S 1365 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEIJc�II NO, 1365
BUILDING DIVISION APPLICA'I'ION/PERMIT PLUMBING.-MECHANICAL
BUILDING,PROJECTIDEM IFICATION
BUILDING ADDRESS' SANI'ITRY NO. APPLICATION SUBMI'1-IAL DAI'li
OWN12R'S NAME: I' ONH: C)N'IR, IORE:'S NAMLIC No
IJ'e-� �T1-Wd-ICI-`, ` CO. bdOG� N(C L'ONruDLX
.',ARCllll'ECHENGINI9HR; LIC NII'. ❑
F 166
��n � Air. ss 9ciZF
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Appficant(Initial) BLDG ELECT PLUMB MFCH
LICI?N5E8)CONIRACIOR:S DECIAR61'ION QTY EI-ECTRIC PERMIT IaIEE "
1 herehy affirm mut Earn Reared role. oolds-A Chapmr 9 sonnneneing JOB DESCRIPTION
�aZ til Sa,ine]I%MO ul DivixiTmJ ofthellusine�,enA 1'm(cseion,Gxle,mrnay license in RESIDENTIAL:
f�-O� n'I'ull ferte.nd dlµ PERMIFISSUANCE
al-f ZL SOIo(o� ❑SPDWh [_3 KITCHEN RG\tODlil.
QUU Lieensc Cl...ClLie.X a CO APPLIANCES-BESIDES PIAL ❑ADDI'1TON ❑PLUMBING RE-PIPE
I-•ZM Die. Conln.r...r
F 6 y. ARCIPITFCPS DECLARATION PANELSElMULTI-UNIT ❑STRUCTURAL
ZOt^Z IunJcntmd my plant xhnl MODIFICATION
OZ=O Oil DO 200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
]01-Ify)CAMPS IMPROVEMENT E]SWIMMING POOLS
that I a "WIELDER m The RATIUN OVER IIXIB AMPS ❑BATA REMODEURIEPAIR ❑ ?MOLTTION
tY x G 1 hereby affirm Inn I am cBcmps from the ffnmo ns Cor ,Any c Law Tor nhc
'X0.(:L F I'o hawin6.mann.ISmuan]113 LJ.Ilusincex and Pndcesinns GadC:Any city m amnry' SIGNS ELECIRICA], ❑OTHIER
4: N which Iegnircx a I,crndt m construct,.offer,improve.demolish,or repair any structure
1pp"W-� nor its is.a.nnac,oleo ruynirexrhe epplinnT fir.such peodl to Glu u signed swmmcnt SPECIAL CIHCUFUMISC.
2N>� 'hat he is licensed punuanun the prev.amns nfthe Cnnvanorx Liecmc Law lChupic,9
cif (cmm�mnciag with Scoion7n)(Dof Division l of me Business and Profca,ions Civic)or TEMP.MIfFER OR POLI:INSII COMMERCIAL'
m a. C that he ie cxe.up,,hm,&om anal Inc bink 1,11[fie alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DHMOI,I']']ON'
X^°- Seaion703 15 by m,y applieam for a permit subjecis,bo applicant to a civil penally nl POWER DEVICES
W an a more In..five bundnNdollan($500). ❑'TENANT El TOO[)SERVICE
1-ZY IMPROVEMENT
Q pLothew work,
the pml.en¢ot is employca withleted ate thcirvlc 194.Bsmion, SWIMMING IOOhID.IiC1'HIC
O will Jo the work.and the structure is rat imm�Jcd or filleted li'r sole f5ec.]WJ.liusiness ❑OTHER
63 ce and Po(usAora Code:Ill,Con,ci License Law daro not apply to an owner nI OIJ'I'LISI'S-SWI'I'CII85-Il%'Il1RIS
posers,who builds or improves mcrcnn,end who does such wort hinuclfnr inn.ugb
his awn comleyms,provided that ouch improvememx mu not imended or offered for NEW RESIDENTIAL ELECIR SQ ET.
sale.IL hawo'en the building or ln,powslaOnl ix sold within Dre ymrof comETICh n.the SQ.FT.FLOOR AREA LSQ.PC
crbuildcr will have The Warden al pmving Out he did nm hold rte Impeow for pur-
posc 0 sale.).
F1 I.as owner of the prol.eny,am exclusively contracting with licensed conmTaon To TOTAL:
onxtrao the prefect(Sec.7044,lluxinox and Podlvvxiums Cala:)The Cmunitnr'x ceo'c 1a,w does not apply to an aw nel of properly who builds or improve.Ewreon.and QTY, PLUMBINGP MIT FEE
who contmcu forxnch pmju+v with u centmrlons)licensed pursuant o the Contractors
License Law. ItiRM1I I'I'ISSUANCE
I un excmp,under Soc. .B R P C far this m...a Ali)
AI:TF.H-DHAINhV -WAI •A) A� �VALUA'IION
Owner D.ec 2
WORKERS COMPEN'SAI'[ON DECLARNI'[ON RACK FLOW PROIFCI'U ICE
I hereby.lfie t under penalty of perjury one of the follmvmg dalanriens:
.red wmm
ill ...na.na CenifcarlComno ins
cnsell' ure for W kc,,Co.T,n- DRAINS-FLOOR,RIX)BA OND, ST 115 I'E CONSTRUOCION
sorer,is......idled for by Scotian 37W of rile Lab...Call,!nhu Iwtlunnentt(,I The L(yp.
wnrkforwMchmixpermitixi...ed. FIXTIRTa-PER'rRnp CMG) 11
E3 have land will maintain Workers Compensation Inxumnce,as required by Section V
37X)or the labor Cale,Ior The perfnrn..nce of the work lot which this ry.iOe iasual. GAS-EA.SYSTEM-I INC.J Of/TLETI OCC.GROUP MIN
wotkcy' (nyJyyti:lri)iiiwwe ea rand PoIicyn ,rLcyy u:
PubL W-VX C� 7 MS-IiA.SVS'ITM-f1V1iH4(IIA)
Corm 1fl'nliN.FROM
CERTIFICATE 01; SNII.ON INNPROM WORKIiRS'
COMI'IENSAI'ION INSURANCE? GRHASIJINUUS'1'BE.WASTE IN'CEHCEI'R)R
BUILDING DIVISION fFES
CI1.i.. thoneW notne...ngJmnl ll,bepcnnit is forone hundred dollen sl..or Icss.) GREASETRAP PLANCHECK FEE
I eenifythuinrhel'e'dnne...c urine work for wbiehmis permit in issued.I shall SEWER-SANICARY-S'IORMEA.2(p FI'.
rat employ any perxnn in any..tanner w s to necomc subjat m the Worked Qampen- I ENERGY FEE
0 Z ,rare.Laws of Celifarnl e.Dam WATER HEATER WNEN'OHLECfR FEE.
O Apprcam GRADING
NONCE TO APPLICANT':If,after making this Cermfiane of iNemption,you should WAIVER SYS"I HM1111 MINE ING
.K' > become whlun m the Workers Compen,.tlon Provisions of the Labor Code,You sea, SOILS IEE
Iimlodkh comply will,such pmvieions or Thi s.....it shall be domed revoked. WATER SERVICE
aQ
O CONS]'RUCTIONLENDINGAGEN'CY NF.WRISIUEN'rl I'LMB. 5Q.FL PAID DlH.cci TX
1 hereby union that u
here i.a consuctimi lending agency for the seefonwuc
nce of s
0.c work f r which Nix permit is ixaunl(Scc.3DA.Ci¢CJ
I" I<ndcrx Nane 'rOTAh:
V lender.Addles, TRIAL:
0. 1 certify that 1 have mail mis.p,lienim and ,are Than the above information re BUILDING IIT E
F- tn eoreeat.Iagree to e...nply with at city and county entrance,and state laws relating to QTY. MECHANICAL PERMIT FETE
L) ,Z, boildingu n,tmainn,end herehyatnhonve repro,cutmivaol"tlikeit"o-Terupon,he SEISMIC 412E
abovo-mentioned popery to,in"'Tion pntpocev' PERM]"t ISSUANCE;
0agree,,,me,indemnify unit keep hnnn e,the Cil,of Cupertino agan,iELECTRIC II?H
B'q
Iluhi'tica,judgmcn,.,can.oml eXponux which mayin anywayaccrue against wid City ALTER OR ADD TO M ECI I.
cgncntt of rbc grmling of Ihi-a permit, PLUMBING PEE
APP H'I'UNDERSTANDS AN[)WELL COMPLY WITH ALL NON-POINT AIH HANDLING ON['1'(11)IBM)CFM)
SOI ;Iii FGULAOONS, MIECTANICAL PEE
AIR IIANDLING UNIT(OVER I May)CFM) CONSTRUCHON TAX
Sign ore or AppGc.nJCm,m,aor Dwc EKHAUS'111001)(W/DUCT) HOUSING MITIGATION FRE
HAZARD(RPS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardous material HEAPING UNIT TO IW,fpO BTID
ev dufinal by We Culvert no)Me licipal Calc.Chapter 9.12,and IM Ilealth and Salcty
Code.Scaien 25532(.)] HHAI'ING UNIT(OVER Iwifix)11'rut
❑Ycs I]Nn
VENTILATION PAN(SINGI.Ii HIiS1U) PAID
I e Will rhea applicant or muse building occupant use e t or device.which Date Raeipt X
Pp b pan .Air n BOILER-COMI'(JIIPOk 100.0011BIU]
mit hamrdnus air mnunninanw as JcfnmJ by the Ifuy Arm Air Quality Munugeme°I TOTAL:
Di snit I HOII.ER-COM1II'(OVER IIXI.(M]ITIJ)
I]Ycx E]No
I have mad he haXanlnu.mweriah.cyuirenems under Chapter 6,95 of the Cut,- AIR CONDITIONER ISSUANCE IJA'I'E
Emmet Health&Safety Code,Seaters 2550.5,2.5,533 and 2594.I undcnnndotal it The NEW RESIDENT AL MF.CIL SQ.EL
building Mea not cutren0y have a cie nt,that it is my tenrymsihilhy to notify the occup:re, �
of the teyuinn.emx which must be net prim to issuance of a Certificate of Occup,ncy. V I/ T
Garlic or aefhorimd ,Vol. Date TOTAL: ISSUED BY. /�
OFFICE