S 1996 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PEI81TNO.
IRJILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL 1996
BUILDING PRUDEC T 1DENTIMCATION
I1UILrlING ADURP_SS: EANI'IAItY NO. APPLICATION SUIIMITTAI.IIA'II
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DAR'S AAS : ' TRAGINy NAME
GV . .d�J LI
NIC CONTROL0Hy �
ARt:I IITECTIENGINEHIC LICN(1: DID "$: ❑
6Air
coNTaCT: veow;; BUILDING PGRMIT INFO
� p() Consultant Fce6 Paid by Applicant(Initial) RhI131.1PLUMB MOH
❑!
LICENSED CONTRACTOR'S DECLARATION QTY ELF:CIRICPERMIT FEF,
I Ill mnrm mal 1 am ficenned under pmweaoms of Chapter 9(emninemc]ng JOB DESCRIPTION
OCz with tienion 91N10µ,miviaiolt?Dube Busineax and Prol'asxioqnv ,Ind my lieelncis RESIDENTIAL:
Jo 7 e PERMIT'ISSUANCI-
W� fill fo�rc�e v`n�A��clTecl. ❑SFDWI. ED KITCHEN REMOUI?I.
QUULI'naw / / Lic.N APPI.IANCfS-RISID[NTIAL ❑AUUI'I'ION ❑PLUMBING RE-PIPE
rFis6a Dam Cnmrenor
ARCHITEC'1'SDECLARAI'ION ❑MULT6lJNIT ❑ETRIGIII2A1.
FaZ IundcatanA my plane shell bo uscA a.v public lwnnis PANELS MODIFICATION
Z O n'" UP TO 2(X1 AMPS
pz— E3 INTERIOR [I CHIMNEY REPAIR
W Licensed Prolva,anal 201-I(NNIAMPS IMPROVEMIiNT E]SWIMMING POOLS
G C C� OWNER BUTDI3R DECLARATION OVER LIMO AMT'S ❑BAfH REMOD L/R. IR Of
Ry7 I hereby uHinn Ibar 1 tan¢serol firman Tho Cunlmtlnre hlcenm Law for the
t�psxC, F U fallowing rens.....(Serino 9031.5,Basirev,and Pmofesvions Calc:Any city or county SIGNS ELECTRICAL ❑U7AITHEk
W 3 W h which requires o permit to comwet,alter,improve,demolish,or repair any mvemre /�
cA poen, issuance,also mquireSthe vpplicum forsuch fat lnfileasignednaiament SPECIAL CIRCUIT/MISC.
a. that lie is licensed pursuznuo the provisions of me Contmemrs Liccnxe Law(Chapter 9 COMMERCIAL,GO (emananeingwll11 Section Tyra)of Division 3ofthe linxinessand 11 1 .0one Code) TEMP.MU'I'ER OR POLE INS'I'.
d y o C Nat lie is exempt therefrom and the bmis on the alleged exemption.any violation of ❑NEW BIAG/ADDITION ❑DEMOLITION
iYfl 4• Sectian7031.5 by any applicant for a permit Subjects the applicant to a civil Penalty of POWER DEVICES
m anmrc lM1an five hundred dollar.(E5110)� ❑TENANT ❑FOOD 313RVICE
H Z i+ ODIFRVIiMENI'
m
[]xQ ❑ Lo the workDndpmperttureis enplended oimwages ustheir sole comprnsiness EWIMMING POOL.131,11TRIC ❑DTIIIiR
(2l). at Prohewon,andmeme Contisnot s Litters oro]mcd for.,appec.'11144,Bmitof
a 3°~ nnA I'nifcssions Guk:The Cnmiacr0h Liceme law Jces not apply to an nwncr of OUTLEI:S-SW'ITCIIIS-PI I'U
property who builds or imposes thereon,and who docs Such work himself or Ihreugh
his own employee,,providnl Ihln tach mr,a),emenB Ire not imendrl or uttered for NEW RESIDENTIAL I1LECTH IT.
sale.11;howcvcq the huilAing or improverncnl ie sold whhin nneynu of cnniplainn the SV.Irl'.FLOOR AREA - EIEQ.FT.
owner-I nilder will have the harden of proving that hedid not build ar improve repair-
five
rpur-
fiva of sale.).
❑L m nwncr of the property,am exdmively canhatnt,with licensed conk m,to TOTAL
meta¢.the prujcd(See.9(X0.Ba,incvs lend lime,Sians Cad,)I'lie Courena,Li
-
uLowdoes not apply to an owner of property who builds or inoproves beccon.and QTY PLUMBING PERMIT i FEE
who contracts for such projects with a rontracanI licensed pursuant o the Contractor's
License law. PERMIT ISSUANCI?
❑ Iant exempt un le'sce, ,Besl'Cfnrmulacasnn
ALTER-DRAINa VIi1f-WA'i'IiR(EA) VALUATIONOwner Date
WORKER'S COMPENSATION DBCLARAPION BACK 11-OW PRUMCK DEVICH 7/1DO
1 herchy alfrm under penalty of perjury,one of the following declamlione
I have and will maintain a Crrlillrnmaf Consenuosdl'-in,me far Worker's Cu..isea- DRAINS-PLOOR,ItUOHARIiA,COND' STORIES 'I'YIS CONS'I'RUCI 1W
,mina.as providnl far by Section 3900ol'tlie[..hot Code,for the parfmmance of 111¢
work for which this permit is iswed, FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3900of lbs Lubar Code,far theperfoonanw of the work far wM1lch this permit is
�"]I GAS-FA,SYSTEM-I INC 4 OI l'I'I.I.I'S OCC.GROUP AI'N
My Wmkc' gMpjv and Policy yiRD '( .Cf0 GAS-EA.SYSTI3M-OVER4(EA)
Carricf carrier Policy No.: - ,J
CERTIFICATE OP fi I:MITION FROM WORKERS' GREASIJINWSTHh WASTE TNI'IIRCF.ITOIt
COMPENSAll INSURANCE BUILDING DIVISION BF.f?S
1Thi,weriouneed nm he aomplrcd l i 111roonil ix larvae hundred dollarv($I W) GREASE'I'RAP or Ices) 1'hANCIIIiCK FEE
I certify thin in the peifomancenf the work for which this permit ixtool],hall SEWER-SANITARY-STORM HA.21014.
not end,any perm in any n courr,n as to become,rda,o la the Wnrkets'Craa,- ENERGY ME,
z .avian Lawaof California.Dale WATER HI ATER W/VCNT/BLEC'I l2 GRADING HE
z 0 Applicant
y NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEMG RP.ATING
a ? become subject m the Workers Compensation provisions of the Lalax Cale,you must SOILS FEE
LkI
forthwith comply Mutant ptismnnsorbie lvamitehidd he dl reused. WATER SERVICE
P 0
7z CONSTRUCTION isaeONLENDING AGIiNCY NEW RESIUGN'I'IAI.PLMB Q14. PAID l Reaiplx
V weak
what, his
issued( ce.30lending agency❑rube perfnmtancc of
F-' dm wod far which mix permit i,issued(Esc.1109,Civ.CJ
Lcndcr'x Nana 'I01'AI'
V Leader's Address 'TUI'AL:
} 14 IIJILDIN i PEEmtcpz
C. I conify that 1 have read this application and stale that above information is Y
L�. h7 correct.l agree to comply with all city and county radiance,and stale laws reining In QTY. MECHANICAL PERMIT I•IiF; 'g ilSfsllGFlil Q
L) ham- mildingenn.Imctinn,and hereby aathonac represcntalive,of nt
111-1 city loecr apnn the tin„
ubave-mentioned property for inspection pugnrses' PERMIT ISSUANCIe�
(We)agree v,save,indemnify and keep beardless the City of Cupertino against IiLECTRIC FEE
liahiboes,judgments.costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECH.
in consequence of 111¢granting of this permit. PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILT,COMPLY WITIi ALL.NON-110111AIR HANDLING UNI'p(TO 10j1do C17M)
M[Cf{ANICAI.FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,0X0 CFM) CONSTRUCI]ON TAX
Sigma of Applcud,Cnnoactnr Dale 13X1 IAUS'I'l ifMI)(W/DUCI) HOUSING MITIGA'T'ION HE
HAZARDOUS MA'ERIALS DISCLOSURE
Will the applicant or from building oaeront store or handle hwardous material HEATING UNIT(TO 101,((10 BTU)
as defined by the Cupertino Municipal Carl Chapter 9.12.and the Ileallh and Safety
Cid,,Section 25532(a)9 HEATING UNIT(OVER IINlreO ii'I'U)
Yes E]No PAID
VENTILATION FAN(SINGLE RESID) Date Receipt It
Will the applicant or future building occupant use equipment or devices which
ends heendous air enntmamou as defined by the Be,Area Air Quality Manugimmnt BOILER-COMP(31I11 OR 100,10013111)fe l AI
District?:1 b
Yes ❑No BOILER-COUP(OV I3R I(q INN]]if U)
I have mad the Intimations materialsarmooments under Chapter 6.95 of the Cali- AIRCONDI'rIONER ISSUANCE DATE
[omiu Ileallh XSId Iy Cdc,Sn'tiom 8505.25513andnspili1 (I unituth that it NEW RESIDHNTIAh MIeCH. SQ.Irl'.
itfroungdnex rims,its
i,mentrofnximbrynnimdymetrertpnnt �.� "Z 9
of the reyuiremenN which must he tar prior ni issuance ofa CenitIDatc of(kcupancy.
Owner nr oumorirod agent Dam "1'UI'AL: ISSUED BN _ C?
OFFICE