S 0378 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL,)ING-ELECTRICAL P[� fl I'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J 0378
BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICATION SWIMI MAL DA'I'H
HUILDING ADUkIL55:
Gt/f�re11V
PUSH L(
OWNER:SN 'HONK, CONT ACTORS NAME: LIC NO: N/C CO 1'kO1,p
ATLCUEN61NEERIL11AO. ED/
CONTACT: PHONE BUILDING PERMIT INFO
/,45, - / /_ _� ^ ❑ Consultant Fecs Paid by Applicant(Iniliaq HL❑DG [LI:CT' PLUMB h1ECii
[L,f!/�-'kf)/ (�•�S y 'JSa/—nal/` ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby am thin 1 am IicenseJ under Oovi,imno of Chapter 9(commencing
GCz wilhsechan]IIDIIInf DivisinnJml the Bwsinesn unJ l'mfessiom Gde.and my license is RF ID•NTIAI' j
.00 in full functional PERMIT ISSUANCE ❑$PDWL ❑KITCIiIiN RIiM�)tl.,L
QUU License Class Lic.11 APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING kIid'I�E
tF Q i Doc Contractor ❑MULTI-UNIT ❑STRUCTURAL.
ARCHITECTS DFCLARAI TON PANELS MODIFICATION Y.l
O Z y Z I understand my plan%shall he wood]as public record. UPTO 2M AMPS
E3 INTERIOR ❑CIIIb1NIiY REPAIR
r,4Lwn Licensed Pmfessional 201-IIgp AMPS IMPROVEhfENT SWIMMING POOLS
CYf,'j OWNER-BUILDEk DECLARATION OVER LBBB.MPS ❑BATH RFNIODEIJRI:PAIR ❑DI!MOLITION
5Q 1 hereby affirm that I am exempt tram the Contractor's License Law for the ❑OTHER
X a U following reason(Serdmi 7031.5.Business mil Pmfeslons Coi Any city Or Heavy SIGNS ELECTRICAL
W 3 LL v~i which requires a permit to construct.alter,improve.demolish,(it repair any 11.0w e
F��� prionoiu iasoana,alsn rtquims the
applicant for such permit to file aligned swtement SPECIAL CIRCUIT/h11SC.
� } that he is licensed pursuant to pmvisinns of the Cnmractors Licemc Law(Chapter9 COMMERCIAL
ta�0a�0 (commencing with Section TKO)of Division 3 ofnbe Businessand Professions Cale)or TEMP.METER OR DOLE INS .
a E c'1 that he is exempt therefrom and the basis for the alleged exemption.Any violation Of (]NEW BLDG/ADDITION ❑DEMOLI'T'ION
Xro{s Section 70315 by any applicant for a pinion subjects the applicant o a civil penalty of POWER DEVICES C1 TENANT ❑1WSERVICE
Www not marc than Boa hundred di(55M). IMPROVCMIiNT
=O ❑1,as owner of nhc pmpeny.nr mycmpinyen with wages us their sole compcnsarinn, SWIMMING POOL ELECTRIC C]OTHER
[-, will do the work.and the structure is nm intended or ollemd forsale(Sec.7(94,Business
and Professions Calc:The Contractor's License Law does not appty to an owner of OUTLETS-SWITCHES-PIX RES
a 3^ property who builds or improves thereon,and who does wen work himself o.through
his own employees,provided that such improvements are not Intended or offered for NEW RESIDENTIAL ELE.0
SQ,F[ PLIKIR ANIiA SISQ.Fn
ole.If,however,the have
building en 01 Proem in told within one build
or i amnplutfor the
owner-budder will hove the burden of proving that he did nod build or improve far put-
,.,c
ur-pre a of xwlc.). L
1,as awnerof the properly,sent exdm'ively c sting with her bit eotnmebas to
mmlNal the mlee,(Sea 71M4.Business and Probesaions CoOt:)Ox,Common r n Li- gYa AID
ase 1.e.docs not apply to an owner nil'property who buildsnr improves therron,and QTY. PLUMBING PERMIT FEF, r
who mnwams lits such propla,with a ono-Obats)liectamd pu.wtuntto the Contractors
License Law. PERMIT ISSUANCE
I am exempt under Sec. ,It&l'C fur this reason
ANTER-DRAINh VENT-WATER(LA) t f1UN
Owner
Did.
PAC K PLOW I'ROl'ECT.DEVICE. TTY ser uurtHTINU
WORKIiR'S COMPIiNS61'ION UIiCLARA'I'IUN
1 hereby alii on under penally of pvajury one nit the fallow ing declarations:
Ihavcandwillntainmin a Cedificue of Conwnnn self incire far W.,,kco's Compare- DRAINS-FLOOR.ROOF.AREA.COND. STORIES 'IYI'E CONSTRUCTION
satin.,as provided for by Sadon 3700 of the Inbon Code,liar the pcd'onnancc nil'the
wink for which this venni]in issued. I>I%'D1RIi5-PER TRAP
1 have and will maintain Workers Campensnllon Insurance,as required by Section GAS-EA.SYSTEM- INC.4 OUTLETS
371glaftha LaorbCada Panic neda
annc,,oflbe work lit,which this permit k a,,.vd. OCC GROUP APN
My Worker's Co urn ln.uurance ca and Policy nylt�(v.'g;S,� GAS-EA.SYSTEM1i-OVER4(EA)
(CLQS
Caricc I 1ON No.: �7
CERTI ICA'1'LOF SNTI NI NFROM WORKI3RS' GRCASIIINDUSTRh WASTE.INTERCEPTOR ,
COMPENSADON INSURANCE BUILDING DIVItiION PEES
(Thissalionnecdnolbecomplced if lheperoul islinonchundreddollars(810M) GREASETRAP PLANCHECK FEE
Loy any that in the anymannwof the,work become
which ject...panilisiawCm,xn- SLWEN-SANITARY-ST ORM EA,200 FT. ENERGY FEE
nor employ of hereon in any manner at as m hcasme wbjccno rhe Wodcri Compcn-
z Applicant
Laws of Cal'domia.Date WATER HEATER W/VENT/HLECfR GRADING I EIi '
Z Applicant
N NOTICE TO APP LICANT:evaftermaking this Certihcme of 13umptiodYen should
alt WATER SYSTEM/1'REATING SOILS TEF.
f-' fur w omp a the Workers Compensm is pmvisinns of the lane Csole,you must
funbwinn comply with such previsions monis pmnnit shall be Jccmodl revolved. WATER SERVICE
CPAID
7,z CONSTRUCTION LENDING AGENCY NEW'RESIDF IAL PLMB, SQ,FT. Dae Rcceiptp 1
U 0 I hereby afrm
rthanman
hem is a construction lending agency Indic perforce Of
cite work for which this permit is ivucd(Sec.3097,Civ.C.) TOTAL:
C) [— Lender'.Name TOTAL:
r {UA Lenders Address BUILDINGE
C I terrify than 1 have read this application and sate that the above information is
FTA c.,.lagme to comply with all city and counryordhences and state laws n ingto QTY. MECHANICAL PERMIT FEE SEISMIC F
U building construction,and hereby authorize representatives of this city to enter upon the
aMva nicauoned property for inspection putltmn. PERMIT ISSUANCE ELECTRIC
(We)agree m save.indemnify and keep harmless the City of Cupertino against
liabilities,judgmsnns.oma and expenses which may in any way aceme agairsrvaid City ALTERORADDTOMECH. PLUMBIN
m consequence mine granting of this permit.
\ APPLICANT /NDERSTAND. IND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANI
SOURCE R 1 A
I
AIR HANDLING UNIT(OVER 10.000CFMI CONST RUCf10N'1'AX
ign at licant/Contrecem Untc EXHAUST HOOD(WoDUCt HOUSING MI'rIGATIUN FEE
'k HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oawpaut state or handle hvurdaus maerial HEATING UNIT(TO IW,"BTU)
as deinW by nhc Cupcnin,Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER ifflLUX)BTU)
Gude.Sidon 25532(a)'! PAI)
D Yes ❑No VENTILATION FAN(SINGLE REMD) Date Receipt
Will the applicua or future building onctlpanl use equipment nr devices which BOILER-COMP(3HP OR ID),000 BTU)
emit h.amdwus our comer inars O,drined by the Huy Aron Air Quality Management 'DUAL: 1
District? HOLLER-COMP(OVER[00,00f1 BTU)
❑Yee F1 No
AI R CONDI I'IONER ISSUANCE DATE )
I have read he hwou
urds m;ncrbals mgnieeo
nnts undChupar 69 of the Cnli-
fumia Heald,k Safety Code,Sections 25505,25.133; it 25514.I unduntmtd ohm If the NEW RES JOENI'IAL MUCH. SQ.FE st,
building does an c ern ndy haven tenant.that it is my nsPumibil Ily In nntily Ibe ttienpam
ofrhemoa,aub ,whichnioVl be nue priorto isxuuncu ofa C'Titteak nilD, 1pmay.
Owner or ambo sir J ogom
)enc 'TOTAL: issu DI{Y:
OFFICE