N'IHCI: PHONE: BUILDING PGItMI'I'INP(!
M3 ¢71 Zy(3 ElConsultant Fees Paid by Applicant(Initial) BLDG fit I PLUMB MGCH
.-/
LICENSED CONTRACTOR'S DECLARATION Q'TI' ELECPRICPERMIT FEE
1 hereby affrmt that 1 am licensed under provisions of Chapter v(atmmeneittg JOB DESCRI Iy
PION
Z with Section'700mof Divi,nor !the Bosine<aand l'ntfr,slons Code.eud mYlicenseis RESIDENTIAL:
�aaX00 in PERMIT ISSUANCE:
e04 tuU fullfnmc anJR _ �n sQ� ❑ADDITISFDWI. ❑PLUMBIN RE-PIPE IZZU License CI., Conaraamr ✓� APPLIANCES-RES1UIiNTIAI. [I ADDITION ❑PLUh1BING R&PIPE
un n Dem
'nDa ARCHII'ECI"S DECI,ARAHON ❑MULTI-UNIT ID STRUCTURAL,
g,D y 1'ANL'hS MODIIsIC6H(1N
z Imnlcrsand Ilyplans.sbzll M1c used:u'puhlic live UI'"I0200AMI'S
❑IN'1'Iik10R ❑GIIIMNIiY It P:I'AIR
Q Ihcr.. l
IMPROVEMENT C]SWIMMING POOLS
J P
N h'teunsorot
..,Innv201-10MAMPS
OWNER-bUIhDHk OEChnItA'I'ION OVER 1000AMPS ❑BATH REMODEIJRLI'AIR ❑DIiMOI.I'TION
y by affirm that I am exempt from the Commends License Law lin the El 01 x G U following rcasun.(Section 7031.5.Bu,ine,s and 1'ntfe,slow Coda:Any city nr county SIGNS ELECTRICAL.
m 3 a y wise regaim,a pertdt m eonam,t.ober,inrpm.e.demolish.o,repair sol mmemre
F'N0< pro n.ntd,i.ssuance.also require,lheapplirant(,,,such paint In flea signed,te¢nted SPECIAL CIRCUIT'/MING.
Y� that he is licensed pursuant to the pmvoions of the Complain',License Law(Chapter9 COMMERCIAL'
t�+1 a, (commencing with Section 7000)of Division)of the Business and processions Call or TOME METER OR POLE I NS I'.
E a c C that he is exempt therefrom and the basis for the alleged exemption.Any violation n( ❑NCW BLDG/ADDITION EMOLI'I'ION
XONSection9(131.5 hyanyapplieant fnrapermil subjecuthe applicammadvil pcneltyof POWER DEVICES ❑TENANT ❑FOODSERVICE'
not marc than five hundred dollars(5500, IMPROVEMENT
FZ6 1.a%owner of the property(IT my employees with wages as their sole competion I. SWIMMING POOL ELECTRIC.
wdidomewnrk,and lhe,aucture is nut!nodes!orothard rowle(SeeAIWJ,Fusinesv [I OTHER
71a
S w noel 1'nrl'cs.,ions Calc:The Conlruh
nnr's License Law Joe,not apply ,on o
Ve nor f 0131 LETS—SW I'TCllliS-1:1X'I UR17 /✓�
prupcny who build,o,improves!helicon,and wbo due,,onto work h reel!o,rhnmgh
hi,own entplo,rr,provided that such inpmrvmnentsm nnot intended on o fl'ered for HE RESIDEN"II Al.FI.FC3R SQ FI'.
sale.IL however.the building orlopmvanenl is sold within one year ofcompleden.rhe SQ,17 FLOOR AREA yJSQ.IR.
nosturohmider will have the burden of proving men be did not build or improve tar in,. r.�
ptrsc of sole.). TOTAL: O V
❑I,a,owner of the pmpeny,am exclusively conferring with licensed contractors m /
construct the project(Su.7614,Business and Profc.aions Col The Contractor's Li-
close Low does not apply to an owner of poi,serty who loulds or improves thereon.and UTY. PLUMBING PERMIT FEF:
who comnmt,far such to lines with a c mmusunH,)licensed pumuanuu the CommetoVs
Limns law. PERMIT ISSUANCE
O lam exempt under Sec. .B&P C fn,this reason
ALTER—DRAIN&VENT'—WAHIR(EA) .0 I'
Hour, Oat.
• WORKER'SCOMI'F.NSAI'IONDIiC1.ARAHON 13ACK FLOW PROTECL I DEVICE /
I Imreby dfrnr undo penalty tel'ar,jury one of the following declarations
I have and will nmintumn CenilicmealC,rwrOrsdl'-ineu.efmr W..ker'e Cungem DRAINS-FLOOR,k(1(1F,AREA.GOND, ST RIES 'IYI'ii CONSTRUCTION
to,provided to,by Seainn 3901,,Ethe LUMtrCale,far the perfornamm of the
work fn,which this permit is is.wcd FIXTURES-PER'I'RAI'
I have and will rememin Worker's Compensation Inmrancc,as required by Section
3700 of the Labor Code.for the perlimnance of the work for which this permit is issued, GAS-EA.SYS'IEM-I INC.J UIJTLITS OCC.GROUP N'N
hly Wnrk Competes Imurancc dI'oliryn b n GAS-EA.$1'STEM1LOVIiHJB:A)
IT'WConno :8s '-on /v fame,
co"d"
CERTI KATE OF E%EhB"G,IR h1W RKF,RS' GREASF/INDUSI'RLW'ASI'I!INTERCEPTER
COMPENSAI[ON INSURANCEBUILDING DIVISION ITES
("Diisseetion need not he completed if the pemtins funone hummaidollan(3100) GREASETRAP
1'LANCHECK IFF.
orless) )o so nfyp Ynthe any
oarworkl' subject
'h t-' Carlo..
SEWER SANITARY l'IUNM PA. FP.
not pl Y' YP � Y u:t M t ,uhjccn 'heWorker,'Gtmp,n, ENERGY ITS
Z Indian I o: !C'ITan Use WATER HEATER W/VI NI/I LECI'k GRADING THE
z o Ap,l n
N(YI'ICE 10 APPLICANT:If.after rook ing this Certificate tel Exemption,you xhnu lel WAI ER SYS'IiM/IREAIING
% SOILS II3E
a > bce,,nre.r cone t m the Worker's pre Cnrnpntxnt is emal hal of the Lehi Qoke You mmr
linthwirh comply with web provi.ann,nnhix pennn,boll fe detailed rooked. WATER SERVICE
1 PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB. SQ.FT' Da c Receipt M
Vz I hereby affect that is a construction lending agency for the performance of
LL I 'he work for which this .it is issued Six.3197.Civ.C.) TOTAL:
O U Iwmdr I Name TOTAL:
r D] LcnJer',Add., BUILDING
4. I trillion 1 have read this application and state that the above information i,
FN .....rt.Iagrecto,omply with all city and c000ll ordinance,and same laws relatingm QTY. MECHANICAL PERMIT FEE tilashuc FE I..
OZhuildingrnnswcunn.and hereby ach pee reprocnfafi vu,nf lhiseny In comf upon the
✓a obnvc nura.lonw sampan for ar,,oi eo purpnwx. PERh1I'r ISSUANCE) E,I.CI'RIC HE
(We)ugrce to save,indenmify and keep bummers the City of Cupenlno ngulnsr
liabilide,,judgmmots,cos,,suit,xpcnw,whicbrmtyiamy way.orne many".said City ALTER OR ADD II)MEC1L PLUMBING li
In rniresberre of the granting of Insofar...it.
API'IIC\NI'UNDERSTANDS AND WILL CONIVIN WITH ALL NON-POINT AIR HANDLING ON["I'(TO 10.000 CFM1 MECHANICAL FEE
SOIL LICE RpGUI.AT10N5.
AIR HANDLING UNIT(OVER BLOOD CFM) CONSIRUCTI NTAX
Signature of ApplicanUCnno-actor Date EXHAUST HOOD(WIDUM) HOUSING MITI,ATION Flit:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingomupanlstore or handle hazardous material HEAPING UNIT(TO 100,000 BTU)
as Jelined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety HEATING UNIT GVER IIg1.INM1 BTI[)
Code.Sccrion 25532(a1^
�Ves n VENTILATION FAN(SINGLE RESID) PAID
Du� Rcmipt M
Will for applicant ,,Comm,holding,,,cupum u,c equlpnrem oNuvim,wlJeb ItO1LER—COMPOHPOR o.omirru)
\� srnif humr:Inun air contaminators,defned by the Huy Are Air Quality Management , 111'.
D"Ifler^ BOILER-COMP(OV11,R 100010RIU)
E]Yet, ,yon
Ihcreat tote hvaNtws mmcrialx rt4uircmcnu under Cbap¢r l.95 of the Cali AIR CONDITIONER f� ISSUANCE I7AFIi
f,,mia 1 th KSa@ty CMe.Sections 25 5,255)3 and 255TL I umlentaml that if the NEW RECIDEN LIA1,NIEC11. SQ.Flt
ntly haw etenunt,m 'n i,my res nnibiI ty to notify the occupant O
, Ih e4 "'hat he ton pn nfa Cenifcm
TOTAI;
ISSUED By:�
OFFICE