S 1339 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE ITNO.
BUILDING DIVISION APPLICATION/PERIDIIT PLUMIIINC-MECHANICAL 1339
BUILDING PROJECT IDENTIFICATION
Iil11LDING ADDRIISS: SANITARY NO. APPLICATION SUBMITTAL.DATE
OW
"'r"'4/a �c_ �_� PHONE a r� CON'I'IIACTOH'S NAME'. I,IC NO:
J NIC CON'I'ROE,p
iARCHiniCTniNGINEER: LIC NO. ADDRESS'. ❑
CONTACT: PHONE!: - BUILDING PERMIT INFO
❑ Consultant Fees PBld by Applicant(Initial) BLDG ELI!CI' PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPI
Z no 3 efthe Busluessamd Professions Cde.andmy license is RESIDENTIAL:
1+100 w PIeRA1R ISSUANCE
FUS
in
Q full and effect.
❑SPUWh ❑KITCIIN RFA0DEL
RUF Licenee ClassLiapU
AI'1'LIANCER-ItGSID1!NI'IAIx ❑ADDITION ❑PLUA1BING HN PIPE
0¢7y[L Dvta Gmtmclnr
W ARCHITIiCI\S UECLAHATION ❑MULTI-UNIT ❑STItUC'I'l1kAl.
zON1� Imill"umd my plowshall be lout o'cla "emed, PANELS MODIFICATION
OL,.O UP TO 200 AMPS ❑INTERIOR ❑CHIMN17Y REPAIR
I-_,F.,n1 Licensed P...Cme bol 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
CCIAATIQ 1 M1ercby a0imr Ihm#amOWER-B e1mDER'me he Contrea ru License Lew for IM1e OVER I"AMPS ❑BATH REMODELfREPAIR ❑DEMOLITION
5�'O y U following mocha(Section 7031.5,Busimm�and Professions Code:Any eiry or rashly SIGNS ELECTRICAL. ❑OTHER
LLl W h.y which requires a permit to muswm,alter,improve,demolish,or repair any strucmrc
Fi..,O priuno it,issuance.also requires the appliumI ko,un,h permit m file avi,rhT,bmmm SPECIAL CIRCUIT/MISC.tb.,ImI,limmuedpuroi (buthepmvi,ion.,0heChumier,LicenseI.cw(Chaptea9
(commencing with Sit70aftof Division 3 ofihe Buvinessand Porrslons Cmae)ma 'HiMP.ME TER OR IK)1.131NST. COMMERCIAL:
t1 M red he is exempt therefrom and the basis for the alleged exemption.Any vinlminn of ❑NEW BLDG/ADDITION ❑DEMOLITION
^m Section 703 L5 by any applicant for a pvor itsubjects the applicant to it civil penalty of POWER DEVICES
nounore than five hundred dollars($500): [I TENANT ❑FOOD SERVICE
F Z> IMPROVIiMEN'I
6 C]I,,she work.the pmpeernme byemnuendrswilh wages rsalc(See WAD,compensation. SWIMMING PO0I.ELECTRIC
will do the and e: he Cha bar, 1-wenw,Low red bn I,,fly m ,a Business ❑G'IHEB
LL1,3 and Pry Mile b Code:The Cmnnaemr'n Lircme Low dcea nal apply m un owner,of OUTLETS-SWI'TCI11!S-FIXTURES
CC.• pI,.,,I whoo,cmv m,victi n theaum,and who Anes rich work deti ciftor nr through
his own employeese building
chat such impnry sold within arc not inurel c m offered for NIiW RESIDEN'I'IAI.131.1!C'!'k SQ ITT.
male.If,howeven ll have to bu d n of playint ithe,h idon build
the SQ.FT.FLUOR AREA $SQ.II'.
er-builder will have IM1e burden of prnvin6 that he aid not buil)m improve for pur-
,,se of-sale.} A
1.as owner of the property,am exclusively cnnlraning with licensed contractors to IAL' A
10 combert me Innjecl(Sec.704,Business and PmreWleas Codm)Ehe Co.mctors Li- �"7
c -Lawdoesom upplyman owner ofpniperty who buildsotimpruvcs thereon,and QTY, PLUMBING PERMIT 01 FEL`
In,cohorts fnrxaeltpr jeris w,the enamel (s)Iicemad pa....on,to he Contractor, - R
I.icen.ve Law. PERM[I'ISSUANCE
❑ lam sae it,,See. ,Bore mrmte reason ^I-�
AI:1'lot-DRAIN&VENT-WATER EAI 01 VA. AT'ION
WORKER'S COMP ISNSKI'[ON DECLARATION— BACK FLOW PROTECE.DEVICE
I hereby union under penalty of perjury one of the following declmmiram: IIS
❑Ihmve and will nminmina Cemifica¢of Concenno smlfimurc fur Workers Compete DRAINS-FLOOR,ROOF,AR IM,GOND. STORIES TYPE('ONS'IRUCUON
stolon,a,provided for by Section Goo ml the Labor Code,for the ,I me,mf Lha
work for which thin panni)iv insult. Iq X'fURES-PER'fRAI'
❑ I have and will maintain Worker's Compensation Insurance:ax by Section
3700ofthe Labs Code.It,the performance of the work for which this permit is issued. GAS-EA.SYSTBM-1 NC.40UTLE.IS OCC,GROUT' AI'N
My Workers Compensation Insurance connector!Policy number arm:
Carrie, Pricy No: GAS-EA.SYS I'EM-OVER 4(FA7
CERTIFICATE OF EXEMM ION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRI,WASTE LNTERCEPIOR
BUILDING DIVISION Ig11;5
(Thia,ecliun need not M1m completed if lhcpermil is formic hundred Jnllurx l$I W) GIt EASETRAP
It,less.) I'LANCHECK FI!li
I certify Wet In the lowhooancemf the work t'orwhich[]ds porde .Issued.Ishull SEWER-SANI'I'AHY-S'T'ORM EA.100 IT
not employ any person In any manner so as to bene subject to the Workers'Camper- ENERGY FEE
z .smarm Laws of Califantin.Date WATER HEATER W/VFoG`/1!I.ECTR GRADING FEE
Q Applicant -
.N. NOTICE TO APPLICANT:IL after making$hi.s Certificme of Exemption,you should WATER SYSTIiM/I'REATING
become subject to the Worker's Compensation pmvisiom of the Labor Cole.you must SOILS FEE
Wfntinvah comply with such provisions onhis permit shall IN,Jemned revoked. WATI7R SERVICE
I� Q C(INSTHUCTION LENDING AGENCY NEW RESIDENTIAL.1'hMII. SQ.I'I'. PAIDnU. Z Ihereb n
rifin (hnma
( ere lseonetmetlmn lending, bathe,eirricance of Dene Receipt#
U O the work for which his pemtit i,Issued(Sec.30G.Civ.C.).)
C) F•' Lender's Name 'I OTAI,:
IU Lamdmr's AM. TOTAL
1 Cmify hot 1 have read this application and nam that the above nomination i, BUILDING ItiE
Ta/l comet.I agree ro.... saint all city and county oNinances and nom laws relatingm QTY. MECHANICAL PERMIT PEE
V Z. building construction,and herehyambilize representatives of this city to enter upon'he S17ISMIC THE
aurae-mentioned a,"y far impec[inn png.nxex. PERMIT ISSUANCIi
(We)agree m nave,Indemnify amt keep of less the Cily of Cnpenino egaina I?LICCfRIC IrEl3
liuhililies,judgmunu.cosh mdexpmn,m whiehmay in anyway accnmagalnstsaid Co, ALTER OR ADIVIO MECH.
in consequence of the granting of this permit. PLUMPING FEE
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO inoolo cw)
OUR R '['IONS, // MECHANICAL ITE
? _ /1 � AIR HANDLING ON]'1'(OVER 10.000 CPM) CONSTRUCTION TAX
Signature ofAppliilmyNCoontyructtoor Y/• `✓ a)�/m EXHAUST HOOD IW/DUCIT
HAZARDOUS MAMMALS DISCLOSUREIUUSING MITIGATION FEE
Will the upplivant or famre budding ncn.pam entre or Imndle ba anlou,material HFAI'I NG UNITO'0 100,000 BTU)
as defined by the Cupertino Municipal Calc,Chapmr 9.12,and the Health unit Safety
Cede,Section 25532(3)'! HEATING UNIT(OVER 1 W q)0 B'IU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Writ the applicant in future building y the B use equipment or devices which
emir harallous lir contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(311'OR 100,000 RTU)
TOTAL:District'
E]Ye, 0 N 1101LER-COM I'(OV 17R 100,000 BT U)
Ihmemadthebuuudaus mvmriale regnirommmts under CM1upmrfi95 nl the CNo- AIR CONIA I'IONER ISSUANCE DATE.
rums,Hedlh or Safety Cade,Straum 8505,25533 and 25534.1 understand Nm if out NEW RESIDEM[A].MECH. SQ.IT.
no[it it Island haveamom
,th us my rc.gmsibility m notify the oacupdm
an ewhialr beer Il[ifFaanee cera eenificale nf,Occ[Ipaney. —e
owner or aamnrired ngem IJP-/fy_v/D/T 'IGIAL: ISSUED BY:
OFFICE