S 1009 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOF CUPERTINO BUILUING-KLKC'FRICAI, - I'r:RMII'NO.
BUILDING DIVISION I API'I,ICATION/PERMIT PLUnnnl9c-MKCHANICAL S 10 0 9
IIUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI ITAL DATE
-7
OW .,S NAMI!: I'HONL: A OR' AME: LIC NO:
O NIC CON'fROLH
• ARCHITECGI!NGINFER: LIC NO: A ESS. � �� ❑
CONTACT. PHONF: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) W ELECT PLUMB MFCH
ICENSFD CONTRACTORS DFCI AGON QTY ELECTRIC PIiRMIT PEE JOB DESCRIPTION
I hereby affirm That 1 am licensed under provisions of Chapter 9(commencing
c with Section 7fXN1 sfUavisinn lofthe Busincaewt{I'mfessinns Gale,imdmylieenseix RESIDFNTIAI:
/ PERMIT'ISSUANCI!
aUc in full force _et.��. ����� ❑SPDWI. ❑KITCHEN RFMO<)lil.
see Liunu Clas i- Lic.p APPLIANCPS-RRSIDENT1AL ❑ADDITION ❑PLUMBING R&PIPF.
Ciba )mos/„--p.{.y�---Cnmtucto.L��/1a.e�-- _
/(J rd"!� ARCHITECT'S )FC(AA'AT44—e pANe1.S ❑MUITh UNIT ❑STRUCI'IJRAL
~t22 Iimetraundtny)inns Shull heusalux public rccma�j r + ODIPICAfION
C Z.-.. UPTO200AMPS
❑INTERIOR IMNIiY RCPAIR
aW Licensed Professional 2OL IBI)AMPS ISEPROVHMENT 0SWIMMING POOLS
gw•,]4 OWNER-BUILDIIR DECLARATION OVIiN IIXX)AMPS ❑BATA REMODF,IJREPAIR 0DF.MOL1'I'ION
6 I hereby ufffm the 1 am exempLfmm+the Convector's License Law Sir 00
d U fallowing reasom.(Section TO 16,Business and Profession,Code:Any city or county SIGNS FLECPRICAL ❑OTHI!R
3 c. which requires a permit to consumer,alter,improve,demolish,or repair roy stmetnre
F-140 mer,its issuance,also reamnes a he applicant forsich .it m file o signed stmemem SPECIAL CIRCUIT/MISC.
that he is licensed pursmm m the pmviions of the Connectors License Lov(Chapter 9 COMMERCIAL:
YCI (cammuml an with Section 700)of Di vision 3 of the BrA ness and Podiexsinm P.Coster ar TEMP.M BTER OR POLE I NST.
a G c that he is exempt therefrom and the baric for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X�--y Section 70315 by any applicant for a permit subjects be applicant o a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SHRVICE
Fixi+ not more Non Eve hundred dollars(S500). - IMPROVEMENT
x6n 0I.is owner oldie propenmmi+ons
y, my employ.,with wages nc their,lode roution, SWI MM I NO POOL FLI:CTRIC
F. willdo the wmk,rad the structure is not mended mothered for sale(Sec 7041.Business ❑OTHIik
W and Professions Cash:The Commuter's License Law doe,not apply to an owner of OUTLEI:S-SWI'ICHF_S-FIXTURES
�'3.. propeny who builds In improves thereon,aero who does such time himself or 0mugh
his own empl)yeese proving thus such improvements me not intended m offered her NEW RESIDENTIAL HhELT SQ FL SQ.PI'.FLOOR AREA g/SQ.Irl'.
sale.ohowever,the bon ding or ofprmmd issold within one year of prove for the
_ -
-builder will have the burden of proving that he did ern build or improve for per- P p
pose of xaley TOTAL: W ,
❑ 1,as owner of the property,um exclusively cnnvacting with licensed conn mors in w
construct the project(Sec.7044,Business and Profusions Code:)]he Convector's Li- ��}',�- t 1V ��
encs Law does not apply n+annvrerof progeny who builds or improvestherem,and QTY, PL '"'fJ^C PMI FEE n /s
whit contracts for such projects with a commerorat licensed pursuance the Contractors C/ v /std v
License Law. PERMITISSUANCH L�• rV•D(� _
I mm emmpt under Sec. B&1'C fonhis rensnn L
ALTHR-DRAIN&VI!NT-WXI'IiR(
Owner Due
WORKER'S COMPENSATION DI!CLARATION BACK FLOW PR(JI'i!Cf.DFVICIi
•I have
and will
ntain a penalty of e at Conery ncofnhefnllowing dislor'inon ACV
❑ IMrve and will maintain aCcrtilicutc at Consent m.elf-Inners for Workers Cun+lre++- DRAINS-PhOOH,ItOOP,AItHA,COND. ORIFS "fYPE CONSTRUCTION
sutinn;as provided for by Section 37M of the Labor Cole,for the perfo=nce of the
or which dd,pem+it i.c ioned. FlXTUR6S-1'F.R TRAP
ave and will maintain Workers CnmFemmunn Insurance,ms required by Section
3 c LAavCode,fornhe perfnnnunroof the work for which this permitln'nsocJ, GAS-EA.SYSTEM-1 INC.4 OU I'LEFS OCC GROUT' : APN
My Worklnxu j � 'd Policy-n �
GAS-F.A.SYSTEM-OVER 4(FA)
Carrier: No.:—
CERTIFICATE:
CERTIFICATE:OF
EXEMPTION FROM WORKFRS' GREASIVINDUSTRL WASTE WE RRCF.PTOR
COMPENSATION INSURANCE BUILDING DIVISION MBS
This section need not he completed ifthe pemdt is formic hundrd dollars 15110) GREASE!PRAP
sur less) PLANCHECK FEF.
I cenifythm in the promm+amccofthe work mirwhichthis Permit is issued,i shall SFWFR-SANITARY-STORM HA.200 PT.
not employ any person in any manner an us m become suhject to the Worker.:Camper- ENERGY FEE
Z union laws of CaFfinnin.Dec WAI HR 1117ATER W/VENT/ELI!C'fR GRADING 17FE
z Q Applleom + '
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/IRFATING
SOILS Flan
(-+ fs"hoodourpin the Workers Compeorthisconnd dshotvines of the
onedLabor Came.you must
forthwith comply with,such pnrvisim+.c or this parotin Shull he Jeentad revoked. WATIiR til!RVICC
G
CONSTRUCTION LENDING AGI!NCY NEW RISIDENTIAI.PLh1B. SQ.FC PAID
(].1z I herehy anion thanhere is aconsioceln lendingageat,for the perfotmanceol Use Re<ciptp
the work k for which this permit is issued(See 3097,Civ.C.)
OU Lcndcr's Name ILIAL.
W Lender's Address TOTAL:
y 1 eerily that I have rent this application it xefe that the aNice information is BUILDING EE
V) enrechlagree ns comply with all city and county oNinances and store laws rclatin6m QTY, MECHANICAL PERMIT FEE SRISMICFIa!
U7
F7 buifdingwngmction,and herebyomhorire representatives afthiseity to enterulxtn the
aheve-mentioned property for inspection purposes. PERMIT ISSUANCE ELFCI'RIC FIR..
(We)since tat wave,indemnify and keep harmks.the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accmeagainn said Clry' ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting of this Ferrol. .
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL ME
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER tribal CONSTRUCTION TAX
Signature of Applicnm/Ccarracmr Data EXHAUSI'HOODIW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or faturebuildingoccupso smmorhandle hezvdou.s material HEATING UNIT OO 100,000 BTU)
as defined by the Cupertino MunicipalJJ��r�a��n Chapter 9.12.and the H.1th pad Safety
Gila,Section 255]2(x)1 o BEAT UNIT(OVER IGLERB'rU)
❑Yes o VENI'l1.AT10N PAN(SINGLE RILSIDI PAID -
Du a Receipt p
Will the epPlicam or(mune buddin occupied use equipment or devices which
•,emit hazardous air malmonams eco def by the Buy Area Air Qunllty Management_ ROILFR=COMP(31IP OR I(NLII(111 B'M
TOrnl.:
District'? BOILER-COMP(OVl!R igk(HX)BTU)
El Yes
I have re ad the haerdous ma crequiemem.c under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCEDATE
li+mi h&Salcty Gxle Sections 25. 25513 and 2$534.I unJetsmnJ the If the NEW RHSIDENTIAL MECH. SQ.ITL:
bd m,d c.crentl1to tormiLthmit aryrevormobilitywnrnify the ocupttm
t ou'primin swddseofa enifi t of ryno600C ey.
r amhnrie d agent Dat TOTAL ISSUED BY:
OFFICE