S 1629 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUn.wrvc-]ELECTRICAL PE rr No
RUII,IIING DIVISION APPLICATION/PERMIT PLILMnmG-MECHANICAL 1629
IIIIILUIN4'PROJECT IDENTIFICATION
BUILDING ADDRESS: SANI'T'ARY NO. APPLICATION SUBMITTAL DATE
)WNI? 'S A 'HONH: CON'RACTOR-S AMI:. LIC NO: "�
_ NIC CON'IAOLN
e / - /
EL/IlJOIN
LOU NO: DDRGSS: ❑
462
GONPAC. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) RLDC ELECT PLUMB MECH
❑ ❑ ❑
/ Ll I. CONIAACT( D[CLARATION QTY ELECTRIC PERMIT FEE
1 ruby olfien w:u I am faa.ed ander povl.amt.or Chapter 9 cndng J013 DESCRIFIION
a,�T�,Tn
OxZ tb Section]mnlnfnivision3ofine Bm,mol,aud Pnnc.xmnxCdx.mdmy license is RESIDENTIAL:
x100 wt I'ERMrp ISSUANCi:
I-Ly- nfull fora and cRecr ❑SFDWI. ❑KI'ICHFFN REh10DIE1.
GVU Limmo Ices Lic.p APPLIANCES-Itr;S1DEN'HAI, ❑AUDI T ION El PLUMBING RE-IIPF
vFiQ6 c: Cnnvamnr ' '
p,pm ARCHITECTS DECL01ATION / ' PANELS
❑MULTI-UNIT ❑STRUCTURAL.
Z 0 ti 7J. 1 mtder o nd mY Plans shall he m.d a public m:nnis MODIFICATION
OZ-Q UPTO200AMPS El INTERIOR ❑ClI IMNEY REPAIR
E=.
4!:all LEcrmcd Pose,monal 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
�, N-� OWNER-BUII.DERDIECLARATION OVERIIM AMPS ❑BATIiNEMOUIi REPAIR ❑DIiMDLII'IDN
2 W W Q I hereby affirm III I atm eacngn trout the Con meter's 1111co e Law for thu
O L O following reason.(Section 71131.5,Business and Professions Cos e:Any city or county SIGNS ELECTRICAL ❑O'TIIIf
R
3 o y which requires a permit re ronmm�,ppli Improve.h permit t ore a sir any aTmaurc
Q Prinnnia issummc,also requires the upPlicanT for such pcmdum lileasignnI weemem SPECIAL CIRCUI'VMISQ VV II
tha he Es licensed punuunl to lheprovlslons of the Conemm's Li,cnse Law(Chaptern
�CqO (.a.... <ing wEThSaaimt]I00q of Uivisionl of the Business and Profcsxion.CoJcptr 'TEMP.METER OR POLE INSII COMMF,RCIAL:
IL y m y that he is exempt functions and the basis for the alleged exemption,Any viol cion of C1 NEW BLDG/ADDITION ❑GEMOLRION
W..y Semon]031.5 by TTny uPPlicnntrornpermiisubjea,The applirnnuoao"I penally nl POWIII<DNVI(:r:S
not Italic than live hundred dols lS500). ❑'I'ENAN'I' El TOLD SIiItVICE
F Z P IMPROVEMENT'
=Q p Lmownerofthe IhO,lr .or wages ra-ale
o,wile70mpenmtien, SWIMMING POOL EL
'SFO will dothcwafk,anddi u,Ceno rare t Licens nro(Yu fee,a,)'apply ]1144,Businda ❑OTHER
and prnfusinTa CnJe!The Cnmmctur's License Law docs urn apply m an owner of OU'r[AUS—SWI'[CUTS—IIXTI] ;
progeny who builds or Entpri thereon,and who does such work himself or through
his own employccs,provided that such improvements are not imm�deJ ur offered for NEW RESIDENTIAL ELL 'Q N'.
vale.ll;however,Thobuildingmrimpnrvemenl iasnldwithinaneyvnt'ofcnntPlc"(,a lis SQ.IH'.FIA3fIRAI21iA $ISQ.Irl'.
eervhuill will have the burden of proving that he did not build or improve for pur-
of snlel.
❑ I.as owner of The progeny,an,exclusively contracting with Ileanserl contractors to
onsama The project(Sec.7844,Northers and Professions Clit-,the Con..--a s Li-
crmel.my dee.not apply to an owner of property who halds or Ilopmvee thereon,and QTV. PLUMBING PF.RMI't' FEE
who uattrucas to,such pmIO,l,with It eommcam(O IiccnscA pumtum to the Cmnnumor's
License Law. PGRMI'I'ISSUANCE
❑ I ant exempt under Sec. .if&P C far this reman
Owner IJwc ALTER—DRAIN&VGNL'—WA'1'LER CA) VALUATION
W iR'S COMPENSATION DECLARATI RACK PLOW I'ROfECf.[)EVICT:by alfA under penally of perjury one of The following Aeclaations:
(] 1 w ill mvineahon Cemfndc ofCaocut to sell-Insure fur Worker's Compen- DRAINS—FLOOR,ROOF.AREA,COND. STORIES 'I'VPECONSTRUCHON
cation,as provided for by Section 37110 of the Labor Code,for 0,pedormmnce of the
work Sir which this permit is Issued. FIXTURES—PER TRAP
❑ I have and will maintain Wndvr's Compensation Insurance,its required by Section
37g0of The Labor Col fin The Perftrnarecol the work ha,which this permit isisaual. GAS—ENSYS'IENI-I INC.4OLTI IIS OCC.GROUP AI'N
My Workers Complumenu n Insurance carrier and Policy number am:
Carries Polley Nn.: GAS—EA.SYS CEM-OVER 4(EAI
CEILHFICAIT Oil EXEMPT ON FROM WORKERS'
COMPENSATION INSURANCE GREASHIINDUSTRL WAS'fG INl'IERCEPIOR
BUILDING UI VISION p13G$
(This section need nor MannpletW ifthe permit is Inions hunJrN dollars($llkq) — --
m Icssl GREASETRAP PLANCHI?CK FEE
I eerily hurt in Tbcperfnmortwelfthe work forwhich this permins issued,I dual SEWER—SANITARY—STORM 13A.2W PC
an employ any person in any manner so as to becomamhject m The Workers'Compete ENERGY ME
zz scion Laws of C.1 forma.Date WATI7R BEAT BIT WOVEN GELECTR
C) Applicant GRADING PEE
NOTICE TO APPLICAN-n If,afar,marking This Certificate of Exemption.you should H'AI'LER SYS'IEMTRHA PING
a become subject to the Worker's Compensation provisions of the Labor Cade,you Trust SOILS FEE
forthwith c,I ply with such provisions m la-.permit shall he d,e vd o vok,d. WN]171Z SERVICE
a0
CONSTRUCT ITC..... LENDING AGGNCY NEW RESIDENT AL PLMtl. SQ.Cr PAID
UO for
hatThemI,inuit(Sce0n97Cileading agencyfirTne pxtormuncc of Date eiplN
f~'T The work for wbitlt thin permit is iswrJ(Sec.3dgJ,Clv.CJ
Lenders Name TOI'Ah:
O V I2nJcr'a'AdJtnF. 'TOTAL:
' W I eerily that 1 have read This upplieadim and num the The above inlnrmwinn Is
j- 0 C BUILDING FEG
.f. y correa.l agree formality with n0 ciry and county ordinances and sate laws relear,to QTY. MECHANICAL PI7RMIT FEE
V building construction,and hereby uuthmnzerepresenmtives of this city to enter upon the SEISMIC FF,
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m sive,indemnify end keep c miles The City of Cupmim,againa I1LGC'INIC PGG
liabilities,judgments,coats and expenses which may in any way accrue againstsud City gLTEH OR ADD TO MECH.In et
msequenec of The grunting nr Ibis Perot t PLUMBING Fp.
APPLICANT UN DHRS'PA NDS AND WILL COMPLY WI'fII ALL NON-POINT AIR HANDLING UNIT TIC)10,(0X1 CRM)
SOURCE REGULATIONS. MECHANICAL IT.
AIR HANDLING UNIT(OVER 10.000 CFMI CONSTRUCTION',
Signature idA,pli,mulConTmctnr Date EXHAUST HOOD(W/DUCT) HOUSING h11TIGgTION IdiE
HAZARDOUS MATERIALS DISCLOSURE
Will the applia¢mT or future heildinguccnpma caro nr Handle haenrdau.muenal BEAT ING UNI'1'('1'0 l(11 BI UT
as defned by the Cupertino Municipal Code.Chapter 4.12.and the Health and Safely
Cale,Section 25532(a)] tIBA')'ING UNIT(QUER IfN1.0011i'IU)
❑Yes E]No
VEN'I'ILAG'ION FAN(.SINGLE 1313SI1)1 zo It 'Tl T T Dan Iteccipt p
Will the apdicvnt or future building..pan(use equipmc a or devices which
em It hazardous air contaminants a..defined by the Bay Area Air Qual'try Management BOILIER—COh1P(3HP OR 100.00)NTU)
DinrirT^ T(YIgL'
E]Yes El No BOILER—COM 11(OVER I point)BTU)
Ihaveread the hazardousmacHalsrcagdremcnmunder Chapter 6.95of The Coli- AIR CONDIT ION13R ISSUANCE DATE
fomin Health&Safety Ctxle,Sections 25505,25533 and 25534.1 understand That If the NEW RESIDENTIAL MUCH. SQ.ET. w ��
building does not currently have a tenant.That it is my responsibility To notify the occupant
of the requintncoU,which oust he met prior to issuance ofa Certificate of Occupancy.
Owner or embodied agent Dae TOTAL: ISSUEERY: f
OFFICE