S 2251 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY /M1��
CITY OF CUPERTINO IIUILDINA- PI t1ITNO.
BUILDING DIVISION APPLICATION/PERMIT "LAMBING-MECHANI AUELECTRIC.\l., 2 2 51
BUILDING PROJECT 11IHN'TIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUIDIFFIAL DA'I'I?
I 10 2 yj 1L I ►.� 0 E.
NQ NER'SN Mli: W . �- PHONE: O CONTRACTOR'S NAME: CIN' NIC CONTNOLp
20,
FARCHH'ECI'/13NGINEE LIC NO: ADDRESS: ' 0 J ❑
COMI'AC'I: PHONE: HUlLI71NO PERMIT INFO
AR J O I ❑ Consultant Fees Paid by Applicant(Initial) HI❑OG ELECT PLUMB , ME❑CH
19
LICENSED CONI RACTOR:S DECLARATION QTY ELECTRIC PERMIT 1'EE /
I herehy i f i,n that 1 am ueen.w awor provision of chapter v Kana nencing JOU DESCRIPTION
O TLZ w'Ih Smlion"700lafDwisioo3of ac Businesxand1'rnfes.ia..s Comy dc,ond licenseI'Y.HMII'ISSUISSUANCE's RESIDENTIAL'
❑100 .
FW
in full fora and c ❑SI'DWL [I KITCHEN kF,MODEI.
EZUVLicen. las Lich /S, APPLIANCES-RESIDENTIAL ❑ADDITION 0PLUMBING REPIPE
F
h<a Date Comracmr
l.Doi A CIII'ITCTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
y q)n,4 I undcrsmilmy plinimQull Is,used as public records MODIFICATION
OZ^M UP10200ANIPS [IINTERIOR El CHIMNEY REPAIR
rs(= Licensed Prfaxsinrmol 201.1000AMPS IMPROVEMENIT E]SWIMMING POLLS
Ca OWNER-BUILDER DECLARATION OVER IINX)AMPS O BATT I REMODEUREPAIR ❑DEMOLITION
m C 1 hereby affirm that 1 am exempt from the Commences License Law for the
xdx O1 U following reason.(Section 7031.5,Business and Professions Code:Any city or enumy SIGNS ELECTRICAL. EOTDER
W 3 u.y which requires v p[rmil to candrm,alter,impone,demolish..,repair uny wamurc
�O�nn� porrmix i,mance,alinionFiresthe applicant forsewh perminv
ofilesimed>mtnnent NPECIALCIRCUTEMISC.
f pr that he is liwnsed pursuant to the pmvisionsofthe Contranm's'Lirensv Low(Chapm,yi
a Q� (commencing wish Secion]rnXryofnivisio,9ntlltclln.inmx and Pudy,,inn.Cudelar TEMP METER OR POLE?INS T. COMMERCIAL:
SO oOoCC that he is exempt therefrom and the basis for the afted exemption.Any violation of 0 NEW BLDG/ADD]DON 0 DEMOLITION
or, Section 7031.5 by anyiFplicamfar.petromtccts thcapplicancto a civilpcnully of POWER DEVICES OTENANT ❑FOODSERVICE
n are than five hundred dollen(5500).
F Z T IMPROVEMENT
0 Lu mvner of the progeny,or my enmployees with wages ns their sole emnpenxmion, SWIMMING 1'DDh ELECTRIC
C0 will do the work,and lhestrm nuis not intended arulTerW tot sale(Sec.1194,Business ❑Ol' ER
4 and Professions Cade:The Canlowler's License Law does not apply In an owner of OUTLETS-SWITCHES-FIXTURES
properly who builds in improves thereon,and it,,docs xuch work hlmsnlf nr Illmngh
his own anployces,provided that xuch Improvcmcnts arc not Intandcd or,'Fend for NEW RESIDENTIAL ELECTR SQ FI'.
sale.lf.however,the buildingnrimprnvcmem is solA within"mere
one yearofcolnplinied the SQ.IT.FLOOR AREA 5/SQ.FT.
mer-builder will have the burden of proving that he did not build or improve far pur-
pnw of salt
01,as owner of the progeny,am exclusively contracting with licensed romnnon it)
TOTAL:
ammidact the Projen(Sec 7W4,Business and Professions Cade:,The Conlmmo.s Li-
cove Law days notapply manowncr nfproperty who hula,nr impn....fhoreon,and QTY, PLUMHINO PERMIT FEE.
who contracts baxuch projectswith acuourn r(s,licensed pncwan0othe Conlnmtol's
License I.uw. PERMIT ISSUANCE
El Innexemptunder Sec. ,B&PCfmthisreawn
ALTIiR-DRAIN&VIeNT-WAFA
TER I ) VALUATION
Owner Dome
WORKER'S COMPENSATION DECLARATION 13ACK FLOW PROTECT.DEVICE
I horohy nffino under p ooll,of Iwjury one or Pm I'ohnwing lechooksoy
0 IInoeandwi'I reunion.aCcddi...ool Consanuo.sell'-Insure for Worker's Compen- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPE CONST RUCTION
smion,as provided for by Section 9]1X1 of the Labor Code.far the wrlorwnce of the
work for which this permit is ismed, FIXTURES-PER I RAP
0 I have and will maintain Walker's Compensation Insurance,as required by Section 11
31(X1 of the labor Code,far the performance of the work for which this permit is issued. GAS-EA.SYSTIiM-I INC.4 OUTLETS OCC.GROUP APN
My Worj!f Cnn p ry nicr and policy numb�r/ys q
Carrier:(-s1 srA �11 w1 Pulley No.:${i ndup GAS-EA.SYS'I'IiM-OVER4(HA)
Cidirri ICAru Up FSFmPfION FIt(IM WORKERS' 11
COMPENSATION INSURANCE? GREASEIINDGSTRL WASTE INTERCEPTOR
BUILDING DIVISION h1iE5
(this section need not be completed if the pernin is for one hundred dollars 1$1 Ed GREASETRAP _ —
nr it('this
FEE
I mnify Urd undo effminaryscofidit,work for which thispermit is issued.I shall SEWER-SANITARY-STORM HA.21X1 FT.
not employ any person in any manner so as to become subject m the Workers'Compen- ENERGY FEE
,z tylion Lawyyf California.Dula WADER HEATER W/VIiN'1'IELEC'1'R
OO nPPlicmfl�J\I 7r P( • J f/ N GRADING FTE
.~N.r NOrICE'1O APPLICANT:11:utter ranking this Cemr ma of Exemption,you should WATER SYSTi7mn REA1 ING SOILS FEE
a , became subject am the Worker's Compensation previsions of the Labor Carle,you must
{tl fanhwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
CL Ca
UO CONSI'NI1C1']ON LENDING AGI?NCY NEW RESIDENT]AL I'LMB. SQ.1'f PAID Dane Receigt#
1 hnuhyich this
Ih:nthem Ixnced(See 30 I7,Cing agency frn Ren pvnfnnnunee of
the work for which Ihix permit Is issued(See 3097,Civ.CJ
C[. Fr Lenders Name '101'AL:
U Lender's Address T
FU4 1 ecr ay that 1 have mad this application and state that the above information is BUILDING F
N7 rorrtcl.l ugrce ns comply wish oil city and county ordinances and slam laws relnfing to Q'I'Y. MECHANICAL PERMIT PEE
U G building conumnion,and hereby..ill immpm,mdmivevafthis city healer upon is SEISMIC E
bi
ahovo-mcmliomcd p.Pc,iy for inspection purposes. I'13RMI'T ISSUANCE
(We)agree to ve,indenmily and keep harmless fbe City of Cupenino ugainat I.],C"
liabilitiex.judgnnen¢ osis nnA expenses which may in any way accrc against snit Ciry ALTfiR OR AUD'I'O MF.CH.
in onsequence of I f this M PLUMB FEE
APPLICANT I' )E .A )S LI 'Oh .Y WITH ALI.NON-POINT AIR HANDLING UNIT(T010,000CFM)
SOURCE 1' ,LA A1[CII ]CAL FEE
AIRHANDLING UNIT(OVER 10,00IC,FM) CONST UCTION TAX
Signuurcof APPlicanl/C rt :etc EX I MUST 11001)(W/DUC7D ITIGATION ITE
HAZARDOUS MAI'F.RIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous mmenal I]HATING UNIT(10 101,000 OR Of
as defined by the Cupertino Municipal Crile,Chapter 9.12.and the Health end Safety f l
Code,Section 25532(a)? HEATING UNIT(OVER 100,M)111
E Yes0 No O
V EN'FILM ION FAN(SINGLE RES II) r Dole accept#
. WiRlhe npp'iaddraimnt,a deddeg,,augur me equipmentQuality
Manis agemens whicht
BOILER-COM 1'(31 IF OR 100,0001U)
emit us air contaminamn m Joined by the Bay A.Air Quality Muwgcmem TOTAL:
District?
EYcs 0 N BOILER-COMP(OVER IIX1,000Ii'U
I have read the hmurdnuv materials requirements under Chapter 6y95 of fire Cali- AIR CONDITIONER ISSUANCE DATE
Forme Ilcubli&Safe,Cade,Scclions 25505,25539 and 25534.1 tint nslnnd that if the N13W RESIDEN'I'[A],MI?CE, SQ.ET.
buildingclu—nal...maily haven craft,Nal iris my rtspa'
nbditymnotify The neeupunl //- 2 —.9—
of the requirements which most be act prior to issuance of a Cenificme of(Xcurymcy. �a�
Owner or aut ])amhorized agent mc 'TOTAL: ISSUED BY:
OFFICE