S 1536 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERT'INO
BUIL DING-ELEi I'RICAL PEIf`�•IT NO.
llUl),DIN(7 DIVISION APPLICATION/PERMIT PING PROTECT
ROTECTIDENTIFIC u 1536
BUILDING 1'HIIJECf IDENTIFICATION
UILDINGADDRISS: nt SANITARY NO. APPLICATION SUBMITTAL DATE
O NIiR. NAME..n � OO,, Tree- /ns CONI'RACI'OR'S NAME: LIC NO:
CQ M' X96-P6 NIC CONTROOL#
ARCHI'I'CCT/ENGINE. IAC NO: ADDRESS: ❑ ./\�
CONNDACCT: /y yn S PHONE: BUILDING PERMIT INFO
vV fNf^ G. �•h 996 P6 ❑ I....Bank Fees Paid by Applicant(Initial) BLDG ELE PLUMB MECH
LICEN CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT' FEE
1 hereby alarm Nat I ren licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
too wilM1 Section 7000)of Division3nf the Business and Pmfca,ions Code and my license is ^ ;ADDITION
1,;OO PIiRMIT ISSIIANCR ll in full force and clacel. DWI. ❑KITCHEN REMODEL
License Class Lic,p APPLIANCES—RESIDENTIAL ❑PLUMBING RE-PIPE
in xe 6 Dale Comncmr
ARC]UTECT'S DECLARATION ❑MULTI-UNIT ❑MODIFI STRUCTURAL
O
Z O ti rZ. I undentmtd my plans shall he unci m public records :JP To 210 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
P 4 Licensed Professional 201-1000AMPS IMPROVEMENT OSWIMMING POOLS
.14 a4 OWNER.BUILDER DECLARATION OVER IINN)AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
�'tX Q I hereby affimt Nal I.,it exempt fir an+the Commemr's license Law for the
ippiS5 O y U following.croon.(Section 7031.5,Busincx.unit PmfieWuns Cale:Any city or oonnty SIGNS ELECTRICAL [_1 LIT
H+3 LL Ha which requires a pemtit to construct,eller,improve,demolish,or repair any structure .f'V_
F'LLC) prim..it i....neelicam
.asoreclaimstheui far such rmittofileosignMsm _tvi ept SPECIAL CIRCUIT/MISC. ad
} That he is licensed punrmin,the provinioleof t]te Cimmemors License Imw(Chapter 9
X00 (°O°1°terming with Sector](NN)of Divivinn3oflhe Business unA Pn+fuxxioav Cnddnr ,'PEM P.MEIHR OR 1101,1;I NST. COMMERCIAL;
d M C
that he in exempt therefrom and the had,for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
-„N Section 7031.5 by any applicant(..a poraitsubjeeta the applicant oa civil Knotty of POWER DEVICES ❑'TENANT ❑FOOD SERVICE
a.,nave than five hundred dollars($510). IMPROVEMENT
�^'6 ❑Ln
as (lit property,nrmyemployees with wages as their cnmpemmn,ioSWIMMING POOL ELECTRIC
$y+�ca will dmhe wmk,nnd lir xlmclure is not intended nrolTmxd inside Cw'.7044,13mine,a ❑01 HERYI v�o and Profmsirns Code 'I he Coal...nis Liecew Law Ares not apply m an owner of DU'I LEIS—SWITCHES—FIXTURES p
6 3^ property who builds ler improves thereon,and who does such work hionelf ler through
his own employees,provided that such impmvemem,art not intended nr ofemd for NEW RESIDENTIAL 1fiXCIR SQ FF.
sde.Il',however,the huildingor nallowenuma is sold will,In one ycarnl rnmpletforion,the SQ.I'1'.FLOOR ARIIA $1501"1'.
c,brilda will have Ire harden of proving thin he did nil build nr Improve pur-
'we of rale.).
1,m wner of the p.,a ,um re
exclusively imm eling with licensed enhances.. AL:
cassias the product(Sec 7044,Business unit ProRssinnn Cu lc:)The.......actors LijIIK
-
aeLawitasno,applylomtnwnei-of any who andiNor improves lhemnn,und QTY PI,UMBING '' MIT FET?
who contracts for such projects with a eomc..r(s)licensed Present to the Cumul s
License Law. PERMIT ISSUANCE (34
❑ I am exempt under St. .B&r Cf.rthisrc
ACTF.R-DI(AIN&VIiMf—WAI'IiN .A7 ^ � VALUATION
caner Dam L...�-�
U h+R'S COMPF.NSA'1'I D 'LARATION BACK FLOW PROTF,CI'.DEVICE
I hereby xlfimt under pe a Y, pc jup (the following dedaretions:
❑ I have and will animism a Certificate of Crnsentto self-imure for Worker's Cmupen- DRAINS-FLOOR,ROOF(AREA,CONO SIORB;S TYPE CONS]RUCI'ION
s lin.sex.....idol lin by Section 3900ol'the labor Cndo,lathe pef'onnunce ul tine
work for which this permit iv issued FIX7URH5-PER TRAP
❑I have and will maintain Warkers Compensation Insurance,as required by Section
3700nfthe labor Cale.for the arfummnctafthe work far which firs lwrmit is issued. GAS—F.SYS T ENI-I INCA OU'R HS OCC.GROUP APN
My Worker's Com amothan Inxurnnce can'icr and Policy nwnrer are
Carrier: Fairy No, OAS—F,A.SYSTEM-OVER 4(EA)
CERTIFICATE OF BXEM PTION FROM WORKERS' GRIiASFJINDUSTRLN'ASI'F.INTIiHCIiProR
COMPENSATION INSURANCE 11 LDING DIVISION IIIN_S
IThkwelinn ovednol Mcompleted if Nepennil in 0a..nrhandreddollan($100) GREASE I RAP
tar Trend PhANCHI? I+ ?
Icenllytan inthe pcdormarictofthe workfo,whichthis permit i,i...ed.Isltall SEWER—SANITARY—$'FORM EA.210 FT.
2-0
not employ any perms in any manner so as m become Athjem..the Workeri Compcn- ENERG -E
OZ ..tion laws..(Cut ifornia.Dale WATER HEATER WNEN'1'/ELECI'R GRAI F:it
Q Applicant
NOT]CETO APPLICAN'EIf,site,making@is Ccammic:ne of Excmdiam you shield WATER SYS'I'EMnRFKr1NG
become subject to the Workers Compensation provisions of the Isdo Cale,you mus 50 L'1+E O
W .+ fonhwitheomply with such provisionsnnhis permit shall he Aeemed mvnked.
WATER 513RVICF.
UQ D
7-. Catthert is a c(lNLItionlim AGENCY NEW RESIDIiN'I'IAL PLMI3. SQ.PI'' Date
C.) Q L far which
that there issued al.3097ndie.agency for the performance of
� FI.mi forwhich this permit is issued(Sec.309].Cie.C.)
Lender,Name
Address
�V IendnF Addruv TOTAL:
tyt a RI LDING FEE? O Q
[r I certify that 1 have read this application and xl:ne Ihm the stove information's
rp correct.l agree locumply with all city and county ordinances and stale law,relating.. QTY. MECHANICAL PERMIT FEE
C.JZ buildingconsmtoioo,end herebyauthnrile mPxr,cmativm.f Nis city in enter uqm the 'SMICFEE
alawe-mcnfioned property for inspection purposes. PHIRMI F ISSUANCE 170
(We)agree to save,indromify and kmp harmless the City of Cupertino agniml '15I:LEC'RIC EI?I:
Iiabilinies,judgmmns,costs and expenses which may in any way accmeagainxt said City ALTER OR ADD TO MECH.
in asequence of the granting of this permit.
PLUMBI.G FF:T:
APPLICANT UNDER TA 5 AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT d.000 CFM) CST
iC A L hili J
SOIJI(C- �.GUI,AI'IONS
OI/ AIRHANDLINGUNI'I'(OVER IBOINICFM) CONSTRUCI'I NTAX
Signature ofApplicanVConuactrn J D¢ EXHAUST IIOOp(W/UUCD f 'N 1 TION FTiE
HAZARDOUS MATER .S DISCLOSURE AP
Will the appliotnl or forum build, ctpmmsore.r handle hrnminuv material HEATING UNIT TO 100,000131 U)
as defined by the Cupertino Municipal. c,Chapter 9.12,and the Health and Safety
Calc,Section 25532(x)? HEATING UNIT(OVER 10,000 BTU) ` '�It V tJVrk-F3IIIV
❑Yes ON. V EN'FILATION FAN(SI NGIB RESI U) PAID
Date Roxipl
Will Napplicant or future building use equipment or devices which
emit fluctuationsfluctuationss air compositions
flee Bay as defined by the Bay Area An Quality nlanaganrnt BOILER-COMP(3HI'OR III0,100 BU) T
Di... G
F7 Y. E]No BOILER-COMP(OVER 11NI,IMNI B'I'll)
I have real hems.u,materials requirements under Chapter 6a5 of Ne Cali- A IR CONDI'T'IONER ISSU"}'DATE
firm.Health&Safety Cedc.Semon,25505.25533 and 255311 undcntand that if the NEW RESIDENTIAL MECH. SQ,ET. a
building does not currently have.a tenant,that h is at,re"msihilily In notify the acup:mn Lt
of the m,uimmc..w which must bu met prior to is i tree of a C nifie e nl"Oc upaney.
Owner or umhnnzed agent Dam TOTAL' . O 1SSUEDBY: Q
OFFICE