S 0532 (2) APPLICANTTO FILL IN INFORMATION WITHIN REO LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PBy AITN L 0532
BUILDING DIVISION APPLICATIOWPF,RMIT PLUMBING-MECHANICAL k`7
BUILDING PROJECT IDEN'I'IFICAI'ION
BUIL IN 11FUIS : n �r --s SANITARY NO. APPLICATION SUBMITTAL UAI'li
y Al Ga�� IV � 2-o r 8 8/7 /97
OW .AMG: 1'I CONTRACIOR:S NAME: LIC NO:
ti/� WE v I NIC CONTROL#
• ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONI ACT �//�) �1 ,I PHONE: BUI[.DING PERMITIN FO
I u viNo.{}/I if//�A' ,37 ❑ Consuhanl Fees Paid by Applicant(Initial) @LDG EL PLUMB MUCH
LICENSED CONTRACTORS DHCLLARRNII/]ON ✓•' �J�y ELECTRIC PERMIT PEE. •Ip`�a( IPTIO JI/p���
1 hereby olTnm mal 1.,it licensed order pPoki.r,PI Chapter 9(cmnm rmi., JOB DESCRIPTION
�aZ withSection Division 3ofthe Businessand ProfessionsCode,onJmy license is RR I2ENTJ1).L:
W p PERMIT 156OANCIi
CSF in full force anJcRcct. FDWL LJ KITCHEN REN10DE1.
aUV Lreense Class Lich APPLIANCES-HIiSIDENTIAI. ADDITION ❑PLUMBING RE-PIPE
F�ZW Date Conunilon
vs6URAL
0. ARCHfrECT'S DECLARATION ❑MULTI-UNIT' ❑MOD1171CATKI
~h Z 1 understand my plans%hall be used as public records PANELS MOUII'ICATION
oZ=- UPT02(XIAMPS ❑INTERIOR ❑CHIMNEY REPAIR
[-W_ Licensed Pmfc%sional 201-1000AMPS IMPROVEMHIST 0 SWIMMING POOLS
Y
,'j OWNER-HUILDER DECLARATION
C� OVER IINXtAMPS ❑BATH REMOUEWREPAIN DEMOLITION
C Q 1 hereby offnm that 1 am exempt from the Cnmmmm'%License Law for rite ❑OTHER
X O i U following reams.(Section 9031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL
W 3lL Na which requires a wont to construct akar,improve,dnnoli%h,Pit repair any suucmre
prior In its issuance,also requires the applicant hu.wch penninP file%signed statement SPECIALCIRCUIT/MISC.
!"�!7�y moi he is lic:nscJ pnrxuannnlM1epmviwons of the Cnnlrumors license Luw(Chapter 9
+00 (commencing with Section 7000)of Division 3O the Inoinev%and Profc%siom,Code)or TEMIo METERORIN)l.l!INST.
a ax e C mat he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑Nfi )dA DWIO�N/,� DEMOhITION
Section 9031.5 by any applicant for o permi,omjectx me applicant to acivil penally of POWER DEVICES Iy����I,NANT VV str*COLE SERVICE
nm more than five hundred dollars($5W). X.l!%IP}2n�t�p11.'NT
=O ❑ L its owner of the properly,or my employees with wages as their sole'i Person P. SWIMMING POOL ELECTRIC j/!- (PUt,;b"):,,,,,_�
(., will Jo the work.and theamcmm is not intended Proffered for sale(See.9044,Business ❑OTHER IIYU
63 m and Profmsions Code:The Contractor's License Law doer not apply to an owner of OUTLETS-SWITCI IH 1%TUR..
progeny who builds nr improves thereon,and who does such work himself nr through
his P.O employee,,provided that such impmvcmm�is are not intended or PBned for NEW RESIDENTIAL R S T.
Pula.ILhawevet0m1mildingPrintpn vlow.1ko,ld witbinoncycurPl iavmlutlor,dm SQ.FE FLOOR AREA $/SQ.II'.
P
owncrUll
M1dcr will have the burden of proving Inst he did not build or improve for par- 0
po ofooalc) 'TOTAL:
L as r of the property,am exclusively contracting with licensed contractors to
onstiucl the project(Sec.WHO,Business and Prnlcssions Coded The Contractors Li-
wLewdoesnotapply manownerofproperty who milds or improves mcrcuo,and QTY, PLUMBING PERMIT FEE Ij0L2
who contracts for such pm e I wins o ezin mrt0licensed p...Panuo the Contractor's ``���� ��J
License �arL. (/ (r /n PERMIT ISSUANCE
❑1 am e r fr !CG
ALILR-DRAIN&VI!NT-WATER(EA) VALUA'DON
Owner Dam
ORKER'S COMPENSATION DECLARATION BACK FLOW PRO]LCT.DEVICE A
1 hereby affirm under penally of perjuryone of the following dedeotionPEl :
[have and will maintain a Ccnificate of Con,enunulf-insure for Worker%Compen- DRAINS-FLOOR.ROOF AREA.GOND.
ST r yteg TY PH CONSTRUCT ION
sation,an pnwided for by Section 3700 of IM1c labor Code,for the perfunumme of the (r/{{�1 T 1 p
work for which this pcnnit is Issued FI%TUNES-PER'I'RAP
1 have and will maintain Workcex Compensation Insurance,as requited by Section
39W of the labor Core.hnmperformance Of the work for which this permit is issued. GAS-PA.SYSTEM-I INC.4 OUTLETSCJ,jip APN
My Workers Conipensmion Inatome canner and Policy number are: `UYr /A,O
Carrier: Policy No: GAS-EA.SYSTEM OV F.R 4(RAE 11'
CHR I'I]TCATE OF EXEMPTION FROM WORKERS' GREAMUINDUSI'RE,WASTE IN]'i!RCFP)'OH
COMPENSATION INSURANCE, BUILDING DIVISION PSIS
(Tbie Pooh..need not be completed if the permit is Ensure hundred dollars($1W) GREIASETRAP '
or IcssJ
FEEI cenify,hnt in the perfeniarre.f1he work far whith,hi,permit is issued,Ishall SEWIiR-SANITARY-STORM I!A.ZIXIFI'.not mnploy ony pen anyn u nersoa,la bmanm mlil"t h.the Workers'Cnmpun_ Y 192I7
Z %anon Laws Of Culdnrnia.Dare WATER HI!ATER W/VENT/ELECI'R NG PHI!
ZO Applicam t
NOTICE TO APPLICANT:IL after making this Cenificam of Eumpt]on.you should WATER SYSTEMOBEATING PER
(~ ; becntne subject m the Workers Cnnpensatian provisionsof the labor Code,you moot
Ii+nM1whh comply with xucn pnrvisionx Pnniv permit moll M1c Acceded rcvnkcA. WAIT2H SERVICE
p Q Z CONSTµUCI'ION LT:NDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. Date Receipt g
U 0 I hereby affirm that them is a construction lending agency mrthe performance of
� - IM1c work(..which this permit is issued(Site 3099,Civ.C.) TOTAL:
0 U Lende,o Name CtYIAh:
Lender,Address '
W I cendy that I have mad this application and state that the information infomtion iz NIIILDING PEE
fyN correct,l agree to comply with all city and county ordimmor,mul state laws minting to QTY. MECIIANICALP17RMIT FEE SEISMIC FEE
U Z building construction,and hereby natnoriae representatives Plinio city tocmcr upon the
above mentioned property for inspection purpooes. PERMIT ISSUANCE! HLECRIC 171!E
We)agree to save,indemnify and keep tamtlea%the City of Cupertino against
bon ilitioss4YY,juuddrrgmemcemisim expenmswhichminanssy``way acerae against said City AITER OR ADDTO SUCH. PLUMBING PER
API'II ti�11S' in n+l ihrs pc�u STV[pa�,a) /•� AIR HANDLING UNIT(TO 10.1XXI CPM) MECHANICAL PIT
SOURCE EGU.AJTT31 S I,JIG.�f6RI}f�YJI
(, AIR HANDLING UNIT(OVER IB.IXX)CFM) CONSI'HUCUUN TAX
Signs r plicunVContracuu L line EXHAUST HOOD(WIDUCI 14OUSING Nil PIGATION FRI.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or name buildingoeevpou,nocor until.humnhms mums.] HEATING UNIT(10 IN),00013'1'U)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 8532(a)? HEAPING UNIT(OVER 100,000 BTU)
C]Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Dote Heceipl M
Will the applicant or Enure building Occupant use equipment or devices which BUILIiR-COMP Elf{p OR IIXI,INXI BTU)
tout hazardous air ctntaminunts a,defined by the Bay Arca Nr Quality Management 'I'Oi'AI,:
•Disuict? BOILER-COMP(OVER 1E0,000 BTU)
E]Yes ❑Nn
I nave read the hazarconx tnumnals requirements end Chuprcr 5.95 of the Call- AIR CONDITIONER ISSUANCE DATE
fmnia Health&Safety Code,Sections 25505,L5533 and 255..1 undentaol ma if the NEW RESIDENTIAL MECH. SQ.I'T.
building does not currently have.tenant,mon i,my reopen ibiliry mminifytheoccupant
of the mquirement,which moa be met prior er issuance of a CInificare Pf(kcupancy.
Owner or authorized agent [)ate 'HYI'N.: ISSUED BY:
OFFICE