S 0238 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 1 1T NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL � 0238
BUILDING I'R11JECr IDENTIFICATION
SANITARY NO. APPLICA'I'IUN SUBMITTAL DAIIi
BUILDING AODHIi55: /
OWN R'SNAME: PHONE: COM .'>R'ti NAMI�.�� { —,� NIC CONI ROI,a
MICHITECHIiNO1NEER: LIC NO: ADD � J ❑
did S Tose _
CONTACT: PHONE: BUILDING-PERMIT INTO
❑ Consultant Fees Paid by Applicant(initial) BLDG ELE PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTYI ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby million for 1 dm licensed under provisions of Chapter 9(commenting
�a2 mSeeltnn]IXXnnf Division3mlrhe Business and Professions Code.and my license is R ID NTIAL:
WO wi PERMIT ISSUANCE GSPDWL GKITCfIfiN REMODIiI.
~OW Fon full fora and CD«I.
Nu Lmcnsm Clans Lica APPLIANCES-RESIDES I'IAh [_1 ADDITION ❑I'hUA1BING RE 111111;
hL Dols-Contractor— ❑MULTI-UNIT ❑STRUCI'URAI.
ARCHITECTS DECLARATION PANELS MODIFICATION
ZO'•y Z 1 understand my plans shall be used as Public mends UP T02M AMPS REPAIR
OZ-O OINTERIDR ❑SWIMMINGPOOL
(:.�.F.41 Licensed P adoxomen 201-1000AMPS IMPROVE
GSWIMMING POOLS
Q' J OWNER-BUILDERDECLARATION OVER 1000 AMPS ❑BATH RF,MODEURF,PAIR ODEMOLITION
��
Q 1 hereby color thus 1 mer csenmt from the Contractorsode:An,
Law lis the ❑OTHER
qx C V following rma equire,
a.fgma,a 91131 S,Business and improve.
deruns Cala:Any oily errra umy SIGNS 13L1?CTRICAI.
YI�+ )y which re9uirts a permit to covwct.ahem improve,demolish,or repair any ntrvcmrc
I�'u•Og pnonnib isauanz.also requimsthmpplicam for such pcwinn Bkesigncd ammmenl SPECIAL CIRCURIMISC.
pN. thin he is licensed Pa..,to the provisions of the Comracmrs License Un (ChapmrY COMMERCIAL
uaia�30 (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEMPMErERORPOLEINST.
ea.
ax c that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION O DF:mol.rnoN
Wim Section 7031.5 by any.PPlierm for apemm,subjectsthe applicav 1.a civil Twadyrf POWER DEVICES El TENANT 1:001)SERVICE
IMPROVIiMHN'1'
t more Than five hundred dollars(850(1).
SD01,as owner+r thepmpeny onny empinyces with wages an lhcirsole cnnlpenx.dnn, SWIMMING I.001.IiLEC'rRIC GOTHh:
F^ will do the work,and the sVvctum is not intended or offered for sale lSa.]IISq.Rusincsn OUTLETS-SWITCHES-1:1%'FUR"
P
La 3 m and Professions Cale:The Contractor's License Use Joel not apply m mer owner of
property who builds or improves thomem.and who does such work himself lar through NEW RESIDENTIAL ELECrR SQ Fr.
his own employee.,provided Na such impmvemcros art not imended or offered for TAry{!ORbISQ.lT.
sale.IL however,the building err improvement i.sold within one Year of cnmpletinn.l VYUer-buiWer will have the burden of proving that he did nal bust]err improve Inr pow.f'sle.). IO9Tl.: ly Uta
0 Lasowoctofthepropertyam exclusively contracting with fisc n,1contmctonsc Use does not apply to an owner of propeny who builds or improves duration,vnd QTY. PLUMBING PERMIT FEF,
who cono-acts farsuch projects with m umtramr(s)IiceMed ..........he Cromme ,I's
Liccme Law. FIRM I CAN
0l am exempt under Sec. ,R&P C for this re wan
,TCR-DR VENT-WAIER(EA) VALUATION
I.OwneT Date
WORKERS COMPENSATION DECLARATION H . :,OW ROTF,CEDIiVICG
1 hereby aflrm under penalty of perjury one of the following declamlions:
O l have and will maintain a CernficalnofConsent to self-insum for Wei Comte.- DR R,ROOF,AREA.COND. ST QµB_S TYPE CONSTRUCT ION
cation,as provided for by Section 37W of the Labor Cale,for the performance of the FIXTURES- R A
work for which this permit is issued,
0 1 have dnd wIT maintain Worker's Compensation Insurance,us required by Section GAS-IiA.SYS -I INC Y OUTLETS
3700 ofthe LnM+r Code,for the perlirrnancu ofthe work for whlchdo,permit is isxua1. OCC GROUP AVN
Y
MWorke' C�ntp{psati+ /e canicwnJ PnlicY mamba m�
Carrier. GAS-EA.SYSTEM.OVI?Hd(1iA)
CERTIFlCATDOESATIONIINN PROM WORKERS' GREASE/INDUSTRL WASTE INTERCEPTOR
COM1II'IiNSATION INSURANCE tlU11.D1NG DIVISION ITEti
(This section need not he completed if the permit is for one hundred dollars lb l OTD GR17ASETRAP PLANCHECK FTI:
ur less.)
Ioyany that in the anymannre suns t work for subjectch to the W ieiarx Couxhnll SI1WI!R-SANITARY-S'IOHM EA 21N1 PI'' PNF,RGY FEE
not m Law of person in any manner n+ss m become xuhjctl m We Workers'Qnnlem
Z Appli Lnws of Culilnmia.Date WAl13R IIIiATER W/V13N'1IIiLf:CTR GRADING 19ili
� O .Applicant 1
N NOTICETO APPLICANT.If,attar making Nis visions m of Emmptlon,you should WgIT:R SYSTEM1VfREAT1NG SOILS FCL'
1% '-'�I bcenmc subject In it Worke ro Comnsmmion provisions of Ne tabor CMc,you mua
Fak1 forthwiN comply with such provisions or this permit shall be Jecmed revoke]. WATER SERVICE
0. Q PAID
.7. z- CONSTRUCTION LENDING AGENCY N12W RESIDENTIAL PLMIL SV.ITh' —D.11 Bacula
I hereby affirm that there i.sa conumction lendingagency for the grforntunce of
V
U 1" lite work for which this permit is issued(Sec.3097.Civ.C.) 'TOTAL:
O Undd.None TO'T'AL:
}U Loonce,AJdmss ZJUILDN
S I vanity that 1 have read this application and state that the above information is
,F, y c m,,,I agree m comply with an city and county ordinances and state laws«lmmg m QTY. MECHANICAL PERMIT FF.F.building condo:chnn.and herehyaninriwrapwmadm,ufthlx cityh+eructation theabswe-mcmumed prnpcnY for Inspeclln purpsca PERMIT'I'ISSUANCE(We)agree to nave,indermily land keep harmless the Cayof Cupertino agoingliabilities.judgment,costs and expenses which may in any wayaccrveatimust said City ALTER ORADD TO MRCPL in unvixmoveofdo,6mming ohhis permit.APPLICANT'UND'RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.00CCFM)
OU RE CUL IONS.
Q AIR HANDLING UNIT(OVER IR,WU CFM) CON59'RUCriON'TAX
Signumrc al App cn VCo wcna Du/ EXHAUST HOOD[W/UUC'I} HOUSINGMI'UCATIONFEE
AZAR1>nUS MATERIALS DISCLOSURE
WlDhcu licmorrfuwm Hating occupant shone or handle hazatdnu.mmcrial HIe61'ING UNIT(TU IfN1,IXX)B'fU)
ac defined by the Cupertino Municipal Cale.Chapter 9.12,mal Nc Hwlth ave Safety IIIiArING UNIT(OVER I(XLIXp BTU)
Crile.Section 25532(a)?
GYcs F1No V ENTILATION EA N(S INGLE REM D) PAID
_ Dam Receipt a
Will the utplicantor linum building:weupanl we egaipmcm orae,lees which BOILER-COMP OHI'OR II j) K)B'Ill)
emit havarJous air coutmm our,us defined by the Bay Are.Air Quality Management
District? BOILER-COMP(OVER 1(10,1X1(il BTU)
O Ycx GNo
1 have th read Nc h ode.Se materials 5.255mans under Chapter 1..r,la of the Caldome
AIH CONDITIONER ISSUANCE DATIi
fomio dowsn r comy Croda haven
Inns 25505.2s m3 anotesp arbil 1 undcrsmnd that dome NEW HIiSIUENT1Al.MECII. SV,FT.
buildingae,to x non cumhi,h haewn .or
o is mace of ICellty m nrnify thc:uoury m
ofthe mquirenwna which must M:ntm prior lar iuuanm nl n Ccnifeme of(kcurymty.
ownwrorauthmdxalagent
DateTOTAL: ISSUED BY:
OFFICE
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