00010082 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY V V I Q Q AL�
.CITY OF•CUPF,RTINO Bull DIh'G-ELECTRICAL FERMI"f NO,
BUILDING DIVISION APPLICATIONIPERMIT I'I,UhIBING-MECHANICAL
BUILDING.PROJITCT IDEN'TIF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUHMI'ITALDATH
1 G c Al ZOO
VNER'S NAM.: I'fIONE: CONTRACTOR'S NAME: LIC NO:
_ W NIC CONTROL p
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CON'T'ACT': PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG / ELG PLUM.' MF,eH/
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby amnn that 1 am licensed under provisions of chapter 9 montnteneing JOB DESCRIPTION
O i'Z with Seen.7(Mo f Division 3uf the Bo,imas and Indies......C,dc.andmylimme,s RESIDENTIAL:
FOO in full forccanJ Chert. PERMrr ISSUANCE
El Timm.aHEN REMODELUV License Clas Lica TC
Nay Dale Contractor APPLIANCES-RESIDENTIAL []ADDITION ❑
ADDITION PLUMBING RIi-PIPE
ARCIB IU 'S DECLARATIONfANE4S ❑MULTI-UNIT ❑S'TRUC['URAL
Z O rn Z I to dentmd my planx.hall be uwd oo,ablic records MODIFICATION
OZN•—a Ul'1'0200AMPS ❑INTERIOR Ell CHIMNEY REPAIR
F4tW Licensed lhofavaraal 201.1100AMPS IMPROVEMENT (D SWIMMING POOLS
CK�, OWNER-BUILDER DECLARATION OVER IIMOAMT'S [I BATH REMODEI/REPAIR C)DEMOLITION
C C< I herchy affirm but I am exempt!mm the Comractor's License Law Ert tM1e
3 LLH following reason.(Section"/(131.5,business and Professions Code:Any City or county SIGNS ELECTRICAL ❑Ol"HER
y which requires a permit to nmauuct,alter.improve,demolish.or repair any.vunure
LtiOa pHarbns iwroneeaknrryuire.IbenppliCant forauchpemrino Ficasigned.sttimmem SPECIAL CIRCUIT/MISC. �(/�/✓ fyl
S'ZT that he is licensed pirmanun the provisions of the Convector's Licemc Law(Chapter 9 r
W 0 (commencing with Section TM)of Division 3 of the Business and Pmfesions Code)or ':'ILMI'.ME' OR POLE INST. COMMERCIAL:
a a e C that he is exempt therefrom and the basis for 0c alleged exemption,Any vinlntion of ❑NEW BLDG/ADDITION ❑DEMOLITION
X�H .d1on 7131.5 by airy applicant for a perm ❑
it subjects the applicant F,a civil Tommy of POWER DEVICES []TENANT
tSFOODSERVICE
Finite than five hundred dollar,(SSW). IMPROVEMENT
Sp ❑Ias owner df the pmpen&or my employee.with wages..theicsole cian,n.cation. SWIMMING POOL ELECTRIC ❑OTHER
oto wJl do the work,and the tenure i.not itnnWCJ ondl'cred fm sole(Sec.NV4.Bmine.
13m and I'mfcsxidn.CnJc The Commuter's License Law does not apply m an cone,of OUTLETS-SWI'I ClIES-FINE URES
lldthem
property who busor improve. on,and who does such work himsell.r thronglo
his own employees,provide t that such improvements are not intended or offered for NEW RESIDENTIAL ELECT SQ 1.7.
some.if,howeve, he beilding.,impro—hent ka,ld withinnne,.m.f appalled"..the gQ.FT FLOOR AREA SISQ.Ff.
.l
inimer-loodder will have the burden of proving that he did not build in improve for pur-
,x cofsale.).
has owner of the Dropeny.ten Cxduaivcly nmvucting wish IkcmeJ convonmrc m L
eomtmal the pn,jott IScc.o an Buer of and fly%I i builds
or i The Camo¢mr's and
Case Taw Ji (not apply aswithaeofpropenywcesed ptirimpmvn Contractors
QTY. PLUMBING PERMIT
whoco '_'m'vuchprojeas withanmtracmr(0licenseJ pursuam to the Conlmn.r's p 4.0
y.�
Lic eLaw. 1 PERMIT ISSUANCE V
ten v. l mder.7 ,R&P C for this mason
ALTER-DRAIN&VENT-WATER(EAT VALUATION
net Dm
under
arthyoiNrjuryo DECLARATION BACK FLOW PR01tC1'.DEVICE T e) 0
Thereby: Gr amdca Certify.e ofConeneoflhe fomm lot declarations: CJ
...,a,and will ai by Soadeni5cemofCe Labor sede.for ler Worker's Com pen- GRAINS-FLOOR.ROOF,ARRA,GDND. STORIES TYPE CONSTRUCTION
swoon,er provided forby Semina 3100.(the labor Cute,for the pcAormnarmor f 0e
work liu whldt this permit i.ixsuoA, 10X'1"ORES-PEN TRAP
Ej 1 hove mid will mviamin Worker's Compensation Insurance,m require.by Section
3710ofthe Labor Code,for the performwceof the work for vach,his iont Ls issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AP
O N/
My Worker'sCompen.afpnlnaurancecanicrundl'olicynumlreram: G_ 7
Carrier: Policy Na: GAS-TiA.SYSTEM-OVER 4(EA)
CERTIFICATE!01'EXHME?10N PROM WORKERS'
COMPHNSAUON INSURANCE GREASEYINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This smtionnccd..ot hccntnpletelifthcpennil is fnronc hundred d.11.,(SIM) CREASE TRAP
or Ica.,) PLANCIIECK FTE
I certify but in theperfomanceofthewofk fprwhich mispmrmil is issued,I'bell SEWER-SANITARY-S'IORM F.A.ME PI'.
not employ any person m any manner..an"become subject In the Workers Caroni ENERGY FEE
Z action Lvwx of CuIlGrmia.Date WATER HEATER W VENT/ELFCTR
0 �� M_.I1 IQR TNG IEE
Z O Applicant
h NOTICE TO APPLICANT:If,after making This Cenlficmc of Cxanp i...you should WATER SYS]'EM/1'REATIN r
III X SO S19iF,
C>
become sabjemas it worker, Conn or thi, pmannbut none Labaredreode,you must Il,j i 1
{LI hmhwith comply with.tech pmvi.unn.or this man but]be.cemed revoked. WATER SERVICE
aQToo—
CONS"I'RUCT ION LENDING AG17NCY NEW RESIDENTIAL PLMB
V 0 1 hereby union that them is a Construction lending agency for performance of Dole RtteiptM
E" the work for which this permit is issued(Sec.3891,Civ.CJ
U' Lender'.Name TOTAL:
V Lenders Address dy TOTAL.:
} y T minify met I have rend this application and state that the above information is 'BU RING FEF,
I'-s rn comma.I agree w comply with sol dry and county nNinanas send stem law.relating Ip QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby uuNonimrepresenmtivex of this city to enter up.n the SEISMIC ITE
ubovomemioned property for inxpeaion purpose.. FERMI'1'ISSUANCE
(We)agmc m—,indemnify and keep harmless the City of Cupertino against ELECTRIC FEIi
liabilities,judgmenw,costs and expenses which may in any way accrue against said City ALTER OR ADD ED NIECR PLUMBING PEE
"nemin (the gmnling of this permit.
APPLICANT l)♦VDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00 CFM) MECHANICALFFE
SOURCE F it ,ATIONS
/`/,(_66
AIR HANDLING UNIT(OVER 10,01MICFM) CONSTRUCTION TAX
igo ser ApphCantiOnar: for Date EXHAUST HOOD OODUCI) HOUSING ME rIGAHON FEE
HAZARDOUS MATERIALS DISCLOSURE
BE the applicant or future tradiing(sampan(sone or handle haear.ou.malarial BEATING UNIT(TO IIXI,IKKI BTU)
as definW by the Cupcnin,Municipal Calc,Chapter 9.12.and the Hcalth and Safety
"Code.Se,oan 21532(a)'1 HEATING UNIT(OVER 100,000 BTU)
E-1 Yes ❑No PAID
VENTILATION FAN(SINGLE RESIDE Date Rcccild C�
Will the applicant or future building occupant nsc equipment a devices which
Coal hvurdoas air Cnatmnitem,a.defined by the Bay Area Air Quality Management Bf>IhLR-CONI'(311P OR IIMa,(XX)BTU)
TOTAL:
District? BOILER-COMP(OVER 100,000111 BE
❑Yea 0 N
I have read the hazardous materials requirements under Chapter 6.95 of the Coli- ATR CONDITIONER ISSUANCE DATE
tnmia Healf,&safety Cole.Sections 255115.25533 and 25534.1 understand that it the NEW RESIDENT IN.MIKEL SQ.ITT � /
building it"urt mntlyhuveaI i that it'v my re.pmsdality to nndytheaccupaan /— /y' 2
ord,m tense who 'ahem non is,aanompf a Cenlficomof Qcupuncy^
Hzcd,gent Date lJ' TOTAL: ISSUED BY:
OFFICE