24639 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HU IL) (:-ELKCTRICAL PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL ^
BUILDING DIVISION IIuILI11NGIIROJFICTIDFINTIFICATION - L
BUILDING ADDRESS: � SANITARY NO. APPLICATT
ION SUBMITTAL DAE
1
L OV `VCMMAS!! UNIT# LOT#
OT AMF HONE CONT A MU: LIC NO:
^ 6 NIC CONfCOLp
0 ARCHITEC'EANGINF.ER: I/ LIC NO: AUDREb.. ❑ 1 `J
f CONTACT: PHONE: Y
s � Q'IY, F.LECI'RIC FERNT PEE BUILDING PERMIT INFO
BLDG G PLUM E
PERMIT ISSUANCE
LICENSEDCONTRACTOR'SDECLARATION ppPLIANCGS- CS IAL JOB, ION
Matz IM1ernhy afErm thnG am liccnuJ mtMrprovisionaofChapmr9(commencing with
aP100 Section700(dif Division Sof live Busineasand Professions C.de,and my license is in PANELS ,
q�V F full force and effen.
NVLicense Class - Lic.p UI'T ) MPS I�~g•{V''
,=y Date Contractor ❑- AMPS
ZOnya'� ARCHITECT'S DECLARATION E txl11AMCS SQ.IT,FLOOR,AREA 'E/SQ.IT.
O'GZ^W undermunA my#lams xhnll he usel m public records. S
F'� W +NEI?LL'CTRA 3(sTVy1
�at Liocnscd Prnl'eselunul OWNER-BUILDER DECLARATION SPECIAL C IISC. �G#
C),F I hereby affirm that 1 am exempt front the Contractors License I.aw for the
3('-m following mason.(Section]0315,Business and professions Code:Any c.. r-5 county TEMP. el )R POLE T. 1a+
eco which requires a permit m construct,altar,improve,demolish,or repair any srmon e
atW}� prior,.its iautroo,ulsn rer,mani at,dicmrfar such .it but file.d,pradawtcmcnt IWWrRS
H<W 0O tat he is licensed pirammn m the provisions of the Commences License Law(Chapter
Tyo� 9(commeocing with Section](100)ofDivision 3 of the Business and Professions Code) O.ELECI'RIC VALUATION
or Geis exempt and the hasisfor the alleged exemption.Any violation of
� Y Section 703 L56 applicant yo ITCHES-FIXTURES
za by app icon perror,subjemstheapplicanuoacivilpend, f
not ,ban fivehundrtd Jollan(55001. 'IAL ELECIR _SQ.FT.
C pw I nwnerofteprspony,ormyemployceswithwagesastheirsolecomNmatiun, STORIES TYPECONSTRUCTION
y3— the Wak,and thesractme is not imendedmifimd burials(Sect.]0zi Business
d Professions Coale:The Commmors Liecnse Law don not apply to an owner of -�
ropmywhobuildim hapmvest corm,wtdwhodoexsuch work himselfmtlwugh his O 1 UP R NITS
nemployees,Provided tatthea improvementsamnm intendedoroffereciforsae.IL
however,Om building orimprovemem is sold within one year ofeempledon,the owner. '�
builder will have the buNen of proving tam ho did not build or improve for purpnu of
sale.).
❑ I.mnwnerofthe propeny,am exclusively contracting wit licensed contractors lo QTY. PLUMBING PERMIT FEE '1. tjl . E A
construct the prnjecl(Sec.]044,Business and Professions Code:)Dim Comtnclne. p13RMl'1'ISSUANCE: A 1 G '
License Law docs not apply loan ownerof propeny who builds mimprovn theman,and
whence Laetsfnnnch pn',jccuwiOl ueommmor(s)Ilunsed pursuem,o to Commnor'e ALTER-DRAIN&VENT-WATER(EA)
License Law. PEE SUMMARY
❑ 1 um cxcm,d under Sec. .B.&P C for his rcoson BACK[:LOW PROTECT.DEVICE TUTTDT FEES
SANITARY V N
Owner Dao ONAINS-FLO(]R,HOOF, GONDRECF,IPTp
WOR K MAN COMPHNSA'I']ON DECLARATION , , . SCUGOL'I'A% Y N
I hereby ullirmthat l have acer,ilicam ofconsent mulf-insure,macenificateof FIXTURES-PERTRAP RECEIPT#
Workers'Compensation Insurance or a cenifed copy teneof(Sce.3800,I.abCJ which PARK FEE YN
covers all employee'an denhis permit. GAS-BA.SYSTEM-I INC.40(ITLEI'S RECEIPT#
Policy# �# BUILDING DIVISIOA FEES
Company GAS-FA.SYSTEM-OVER 4(EA) PLANCHCCK FEE
CICenifiedcopyishembyfnmished.
❑ Certified copy is flet with the city inspection division. GRFASrONDUSTRI.WASTE INTERCEPTOR GRADING FEE
CCITT IFCATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILSTR
COMPENSATION INSURANCEGbissectionneednmbecompletedVinepermit is(Drone bombed dollars($100) SEWER-SANITARY-STORM P.A.300FT. ENERGY FEEor less.)
I ceniffled inthep aficrmmcamflho Work fir ich this permit i.issued,lahall WATER HEA'L'ER W/VENT(ELECIRno, employ my person in any manner so v m become subject t. he Workers PAID
z ACPapanti',imiLawsofC.liforam. DamWATERSYSEMfERUATING Dam NOTICF.TOAI'PI.ICANT:lf,uflermAin thisCenifiamofExem I n g pro e,you null NF:W RFSIDI?NTIAI.PLMB. SQ.PT.Z > become mhjenmthe secrkcr's Compensation pmvisi.nsoho eLahr Cvoked. must, forthwith comply wit such pmvisi.ns.obis permit shallbedecmed invoked. ❑UILDLNG FI?U
zCONSTRUCTION LENDING AGENCY SEISMIC FEEI hrcbyuffirmtat there is a cnntructinn lndingageney far t.performunttofI'LECI'RIC I'lil?The work for which dui ltcrnd ix boned(See.309].Civ.C.)
Fk. Lender's Name -
LendersAdins. QTY. MI?CI IANICAL PERMIT FEE PLUMBING FEL?
U 1 certify,ha,1 have read this application and state that the above information is
t�" W comit.Iagree tncomply with all chyand county Ordinancesandslme laws relating to PHRMTF ISSUANCE _. MECHANICAL.FEB
rF-n building construction,and hereby authorize representatives oftis city to enter upon the - CONSTRUCTION TAX
V Z above-mentioned propeny fm inspection purposes. ALTI?R OR ADD TO MUCH. r�
(We)agme to save,indemnify and kap harmless the City of Cupertino against
lidbilitin,judgments,costs and expenses which may in my wayaccme ninstseid City AIR HANDLING UNIT(TO 10,000 CFM)
in of the grmlingo Ibis perm
AIR HANDLING UNIT(OVER 10,003 CFM)
Signature of pp canUlomracmr Date E%IIAIIST HELD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Date Receipt#
Will the applicant orfuture building occupant store or handle hazardous material NI?A'1'ING UNIT(OVER 100.000 BTU) TOTAL:
u defined by te hCupertino Municipal Code,Chapter 9.12,and to Health and Safay
Cale,Section 25532(.)] VE pDLATION PAN(SINGLE RFSID)
❑Yes ❑No :1 511
Tt
Will thI, damium is ar,as building by the A .Air ordeviceswhichemit
OOILER-COMP(3HP OR 100,000 BTU) ISSUANCE A
ardour Dir nmmminmts m defined by the Be,Bay Amo Air Qmlily MmagCmenl
OimP BOILER-COMP(OVER 100,00)BTU)
1:1 Yin, 0N NI?WRFSLDI?NTIALMECII. SQ.FT. �' ,� -
I h:rvc rad the hu>allous materials requirements under Chapter 6.95 of the a / I
Collf.miu Llcuhh&Safety Code,Sections 25505,25533 and 255. . I a.,Than that W
iflha Biilding docs not currently lmvca¢nam,tat it is myrespmsibilayso nmily the r ,tom
occupant of the requirmucals which must be met prior m issuance of a CeniOcme of I.JAN 2 0'79k,
Occupancy, /.f /-�J�I��%
Owner or authorized agent Date Issunp q�': I lwy
OFFICE