S 1003 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF]RTINO NUILUINC. F.LEC'I'RICAL I'EHNI T NO,
BUILDING DIVISION APPLICATION/PERMIT P`UM`"NG MHCHANICAI. O O
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARYNQ, APPLICATION SUBMITI'AI.DAPI,
76 S o (,A k 11
OWNER' NA PHONE: CONTKACT;, R Id fir I,IC NO ��
Uvl N /aa�x Yf NIC CON ROLA
ARC ITECF/ENGINEER: LIC NO: AO : ,I B C'{7(•ct 1. ❑
CONTACT. PHONE: BUILUING PFNMIT INFO
�yn� k�I„ ❑ Consultant Fees Paid by Applicant(Initial) I L til-ELT PI I`IMB_ MECH
xe{[``l /� ❑ ❑
I.ICENSIFO CONI"RACI'OR'S DECLARAI'FON QTY. 17LECTRIC PERMIT FEE 'u`
I herehy drmi chat I a e licensed molO,pmvi.ionx or Chapin,9(anutnlmeng JOB DESCRIPTION
ag with Scenion 9(1(111)nfDivieion Tdnhe eusinecs unJ Pvdessions❑,de.and my license is PF.KMIT ISSUANCE
RESIDENTIAL:
C O II force and eRci Z !eL 3 ❑SFDWI. "OU HCHENREMODF,L
Licence Class {� Lic.N O A A
Q U APPLIANCES-RESIDENTIAL [I ADDITION UMBING RE-PIPE
H Iv1 Dam Cnmmgnr
eQa ❑MULTI-UNIT JC STRUCTURAL
ARCHITECTS DEChAKAIION
O`2Z I mufemmnd my plameholl beusedexpublic records PANELS MODIFICATION
Z
OZ— UP TO 200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
F'3 F'W Lmensed Profeminnul 20Id0(XIAMPS IMPROVEMENT C]SWIMMING POOLS
OWNER BUILDER DECLARATION OVER I(NXIAMPS H REMODFIJREPAIR ❑DFMOL1'TION
C Q I hereby nlfimO(hut I um exempt from the Cootrucwr's Llccusc Law f r OM1c
3 A,U following rcavm.(Section 9031.5.Business and Professions Coyle:Any city or county SIGNS ELECTRICAL (YI'IIER
y which requires a permit to con.suuct,alter,improve,demolish,or repair any structure
F�0g primtoilsi...amN,mm requites the applicant fnrsoch permiuo fileasigned statement SPECIAL CIRCUIT/MIS.
that he is licensed par suannothe provisions of the Contractors License Law(Chapter 9
tAjCO� (commencing with Seellon 10gH11f DM,1oo3,,fthc Business and Protusion Cedtfor 'I'EMP.METGR OR POLE INST. COMMF,RCIAL:
that he e,exemin therefrom and the basis for the alleged cxenption,Any viomfnc of [I NEW BLDG/ADDITION ❑DEMOLITION
Section 703 t.5 by any applicant for a Permit subjects the applicant to a civil penalty of 14)WER OF ICES
not i Nm live hundred dollars(S500). ❑TENANT ❑FOOD SERVICE
~=Zpa as owner the propsior my employees with m
wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
I] L
WFC will Ao the work,unJ the sOructurc is not ielended....ffleri Formic(See 9144.Business ❑OTHER
W a m and Prefessinns Calc:The Cnnm,cmr's License Law docs not apply to un owner of Out -SWIT HES-FIXTURES
C property who build,or improves tnercon,and who does such work himself orb..ugh
his awn empmyces.Provided that such improvements are not intended or offered for I NEW RESID/Fi ELEC RI SQ ET.
sale.lLh..wcver.the building or improvement iswudwithin, ycarolcomPletinn.the SQ IT.FIAORARIp1 $ISG(-I'.
ownerhuilder will have the harden of pawing that he did not build or Improve far pur-
rw saleJ. ¢7 A 1
❑ I,is owner of the property,am exclusively contracting with licensed contracuns to TOTAL: N D
cont, act the project(Sec.9014,Business and Professions CaleI The Comracmr's Li- n
c uc Law do., atn,,Iy man owner.1'Property who build.,,,improves thereon,and QTY. P. NG PE N .F ®{/
whocommels f..rsuch projects with a aommetm(s)licensed pursmuum the Rnnmenn's T 07 REC,v
License Law. PERMIT ISSUANCE r P�IV•
❑1am exempt under See ,B&P C for Ilikooun O
Owner Date Af,TIiR-DRAIN&VIiNI'- T: IiAI UrLYP,y4�TON
WORKER'S COM PENSAI'ION DECLARATION BACK FLOW PROTECT DEVICE V�
I hereby utumO under pea.],,of perjuryone of fe following cl,damti..w �N
❑I have and will maintain a Ceniticme..fComenuo self-insure,far Workers Compen- DRAINS-FLOOR,ROOF,AREA COND. STORIliS '11,Y PECONSIRUCTIOP
cation,as provided for by Section 3]W of the(aha Code,for the perfnrmvnce of the �•
work For which this permit is issued FIXTURES-PER TRAP
❑ 1 have and will econmin Workers Cnnipen,mint Insurance,as required by Section
3700 ofthe Lada Code,for the performanceoffc work for which anis permit is issued GAS-EA.SYSTEM-1 INC.J OUTLETS OCC.GROUP APN
My .kers Compensation Insurance carrier an J Policy mm�her arc
� Policy No.:-in ^ lir I� 9-7 GAS-EA.SYSTEM-OVER4 H:A)
lin C:KTIgF ICATF- ;O(`EXEMPfION FROM ORKERW S'
COMPENSATION INSURANCE GREASIOINDUSTKL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be complcted ifthe permit is for one hundred dollms S l fXll GREASETRAP
or Icss 1 PLANCHECK FEE
I certify that in the parforompecafthe woA for which this pennon is issued,I shall SEWI7R-SAN[TARY-STORM EA.200F.
nen cmpfoy any person in any manmc,sat m n,heam
, e subth
jca to e Workers'Co.,.- ENERGY FEE
zZ ration laws of California.Dam WATER HEATER WNEN'1'/FLELTN
O A,Iicam t GRADING FEE
ren
NOTICE FO APPLICANT:If.after making this Cenificarof Exemption.you should WATERSYS'I'EWI'REATING
a , became subject to the Workers Compenvtim provisions ofine Labor Cale,you must SOILS FEE
forthwith comply with such provisionsor this pcmit,h011 Be diseased revoked WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW HESIUENIIAL PCMB. SQ,FT. PAID
UO l for
rwhichmm thatthemisscorowe.innlending agency for the perfomO;mce of Unto Ret"
OFLc work for which this pennon is issued(Sec.lfN'l,Civ.C.)
Lender'..Name 'TOTAL'
� lender's Address
1 ect ify but I have road his application and stem Ihm the above inam,,muon is BUILDING F'
.F. fop correct.l agree to comply with all city and county ordinances and slate
m laws relalingtu QTY MECHANICAL PERMIT FEE
Ll r� building amuction.and hereby anchorite reprewrimtives of this citymemerupon ha, SEISMI sE
above-mentioned progeny for inspection purposes. PERMIT ISSUANCE
(We)agree a,save,indenhudy and keep homeless the City or Cupertino against IILECTRI 'IFI',
Iiahilities,judgments,costs and expenses which may,in any wayuccon"gaimnuid City ALTER OR ADDTO MECH.
consequencein of the graining of this Permit. PLUMBING FE
APPLICANT UNDERSTANDS A>iYWILL COMPLY WITH ALI N011 ADR HANDLING UNII'(TO 14(XXICFM)
SOUR �GULATIONS.
/VKII/. MLCHANICAI l3G
AIR HANULINGUNIT(OVEK I(I,INXICPM) MECHANICT )NTA%
Signatumof ApplicanVCommaor Dam EXHAUST HOOD(W/DUCT) DOUSING MI'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantor future building occupant store or handle haeard,,us material HEATING UNIT(TO 101(1.(X10 RTC)
as dcfnO.d by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532(,)7 HEATING UNIT(OVER 100,000 It TO)
❑Yes ❑No VENTILATION FAN(SINGLE RESID I PAID
Will then applicant or future building t use a ui I or device,which Dam ccipt p
PP dby thea,, q it Qu BOILER-COMPCHPOR I00.000BTU)
mil hvaN..us air contaminants m defined by the Ifuy,Arca Air Quality Management
District? TOTAL:
❑Yes E]No BOILER-COMP(OVEK I(XLIXq RTU)
I have read the hantandous materials requirements under Chapter 6.95 of One Cali- AIRCONDITIONER ISSUANCE DATE
fomie Hcalth&Sel'ery Cole.Seen...25545.25533 and 25534.1 un demon tnnc if the NEW RESIDENTIAL MICA. SQ.17L
building docs urn currently have a tenant,that it is my reapmsibility m notify the covalence
of the mumomoven,which teas,be incl prior,,issuance of u Cenlfcum of fAcup,na,
Owner or amharizN agcn, Dane 'FOFAL: ISSUED BY:
OFFICE
PLAN CONSTRUCTION CO., INC.
General Contractor
Sime 1981
ucen,e *426883
6455 ALMADEN EXPRESSWAY *210
SAN JOSE, CALIFORNIA 95120
V ) 927-8501
X (408) 927-8502
JOE AMAD