S3141 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE fITNO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 3141
ItU11.DING PIt11,lEC1'IDENTIFICATION
BUILDING ADDRESS', SANITARY NO. APPLICAIION SUBMI'I'IAL DATE
f 14— .
OWNS '$NAME: PHONE:: COyTRACIOk'S NAME: LIC NO:
NIC CONTROLN
. ARCI{H ECI]F,NGI IEIt)3R: LIC NO: ADDRESS d ❑
CONTACT: PHONE. ? BUILDING PERNIET INFO
❑ Consultant Fees aid M1y Applicant(Initial) BLDG hF.CT PLUMB MF,CH
El 1:1
LICENSED CONTRACT OR S IV.CLARAI ION QTY ELECTRIC.PERMIT FEE !
I Thereby affirm tbut at,,I' ed ande,provision,of Chapter 9(commencmg JOB DESCRIPTION
M�Z is ith Secifio.]IX0)ofDivision 7 rifl, Baiiida,smalPmf sion,Ctdc,an my license RF DENTIAI:
110 PERMIT ISSUANCE
��0 in fall " JeRec �-{I v�e��i�tfty JSFDWL ❑KITCHEN REMODEL
QUO LiceLc N '" '-� AI'1'LIANCES RESIDENTIAL ADDITION ❑PLUMBING R1;YlYE ,
F-Zm Date CnI
Pn66 ❑MULTI-DN['E ❑STRUCI'URAI.
ARCHITECTS DECLARATION
ZO�Z 1unJersmnd my plans shall be usul as public records MOD1AN0b CHINIFICATION
OZLa UI'T02(0Ah1P5 ❑INTERIOR ❑CHININEY REPAIR
E�¢+!�F,W Liceaxed Professional 201.1(X0AMPS IMPROVEMENT C]SWIMMING POOLS
"-C C Q Ighcreby uflirm then ;un exentpl fnnn the Comrmmr'x hiccvsc Law lin the OVER I0IXIAMYS ❑HATH REMODF;UR��AI�DEMOLITION
Iy�; OWNER-BUILDER DECLARATION ��E �-I V R
CCU fullowin•mason.(Section 9031.5,Business and Professions Code.Am cit t Ery OTHER
'a( y nr coon Y SIGNS L'LF.CfRICAI. \,
1+13 a y eq
which requires a peconsumer,t to con ,aper,imtpmve,demolish,or repair any sem
ucre
prior to its issuance,atm requires the applicant tau such permit to file a signed statemrntSPECIAL CIRCUIT Ad ISC
F. y that he is licensed pursuant sion
u the provis of the Contractor's Licari
sc Law(Chapter 9
Waco (eommencingwith Section]IXXBof Eivi.ion 3 aline BusineasvnJ l'mfe—mm Coddrr TEMP.METER OR POLE INST. COMMERCIAL:
Thal he Is cxm^pt therefmnt^^d the basis lite the alleged exemption.Any violation of El NEW BIAG/ADDITION [:1 DEMOLITION
��H Seaion]0l L5 by vny appllcum tnrupermit.whjccU the opplicnmmxcivil lwnulty of POWER DEVICES ❑TENANT ❑FOOD SERVICE?
Chu
net moa n five hundred Aellm,($500). IMPROVEMENT
Sp ❑1,as oxucr mf the pmpcny.or mycmploy«s with wager as their sole rompcmminn, SWIMMING POOL ELECTRIC ❑OTHER
F• will do the work.and thcsuacture is not inandcJuf.tiered fo..ule(Sce.]I114,Business
W god Pmfe,mr,Coe The Commetora License Law docs on,vpply m an owner of OUTLETS-SWITCI IF: X"TURES 1'
'' pop ty l b )d. p ,F c h does h kit If IhmPbh
his y pr 1 J that h' p t:arc air' t ended.,,,Iran,,]lin NhW RESIDENTIAI. ..'T SG Ff
sale,If.however.however.the building or improvement .old within One year efcompletion,the SQ.FT.FLOOR AREA $/SQ.FT.
awnwalmilder willh h burden f provingthth did notMIld at nipmwcfor p,
pos df,dc.),
� 1 he property, I . ly t tg 'tbl d tit IP D
can I I tire primac,(Sll.7044 Bovines,and I I :Cada,)Fi Coullairol,1 -
c I 1 Itppl)I fp I ly b 'Id. ' p tit I QTY. PLUMHINGP MI' FEE
_ whoconfined,fmrmchp 1'cn with acmmtractmh 1wd pur,tintan,the Can.. I JUL — 9 1999
LaLaw.w, PERMi r ISSUANCE
❑I am exempt made,See. .H&P C for this Person
AI:I lik-DRAIN N VENT-WATER(IiAI VgLUATION
Owner Dale,
WORKER'S COMPENSATION UECLARAfH)N BACK PLOW PR(YI'IiCr.DHVICI? By
1 hereby vff rte under Two 1)of perjury one of he following declarations
have and w'll maintain a Carlini fConsent t if moure I WriC open DRAINS-FLOOR ROOF,AR E- ,CONE. STORIES 'I'YP NOT,UCfWN
s i of as provided ftrby Section 3700 ofth Labor Code.for the ped of the
Iwo ohich,hisiparvoliki—ed. f1X'fURES-PERTKAP
1 have and will maintain Workers Comlema(on(nominee,as required by Swi on
3 )0of Iu Lahar Code.fu0uaperrornanevut The woM1 for which Thi permit is iv,ned, GAS-EA.SYS"1'NM-I INC.401J'I'LE'I8 OCCORUUP AI'N
My Wor Compo moh,ja red Policy
Car,ier: 4 a Policy No.: aVe3O) GAS-I?A.SYSTEM-OVER 4(EA)
ERTIFICRI EOFEXEMPI'[ON FROM WORKERS' GNTi\SI%IHDUST HL WASTE PKI'. CEPTOR
COMPENSATION INSURANCE BULLI NO D[VISION FEES
(This rection need nal be complded if the permit is far one hundred dollars 1$100) GREASLTRAP
or less) I'hANCIIECK Il4i
certify that in the performance of the work for which]hie permit la ivsuCorinn. SHWER-SANI'IAItY- ORME 200FT.
not employany person in ungmm toM1 yy' uInject lm the Wmkcn'COmpe.- IiN1iRGV FEE
Z smimn lase.,rllj':Qif ,Elm tltcgyr 1n 1A WADiR l{Ee TF,RW FBUELECIA GRADING FF.fi
ZApplicant= ca a 1 1
.Ni NOTICE TO APPLICANT:IC otter making This Cenif cafe of Exemption,you should WATER SYSTF nREAI'ING SOILS FEE
F bcvo,nd object m the Worker's Compensation pravieiona nflhv Labor Cale,you caro
Wronhwith comply with such provisions or this perin i shall he devoted rcvok il. WAI ER S' ICC
n' CONSTRUCTION TAi ]cramAGENCY NIiW' SIDENTIAI.YLNIR, SQ.FT PAID pate ReceiptX
U O kheaclay
which rte lauhcreisacomwc.30 leading agency Truth,perfomtnnce of
H
'he work Ln which this pemuns issued(Sec.lfO],Civ.CJ
O ULender's Nunn 9ti11'AL'.
Lender's Address TOTAL:
'�.. [S.7 I{1111.DING PEIi
F' 1 I candy that 1 have read thist, it county un Imd dose that ate ebirve w,mann,is
Z corecL lagmcmco.an wiN all citkrepresentatives
of and ,aicity
to ntrupon'he QTY. MECHANICAL PERMIT FEE
V ,� building eon.umaion,and hereby auNome mpa.cntaives of this city to enter upon'he SEISMIC FEE
above-mcnlinneJ property fur inspection purposes. PERA11'IISSUANCE 130 V/�
(We,)ugrcc Io save,inJcmniry end keep harmlms Phe City of Cupertino ugninst ELECTRIC PITH
lieb l'nics,lulgmmns,casl.v nnA expense,which ntaylnanywayncannra,d.,O:ICcy AUILR OR ADD'10 MECH.
PLUMBING Plili
in nICANT Nthe RSTAN SNis peteiIL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(f010.IX0 C1�M)
SZ RF,GULATIOyNS\1 MECH,\LAICAL(cIi
V I I9�t AIR HANDLING UNIT(OVER 10,00(t)CENT) CONSTRUCTION TAX
Signnwa ,I AITmnUConwetor DsI 17XIIAUST HOOD(WIDUCT) I IOUSINGMI'HGATIONFEE
HAZ,ARDOUSNINrERIALSDISCLOSURH I
Will Neapplicmnurs fuwrc buildin6'ecupam store nr handle hazardous macrial 1{IiATING UNIT(10 100.000 BTU) Y✓
as JefneJ by IM1e Cupertino Municipal Cnc.Chapter 9.12,and the Hedtb anA Safely
Cale,Section 25532(a)'! HEATING ITS"I(OVER 100,000 If IU)
p Ye,. ❑Nu (SVD
VLNTILA'CIONIAN(SINGLE RES]11) ale Rvecild#
Will the applicant or(marc bulging camp..use cspoln mor devices which
nruru
due air eentantinants as deficed M1y the Bay Accu Air Quality Manugnnent BOILER-COMP OHI'OR 1000M b'1'1A
nctR 'r(l'PAh
't h :
p Ycs I] BOILER IW.gXI BfU)
Nn
I have ren the haraalaus material,nNinicanum,under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DAT
forma Ileadth&Safety Cala Sccriutw25505,25533 and 25534.1 understand thal d IM1e NEW RESIDES PIAL MECH, SQ.I'll
brilding dies not currently have a tenant,Ilial it Is Imy aspotwilahly m ratify Ne vc,ttl am
of'he PaBiame^ts which most be met prior m issuance of it Certificate of Occupancy.
Owner or authonzed agent Date, 'I IYI'ACISSUED BY:
OFFICE