S 1837 (2) —APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELKCfRICAL (,SIT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL, `V /
BUILDING.PROJF.CPIDENTIFICA'I'ION
JRRLDINGADDRI,Ssu '- SANITARY NO. APPLICATION SUBMI'ITAI.DATE
O ;:v ,* A ;�AV aC✓ Q
OWN( 'SNAMIi'. IONG'L � � C'ONTRA"101," AMC: •J LIC NIT.
P NIC CON'f1i01.#
. ARCHITECf/ENGINGGN; LIC NO: ADDAESS v/S �� �// ❑
CON'I'AC'f: PHONE, 'HUILDINC PI?RMI'I'INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
i 99- ❑ ❑ ❑ ❑
hIC[N}I O(ON TNACIUIt}OPCLNIAI ION QryHI LECTRICPERMIT� ,¢�� BEE,-
Iaacbymtitrahtl J Is,p of Chapter 9 a,nn ' I, I' JOB DL]SCRIF11ON
DMZ willhSution]gIB)nf Di i.imJn1'Iheeu sa uaJ ProfesonsCode unJ nylce.m's �r / RESIDENTIAL'
WOO Q PIRMITISSUANCC W • 0
F1- n full forte and eflec O� bq ❑SFDWI. ❑KITCHEN REMODEL
ZZW Licenip LlcN AI'I'LIANCLS-NIiSIDHN'fIA1. ❑ADDITION ❑PLIIMHING RIl.PIPF,
N<1 Ilulc CJ Conlr:FC
FOy ANCIII'I'I?CT'S DIiCLA tAT ON PANEIS ❑MGLThLNIT ❑S'TItUCNRAI,
wZ Itndemahnyphers.hall beco]aspodiviscafds MOGl F[CATION
OZ4� UP 10 20h AMPS El Hsi ERIE IR ❑CIHMNEYRFPAIR
W Licrosal['roressi^nal 201-I000AMPS IMPROVEMENT 0SWIMMING POOLS
..1
OWNER-BUILDER UIiCCARAI'I(IN OVER 1000AMPS ❑BATH REMODBIJREPAIR ❑DEMOLITION
I hereby aHna that I and exempt hour[lie Contractors License Law for the
XXl3 LL F following reason.(Section 71131.5.Business and Professions Code:AnY cilY nr coo^IY SIGNS ELECI'NICAI. [IOTHER
LL y whidh requires a permit rah conntruv,vl¢r,impmvr.Jefnnlish,ar repel(any smcune
M•+06 prior m it osuance.also require 0enpplic:mt l ineucfi,sar nofilcaolhalsmrcmem SPECIAL CIRCUI 17MISC.
pZ..LL thus he ix llecnxal puremnt mla
hpnisi
mnmof the Conuaclnre l.ieow nLaw
y�
1+1a00� (,1 ovncingxilh Section 9101pnf Division 9 of the Hudnesund Prof oustsCo,R)or TEMP METER OR POLE INS']'. COMMERCIAL'
tL 1 e W that he is eacmpt themfmm and the basis for the alleged conniption.Any vinlmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
m_LL Section 7031,5 by atyapp]icunt for a permit-objects the uDdi:vnt to It civil penalty of POWER DEVICES
nanne'had five hundred dollars 11500). C1 TENANT El FOOD SERVICE
IMPROVEMENT
��Q wi Lo(hework,the pmpeuct remyempinyceawllh wueesoa lhei(aele connpnhsatlon, SWIMMING POOL IILEC'rNIC
f.0 will dnlheinrk,and lh^ a Cartr ,lanot immndave a.desforsllle(Su.d.,I Ruact of :1 OTHER
6 3 w and eddy who builds Ctor ime Comnctorn Ciccone dos suc not apply m It owner of OII1'LITS-SWITCHES-FI%TI1RF_S gy p n
hit own whooyor improves cs thereon,and who d,".•such work houcled oro(through
— t
hit own employees,provided Ilfut wch ingvuvnnen¢^m nm intenMA nr offered for NI!W IIESIDEN'1'IAI.CLIiCP'k SQ FT.
odr.11,hove,c,Ihe buildinger improvcmuniaauW within one year of enn:plclioq lhu SO EIP'L1Oj1AjZE IAI1�1�n $ISQ.FL
owner will have the burden of proving that he did out build or improve for par �VL 13 /111JrD
proc of wle)
1 t thep pentexclusively I' t b rah licensed t ors to IOTA(: (�
n 1 , h p I 'I(S .7044 B : II f.: Cod,)1Th C 1i mrsl' --.. C1i f�/
Uf IIUrChIIN
Iawdoesml:pplyt'antw rofpr hpcaywhohul(i mfr o
cshcmneh:d QTY' 'PM
LUBING PERMIT : FEE
who contran.a for such projects with a contraclmG)licensed pursuant o the Conddich rs
License Law. PERMIT ISSUANCE
Ion exmnpl under Sec. .B&P C ILr this reason
Owner Ilme ALI171t-DRAIN&VI!NT-WA I'17R(EA) VALUA'I ION
• WORKER'S COMPENSATION DECLARATION BACK FLOW PN(ITECT.DEVICE
I hereby alBmh under penalty of perjury one of the following declarstrar:
❑ IhaveandwillntaintainuCcnificateof Cunscnttoself-inxumfor\Vorkcr's Compen- DRAINS-FLOUR,ROOF.AREA,CONO' S'IOkIES TY PE CONSTRUCI ION
anion,us prOvjd,d In by Section 3](10 or the Labor Cnde,for the pedonmmec or the
work lin which Wis permit is koucd. FIX1 URES-PER TRAP
❑ 1 have and wIll mmntain Workces Compensation Insurance.as required by Section
3700 ofthe LaborC,de.fortheramnnce ofthe work for which lhiV tis issued. GAS-EA.SYSTEM-1 INC.q OUTLETS
ler fermi OCC.GROUP AI'N
My Workers Ghmpcneauon Inn'urunce Cartier mW Policy annunciate
Carrier: - PIONFRO: GAS-1'.A.SYS'I'IiM-0V9RJ(IO
CEItTIPICATEOIr SATIONIINSURAN WORKERS'
COMPIiNSAT10N INSURANCE GRfiASi%INDI/S'1 RL WASTE IN'I EHCT:1'J'ON
BUILDING DIVISION ISIS
(Ibis aectinn need not M+mmplemol if lhcpermit is fnnmc hundred Jnllura($I(p) GREASE TRAP
or Inn.) I'LANCHECK IIiP.
Ireton,that In the pctlormunceofihcwork lerwhlchlhiapermif is lean ed,lx hall SEWER-SANITARY-STORM HA,200 FL
not cruploy any person in any mann• enol ha n M1ecOnthe Work...Conifer- ENERGY I9?i?
Z onion Laws of�ghf�n' .1)✓! a l p WAILR HEATER W/VENTIELIiCTR
Z
O NO]ic'anl AI¢� u GRADING PEE
H-f y Nf YI'ICC'1' AI'P.-CAF`. 1:after making Ibis Certo,ar of Exam tion,you should W11 HE SYSTEM/IREATING
X- ?
heroine afbjcO to the Worker's Compensation pmvieions of the Labor Gale,you must SOILS FEE
W forthwith comply with such provisions calfik permit shall be de, d revoked. WA'i'IiH SERVICE
91.
U O un CONSTRUCTION U NOING AC.ENCY NEW NESIDEN'I'I Al.PLMH. SQ,14. PAID Uc ktteiP t#
Ihcrehy nl'llrm lh:rt there is lfmmlmclileadingagry enfnr lie perluu'rmanceol
rr Jac work]or which this pcmthis isuied(Sce.91197,Civ.C.)
0 F n
Ledm
ers Nae TOTAL:
U Lenders Address AYI'AL:
>w 0. I erfly that I have cad II . ppl t d'I I th t th b e i tf rot f a BUILDING FEE
fF".t V3 101. 1d,n fly Inhall Ity I' it,colidonar,and 1,0aw,ilatic,m QTY. I MFCHANICALIIFRMJT FEF.
L) Z building Couvroafamr.and hen0nn
ly.torzc nl rcaenWl s:d lelty to auupoh l he h SEISMIC 117
.Noe-mentioned'roped,IF in.a am.parswe" PGRMI'IISSUANCE
IWC)agree m m
save,indemnify and keep harmless the City of Culeninn against fa.l!CfRIC hili
built tics,judgmvntn,costs and expenses which they in any way accrue against.said City ALI I:R OR ADD'I 0 M ECH.
n
in consequence al the gmnij ng u1 this pernhit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,011h CPM)
SOUR ER ULA YSA / CONS PRICAI.FF.E
/i/(( j(J/ AIR HANDLING UNIT(OVER 10,(MCFM) CONS'fkUCTION TA%
SlFnuuna nfAppllcun Canlraz nr Date EXHAUSTHOOD(WIDUCI) BOUSINGMITIGATIONFEE
HAZARDOUS MAI HR]NS DISCLOSURE
N51l ilmapplicanlorfutnrebni[Jing,<cupanatore ar handle hamNnm matvini HHA'UNG UNI'I(1'0100,00h BTIA
u.defined by the C.peniea Municipal Code,Chapter 9.12,and the Health and Safety
Cod,,Section 25532(a)P HEAPING UNIT(OVER 100INIO BTU) -
0Yes I C]No PAN
V 13N'I'ILATION PAN(SINGLIi It1?,SID) Doe Receipt p
Will the applicant or future building,weuputn use equipment or devices which
noir h.rardom air Cor ,ar iunnrc as dettned by dm Bay Are.An Quality Manngemem BOILER-COMP OHP OR RX)J R RTU)
Dowel? TOTAL:
'Yes nNo BOILER-COMP(OVER 10k.00E13TU)
r
I have rc:ul the lhazvdou.v arsenals nitrification,under Chuprcr 69$of Ne OJiAIR CONDI'1'IONRR- ISSUANCE DA li
lnmia Health&Safety Cade,Sections 25101,21111 and 255,61 l underso d that file
NEW RESIDP.N'I Al,MECH. SQ.Ff.
hn0dmg I've not ainently hove n leant,thin it ja any m pn....h ity to nodry Ila enupunl
of the rcquircfncnu which must he fact prior to issuance ell Cernfmam of Oocvlwncy.
Owncrnrautbnrf agent Date TOTAL ISSUED BY:
OFFICE