S 0355 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELJH,I'RICAL PT:RMIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
RUILDINO PRO.IKUTIDEM'IFIC'ATION
3SANIANOAVPLICAION SUHMITITI.DAI'liH ILDIN rAODRE55: L�NIiR'SN M?' PI ONIi: CONTRACTORS M.: 0:- /fH01/N~
u
MIITF, /I!NGINL'.R: O PIR
NO: ADD
BUILDING PERMIT INFO
CONTACT: /�/ 9 PH( E.
TL. Cy / Z ❑ Cons an Fees Paid by AP licaw(niliap !K-:J pxq PLUMB .ECU
LICENSED CONTRACTOR'S DHCLARA'I'ION QTy" ELECTRIC PERMIT FEE JO DESCRIPTION
M1emby affirm that 1 am licensed under Provisions of Chapter 9(commencing
�OZ Seetinn'ltxgf of Div 'on 3 offs,Busincssand Profession: ode.vndmylicemeis R I
F in full force and elfecl. I'F.RMIT ISSUANCE ❑SFOWL ❑KITCHENREMODF.L
aVk~j License Class Lie In APPLIANCES—RESIDENTIAL []ADDITION ❑PLUMBING RG PIPE
inQi Date Comma"r ❑MULTI-UNIT [I STRUCTURAL
AHCHITECPS DECLARATION PANELS MODIFICATION
F5z Iunde mndmyplan.,xhall heuwdo,publicnsord, UP TO 2W AMPS
CZ—aF Y'..�W Liecmnl Poole...onal 201-100p AMPS IMI'ROVI!MEN'1' SWIMMING POOLS
YOWNER-RU1LDER DECLARATION OVER Id(X)AMPg 11 HAITI RFMODEL/REPAIR 0DEMOLITION
C{ Q 1 hereby off set shot 1 am exempt from the Cnnlmnor s License Law for the ❑OTHBR
YXxl 3 C U following reason.(Section 7031 S,Business and Professions Cade.Any city Or eotmty SIGNS ELECTRICAI,
which requires a permit m consumer.alter.improve.demolish,or repair any someone
F. a priorm its iswunce.al-O aiis,Incappllcvn finvach pemmino fileasigneJ stmemenm SPECIAL CIRCUIT/MISC.
EM} that he is licensed promand to the provisions of the Counwon'.,License Law(Chapmr 9 COMMERCIAL
ne
DON
nea00 (commencing with Section 70001 of Division 3 of the Business and l'mfessiun,Code)or TEM('.MELER OR POLT;INS'r.
El NIiW BLDG/ADDITION [I DI?6101.1
d a e C that he is exempt thcrcfrom and the nazi,for Om ullcgW excnmplinn.Any violation of '
Section 703 L5 by any applicant for a permit suncels the applicant o a civil Penally of POWER DEVICF_S 'NAN'1' ❑FOODSERVICE
not marc than live hundred dollars($5W), IMPROVEMENT
F1 SWIMMING of the pmpcnY or mY employees wise wages a,IM1eirwle compensation. SWIMMING POO(.ELGC'IRIC ❑OFF]HER
SO wllJ th k dth t t rci lint d I D df I (S "(1114.Business
F.m mertk UTLISS SWI"TCHCS—FIX"TUNES
W and] f .-Ch Th C m� t '1 c W d : t'pPIYt til
c.3— rrapenY h h 'IJ:or rep c,,hcm.n.and no does such mk himself Ihmugh NEW RESIDENTIAL CLECTR SQ IT.
his r cs•P J❑ t h p t. t ti m o l e dere.]far SQ.IT.alq )OR SISQ.fT
sal If he Ithi 6 d P rt twithin Idr y f M tion m,
owner-nM
arar will
n hnavage mN,na ,m of pros ng that bdid not bairns improvebmr par,
pow of side). TOTAL: '
1,us owner of the pmpeny,am exclusively contracting with licensed contractors m
Ionone,ore facie",(see.704il.Ituslne,s and rrofessianx Code.)Doe Cmdrnclnr's Li- FEE
(11�
cense Law ds not apply to an owner ofpr.p,ny wno build,or improve,thereon.ad nQTY. PLUMBING PERMIT
or
who contracts or such projects with o contractor(s)licensed pursuant to the Contmmar's I�
License Few. PERMIT ISSUANCE
I ton exempt under Sec, ,B&P C for this mason /•�/
AUI RR—DRAIN&VENT—WATER(EA) VAI.t1A1'ION
Owner Dale A 1—
WORKE:R'SCOMPHNSAIONDECLARATION BACK FLOW PROFECT.DEVICE ^(,+�/Nr�'�
Ibcmby affirm under penalty of periuoy one of the following declaration,: ++ ✓✓
I have and wil l mainmi a a Certificate of Consent to for Worker,Compen- DRAINS—FLOOR,RODF,AREA.COND. STORIES 'TYPE CONSTRUCTION
xalinn,as provided for by Section 3701 of the labor Code,for the perfonnoncc of the FIXTURES—PCN TRA('
work for which this perand is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
3]W oft Labor Code,for the performance of the work for which this Permit is iswed. GAS-1!A.SY59'I!M-I INC.40U'1'LI!'TS (ICG GROUP APN
MY rk -doartier
nce .sed Policy number are: GAS—PA.SYS'I'RM-OVER 4(PA) -
Policy No,
CFRTEI'AT. PEXF.MPTIONFROMWORKIiRS' GREASFYINDUS'KI,WASTE INTERCEPTOR
mcr. COMPENSATION INSURANCIi GDIVI$IGN FF.GS
(Dissection necdnmbecompleted ifthepemmil is forum hundtcddollats08100) GREASETRAP PLAN H . Tili 6
m le,s)
I certify that into,ped....ncmdthc work for whichdd,permit is issued,I shall SEWER—SANITARY—STORM EA.2IXI PT. ENI! LE
not employ any p,an in any manner ,,slum become sonieet to the WorkersComlwn-
Z _d..laws.f Culif.mia,Dec WATERIII7ATERW/VCNT/ELFC9'H GRADING
zApplicant
y NOI'ICE'IY)API'hICAN"1':If,a0,r.raking lois Cenificme of Cxmnpti.n,you should WATER SYSTI!MO'RI!ATINC, SOILS FEE
I•' bcmme xuhjem mthe Workers Compensation pmvisi.ns.f the Wbor Ctde.
Yen"'
f.nhwho comply with.uch pwaski.n.v or this permit.hall be deemedrev.ked. WATER SERVICE
(]0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID Dec cttiptM
1 hereby affirm that there is a construction lending agency lir the Performance of
{LZ - the work for which this pemtil is issued(Seo.3097,Ci,C.) TOTAL:
C) Lender's Name 'TOTAL:
IDA Lendee,Address BUIL IN I
I cer ify that 1 have rand this application and state that the aMve information is
F' tn correct.l agree to comply with all city and county ordinances andmale law,relating l" QTY. MECHANICAL PERM I FEF, SGS I( :FU
V Z huildingcm«mctl.mvnd hereby authorize represent,o,laftbis city to enter.,.,he
abrve-mentioned proseny for inspection purposes. PERMIT ISSUANCE El. TRICITEE
(We)agree m save.indemnify and keep harmless the City of Cupertino against
liumblies,judgmmrits,co.n andexpenseswnichmayinanywayaccmeagainstsaid City ALTER OR ADD TO MECH. PLUS INGFF.
inconsequenceoflhegr lingofthixpennil.
APPLICANT UNDER LANDS AND WILL COMP LY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.WOCFM) MECHANICALF
SOURCERE I N.
AIR HANDLING(NIT(OVER III,IXIB CFM) CONSTRUCTION S
Ire nfApplica JCommctor Dam EXHAUST HOOD(WIDIIC) HOUSING MITIGAI'R THE
HAZARDOUS MATERI .S DISCLOSURE
Wintbeappnesaumbtumbaddingt ,Pum stnrcor handle haraNOus mamriul 1 EATINGUNI'F(TOIW,000FITIJ)
its defined by the Cupcnino Municipal Cod.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW.IIfAI BTU) s
Code,Section 25532(0'1 PAID
❑Yes ONO VENTILATION FAN(SINGLE RISID) Date R 4
Will the applicant or future Wilding necupmn use equipment err devices which BOILER—COMP CUPOR 110010 BTI(
to t M1vuNons air ummminnnla us Jcf ncJ by the Bay Amu Air Quality Management OTAL.
District? BOILER—COMP(OVER I00.0a)( BTU)
0 Vex ❑No
1 have rem]the h ode S ma,155 requirements under .I cad r,ta 0l the Cali-
AIR CON DI'1'I ONER ISSUANCE DATE
f.miegdoes&Safety
tlybaSection,25heni2553]and25534.Iundetsmnd that If the NEW RISIDHNPIAI.MF.CIi. SQ.14.
building uircnM currently have a Rm,Lmat it isua ce of a Certificate of
the Occupant
of the reyuiremm�u which must he mm prior m issuance of a Ccnifcam of[kcupancy.
Owner or amhorized agent
Date TYPAL: ISSUED 13Y:
OFFICE