S 0853 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
,CITY OF CUPERTINO t BUILDING-LLECTRPCAL - PERIOD No
BUILDING DIVISION APPIACATION/PERMIT PLOWING-:HECIIANICAL
" BUILDING PROJECT IDRN'fIFICA'L'IONS J
BUILDINGADDRESS: SANI'IARV NO. APPLICATION SUBMITTAL DAR
OWNER'S NAME: . 5 P3
E'. 79 CONTRAC" R':N C' LIC, O'. NIC CON 1ROLp
[L
•ARCHITECT/ENGINEER: - LIC NO: /IJI]@AyY �L\./ a"-#-
❑
CONTACT, J)� /P/yO E' 5L✓. N/.' _ 'BUILDING PERMIT INFO
(/ r L ��/� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT •PLUMR MVCU
LICENSED LINT RACIOR'S DI CLARnd'[ON QIY � hLBCTRICIHRMIT. .•:r EEE t JOB DESCRIPTION
1 hereby affirm that 1 licensed J provisions I'Ch'pl 9(commercial,
_
QaZ th Secfon]0(NOof D' - n3 flhe Bu. aJlr fessi m ode aWmyhc se RESIDENTIAL
Poo wt 1.1RMU ISSUANCE.
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in fnrcc.WdY .11 b s - ❑SPDWI: El KITCHEN RCMOOIA,
QUV Licese Cl Lica Tom-/ APPLIANCES-RESIDENTIAL ❑ADDITION ❑I'IAMIHNG RI7.1111I.
FF Z LL Dam Contmcl r
rn60.
❑N ARCIITCfB UICLARn ION ❑MUI.TIUNII' ❑S'['RUCIURAI.
PANELS
F Z I understmmd my Place shall be used vs puhle,recon], MODIFICATION
ZOIC UP 1'0 200 AMPS
OZ- C1 INTERIOR [3 CHIMNEY REPAIR '
41 Licensed Professional 201-1000AMPS IMPROVEMENT ❑SWIMMING POOPS -'
W.d 5.4 OWNER-BUILDER DECLARATION OVER I XX)AMPS ❑RA'RI REMODEIJREPAIR ElDI3MOL ETON
C < ffi
I hereby amt That 1 amComm
exempt from the Comtters License I.me for the
ip5.O0.U (allowing reason.ISerinn]pl LS.Itusiness anti Professions Code:Any city nr umntY SIGNS ELECTRICAL ❑OTHER
w a LL I" whim rcyuirex n permit to constnmt,alter,Impmvc,demolish,or m,aa,any snncmre - Q /f�T Kl
g-LLO pri mn,nimance,also teyviresthcapplicanlformch pmon ftleacignednmement SPECIAL CIRCUI'I'IMISC s
Wythat he is licensed pursuant o the provisions of the Contrecmfs license Law(Chapter 9
COO (connnencing with SCCUOII]000)ofDiti,i.m113ot he lfnsinesand PetriCode)er' 'IF ME M H'1'HR OR POLE I NST COMMERCIAL +'
6 0.x e eC that be is exempt thendoon and the basis for the ullegeal exemption.Any violation of ❑NEW 11L)OADDH ION ❑DIiMOLI'I'ION
W^rn Section 7031.5 by any vpplimm,for a Permit'subject,the applicenno tomil penalty of POWER DEVICES ❑TENANT' E3 FOOD SERVICE
F+Z p. notnauc lhvn fee hundred dollars($500). IMPROVEMENT
❑Las owner of the prit'li,mmy employees with wagesus their sole compensation, SWIMMINGPDOI.ELECI'RIC 1-1HER
F• will do Nework,andthe.arstureisnnt itnendednefferedfnrsale(See.O(W,Business
6 3 and 1'ndexsinos Cods,The Connnetors License Low does not apply In as owner or OUTLETS-SWITCHES-r`X'1'URES
4' progeny who builds or improves thereon,mrd whit cars such work himself or through - 71
he,awn employees,provided Nm such impmmrs
veenam not intended or offered for NEW RESIDENTIAL IiLGCI R SQ 1-1SQIT. .)ORARGA LSQ.I'1'.
,,milder will have the burden of proving Net he did oat build m'Impmvc for Bur- -
pose of cele.).
I,as owner of the pmpeny,am exclusively contracting with licensed contractors it)
TOTAL:
cmobt r Ne project(See ]PIM 11 :i ss d P f .ions C I )I'I Cntma ns Li
ease Law Jcesnet applyt er ofp pent hnbuilJ: 'man .Neuron,and QTY; t' PEUMBINC IFRMIT ' fm FEF.
who connects for such projects with a monarchists)licensed pursuant a)the Comncmd
License Law. - PERMIT ISSUANCE
❑l nm et,di under Sec. .B&It C 1'6i do,m...n -
ALTER-DRAIN se VENT-WATER(EA) / VAI UATIOS _
Owner ❑etc
WORKERS COMPBNSKfION DECLARATION BACK PLOW Pii(YTECT.DEVICE .J
I hereby affirm under penally of Perjury one of the following declarations:
❑ I have and ill rommun a Cenifcam of Consent to self-insure for Workers Camper- DRAINS-FLOOR.HOOP,AREA,COND. STORIES TY PE CONSTRUCTIO.
mtlon,as provided for by Sienna 37W of the Labra Code,ho the pemannerac of the -
�17(, fnr which this Benoit is ixuW. 19%'fI1R1iS-PER'I'RAP
..
have anti will mainmin Worker's Compensation Insurance.ae rcyuired M1y Senionol tlme Lm mr CnJc.lnrtrofinerlanyncu ofthu work fnrwhiclm this permit In issued. OAS-PiA.SYSTI?M-I INC 40Uf.Ti (CC.CIU)Up APN
orGAS-EA.SYSTEM-OVER4(EA)
ec !/7l!!�•• C/Yi!/'/
CERTI EICATE OIt EXEMPTION FROM WORKERS' OItPASP%INDUS'i'RL WAS'IEIN'I'1 RCEPTO
COMPENSATION INS URANCIi - BUILDING OIVISI 1 _
(This section need not be completed ifthe peadit is for one hundred dollars 18lot) GREASETRAP
or less) PLANCH CK FEE
Prettify Nat in NcperfanemeefNcworkforwhich thispermil s conal,I hall'- SEWER-SANITARY-STORM E,.]AT.—I:•
not employ any person in any manner so as to Increase
subject to the Workers'Carper- FEE
Z sation Lows ul Cafifornin.Date WR'I'ER[]EATER WIVES DFLECHt GRADING PEE
Z 2 Applicant - -
NOTICE TO APPLICANT:If.after making this Cenificmr of Exemption,you should WATER SYSTEM/TREATING
1•• become subject In the Worker's Cion,mmian pnrvisinm of the Labor Code,you aim, SOILS FEE
rnnhwitlb comply with such provisions or this permit shall be Jeered invoked WATER SERVICE
0
.0.7. Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMR. SQ.EE PAID pate Receipt N
U O Ihemhy affirm non there lxaeonxWedion hiding agenry mor rhe pednnnunceuf
the work for which this penal is tamed(Sec.309].Civ.C.)
�'• U Lender's Name TOTAL:
Lender's Address TOFAL:
6. 1 certify that 1 have read this application and state thus the alxwc information is -t • V BUILDING FEE
FTA correct.i agree mcomply with all city and county ordinances and state laws resting m QTY., MECHANICAL PERMIT !EI:E 4)
U Z bnbdhngearw
nanuea.and hereby aehoriec represenmro
ves f rym
this city to enter uthe 'r r. SEISMIC FEE
abanwit ernienm property for inspection Impose, PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against IiLECTIUC FEE
Iiabll'iiesjudgmenu,costs and expenses which may in anyway accrue against said City ALT ER OR ADD TO MUCH. PLUMBING FEE
in consequence of the grunting of this permit.
APPLICANT U RST//ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(*IT)Iflood CFM) MECHANICAL 17I:1
SOURCE RF:O
[�/� ((( AIR HANDLING,I1NIT(OVER 111,1X)0 CPM) C'UNS'I'I1UC'IION'I'AX
Sig ren( plicaMContractor � Date EXHAUST HOOD(W/DUCT7 HOUSING MITIGA'f10N EEE
HAZARDOUS MATERIALS DISCLOSURE •
Will the applicant or future building oecupant.aore orhandle harallous material HEATING UNIT(TO Hurst)RTI)
as defined by the Clairton Municipal Gale,Chapter 9.12,and the Health anti Safety
CeUySee, I25512(u)'! HEATING UNIT(OVER 100,000 BTU)
Yes
VFNTILATION FAN(SINGLE RESID) PAID Care RrcciptN
Will the appllumt or furore building occupant um uryipmem or revives which BOILER-COMP(JHp OR 1(NI,BBII Ifffl)
emit hax odnus air turnarounds as defined by the Ray Arev Air Quality Management Tr UAL: D
Daniel? HOILER-COME(OVER 100.000 FITU)
❑Yet
.
1 have wad the d
hazardous meicals mquimm
nnts mule,Chapter 4.95 of are Cali- AIR CONDITIONER ISSUANCE/DATE
Tornio Hwldh&Safety Cedle,Sections 25505,255]3 wall 1 understand that if the NEW RUSIDEtNE IAL MECH.. SQ.if. /� `1•-.�a�y
building does pe to'( (
o(the
wh must he met pilot m issuance of a C c cy.
uugenl - Dal. FT
'POTAL ISSuLO HY.: O
OFFICE