S 0249 (4) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUT MNG.ELECTRICAL PERMITNO,
BUILDING DIVISION APPLICATIONIPERMIT 1'1 nmING-MECHANICAL Q 0249 A A
BUILD G PROJECCIDEOTIFICATION J 4 �7
BUILDING AIIII :� I /� SjNICTARY NU. AP0-7-o2 - "? _7
CA'IlON 5UI1Ml'I'PAh DAL 1;
Leg- ,T/I/// 1�—v, 7•o2• ► _7
O 'NAME: PHONE: CO ORjNAMC LIC N( CON'TROI.e
. EJ
HI .CUENGIN R: /j LIC NO: AT )HESS:
21
CON TACT. /4,,5Y 1 s5 a El Consullnnl Fees Paid by Applicant(Initial) BLDG BUIIF"I�PER PLUMB
naiCH
Yr/�-(3.•W�, / ( (G / V SCO
LICENSED COcefoed I'OR'S DECLARATION, QTY. ELECTRIC PERMIT EEE JOB DESCRIPTION
1 hereby uftirm that I tan licensed unJvr provisinnu of Chapter 9 Uonnncncing
,mZ with Section 91x10)MUlvinion 5al'the Husiness and Pn,It,..lnns Code,and my liana.is RESIDENTIAL
WOO PERMIT ISSIIANCIi
C W E, in full Tone and cRccl. Q SI'DWL E]KI'1'CHIiN REMODEL
Elective Cl... 'Lice APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPIT
I:
C"tractor ❑MULTI-UNIT ❑STRUCTURAL.
ARCHITECTS DECLARATION PANELS
�'nz I understand my plain shall he,used as public mulls MODIFICATION
Don
ZO
OZ— UP TOIN)AMPS El INTERIOR ❑CHIMNEY REPAIR
F4F'0W Licensed Prelpoin ml 201-1000AMPg IMPROVhMIiN'f SWIMMING POOLS
CY j OWNER-RUILDER DECLARATION OVER 1000 AMPS ❑BXI H RF.MODEURF.PAIR ❑DEMOLITION
C C Q 1 hereby affirm that I em exempt from the Contractors License Law for the ❑OTHER
X 3 L U following reason.(Section 0031.5.Business and Professions Calc:Any city or county SIGNS ELECTRICAL
W W N which requires a permit to con tmer alter,improve,demolish,or repair any strunure
FLL'OQ pr ort t '.: I. req th ppl' tf hPe n tl g d't mem SPLCIALCIRCLIUMISC.
"y•..11 thin he fieprocomisoup to the pro War, Ito Contractor':1 Law(Ckpter9 MFR I I'
tat..00 (win ncngwim Sccl' n]IxxllnlUvsn M1dtbclfuxne dY I -.'tins CoJc)nr D,MP MI?'f ER OR POLE INS'I'.
Z.n e r� tbm he is exnnpt therefrom trod the k vis for the alleged exemption.Any violation of F:W BLDG !)DDI'I ION ❑DIiNIOLIT10N
Section 7031.5 by any applicant for a permit subjects the applicant v civil Penalty of POW RDE ❑'LIE ANT FOOD SERVICE
F Z Y not more than five hundred dollar.(55(ft I.,PROVEMENT
< E] Las owner of the property,or my employees with wages a%their sole compensation, SWIMMINOI .LECTRIC ❑OTHER
PFG will do the work,and thc,lowhre is not intended orolibmd for sale(See.]IW,Business
uN], w and Profe.siats Code The Comna,mr's Lieensc Law does not apply o tat owner of OUTLETS-S ITCH_-FIX'I'l1Rli5
C' properly whu huilds or improves Thereon,and who does such work himself or Through
his own employees,provide)thin such improvement,arc nm intended in oliered for NEW RESIDENI'I 'LECTR SQ
sale.if.however the building or improvement is sold within one year ofmntpletiom the gQ.f4.FLOOR AREA 8/SQ,PI'.
owner-Nilder will have the burden of proving that he did not build or improve forpm-
pow of sowne TOTAL:
❑Lowns
/J O
as of the See 709,um exclusively contract ng with License)contractors i- A_/
conwrud Nu prnjan ISa:.IlW4.Nu.innss mA Professions CnJeJ The Cnmmnors Li- ✓/
ectw Law does not apply to an owner of progeny whu builds or improves thereon,and QTY. PLUMBIN 'RMIT FEE /
who contra for such projects with v conttaetor(s)licensed pursuant In the Commeme s
License Law. PERMIT ISSUANCE
❑1 vin exempt under See. .B&P C for mason •�
ALTER-DR VENT-WA'I'ER(EA) VALUATION
Desna Dam q jGROU11
WORKI',N:S COMPGNSATION DIiC1,ARA'1ate BACK F 1 ,DI?VIC❑
1 hereby affirm under Penalty of perjuryoneof the fallowingdeclarations:
I have and will maintain a Certificate ofConsennn.elf-itnure for Worker's Compen- .HOD . IiA,COND. IVI'Ii CONlI'HUCI'ION
ration,as provided for by Section 37M of the Labor Cade,fur the performance of thework for which this pewit is issued. P TUP� YEH P
❑ 1 have and will maintain Wmker's Compensation Insurance,as required by Section3II10ofthe LahorCoda.fondle perbmnce ofthe work forwhich this permit I%issued. GAS-EA.. -I OULETSOAPN
My Worker's Cmnpenwtion hournnaeerocrmN Policy mmaberme: GAS-EA.SYS'I'I VER
Cavies Policy Noe:
CERDECATEOFEXEMPION FHOMWORKERS' GREASWNDUSTRL ASIS INIIiHCEPfOR
COMPENSATION INSURANCE I11/1LDING DIVI' )N FEES
(Thiswctimnocsclam becompletedif Ne Permit i.Romahundmddnllva(SICO) GREASE TRAP
PLANCHECK 1.
or let,)
Immil'y lhuturm. spoonmmccol Nework forwhich thopermit i.'deued.I0ha11 SEWER-SANITARY-STORM ITA.200 FT. ]TNT:RGYFF.F
not employ any person many nmmner so a,it,hea,nm subject to d,e WuNcts Compel'-
z satiom Laws of Califumia.Dime WATER BEAT ER W/VENT'/IH.IiC1'R GRADING e.
z O Applicant
NOTICE TO APPLICANT If.after making this Certificate of Exemption.you.should WATER SYSTEIVTREATING SOILS E E
f' ^ become subject o the Workers Compensation provisions of the Labor Code,you must
ai forthwith comply with such provisions or this pe.if hall he deemed revoked. WATER SLRVICIi
wo r
CONST RUC I'ION EEENDWC AGENCY NEW RESIDENT IAL PLMB, SQ.IT, I'AIU
U Z Uulc Rccci e e
U IL O I f r whit imt lhm ick I is..ed( eetinn lending agency for the peniamanee of
the work for which his Person is isucJ(Sec.lfX)].Civ.C.) TOTAL:
0 F" Lends/s Name
I]U l 's Address TOTAL: O
'� G.ICL renderBUT F'li
1 ecnify that 1 have read this application and state that the above information is
ZI c veer.I ngut comply with all city and atom yonJinanees and stale m Iowa elmig 11, QTY, MECHANICAL PERMIT FEE
5I SMI ail?
U z huilJing tronamninn,unJ haruby umhnrim rcpm.auudvcs ofthi.airy urentcr upon mho
above-mentioned property for inspection purm,ws, PERMIT ISSUANCE I..;' RIC IT
(We)agree to save.indemnily and keep harmless the City of Cupertino against
Iiabilities,judgmetnx.costs and expenses which may in any way acerae against said City ALTEROHADDTOMECFL . .MBING FEE
in consequence of the granting of this pctmit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 10,000 CPM) ECHANICALI C� O
SOURCE REGULATIONS.
AIR HANDLING UNI'C(OVER IOdxX)CTM] 'ONSTRUCHON'IAX
Signature afApplicanVCommnor Date EXHAUST HOOD(W/DULT7 Ii SING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant wore or handle hazardous notedal HEATING UNIT
llp.gll)N'I'U)
as defined by the Cmamno Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I l ,INN)B U)
Coda,ScOiun 25532(p)?
E]Yes, F7 No VENTILATION PAN(SINGLE R17S I D)
Will the applicant or future huilding acupam use equipment or devices which BOILER-COMP(3HP OR 10011)(10 BTU)
00•re hazardous air contaminants as Jefined by the Bay Area Air Quality Management
Dihrict! BOILER-COMP(OVER 100.00013 FU)
❑Yes ❑No
AIR CON DII'IONHR ISSUANCE HAT If
I have reS the hwartlous taderi 55 rcy255n13 a under Chapter rson of the Cali- �T
fomiagdoes&Safety Cedesea wars 25505,25533esp25534.1 to ands ththatif the NEW RESIDENTIAL MECII. SQ.Il'. 1
building Jas not comedy have a bosom,that it is my rexPen.ibility In sonify the tecupanl
of Ne requirt ents which most he tan prior to Issuance of a Certificate of Oes-Pattcy.
TOTAL] �� • ' ��
Owner nr umhorir d"cal Date ISSUED By.
'� OFFICE