S 1376 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PITT,N0. 1376 376
RUILDINC DIVISION APPLICATION/PERMI•P 1`LHMBING.MECHANICAL. `V
BUILDING PROIEC'I-IDENTIFICATION, '1
N1111.O1NG ADDRESS: �y O n A t/ L�L✓ /0 T, � /c v P rL-p qi �k o 1,CA-
SANITARY NO. APPS AlIDN SUIth11T1'AI,pAT13
OW ER'S NAlltl!L .M�E: /r L 1•'['][ONN\H'. 1 l-CP N'PIACI QR S NAME.•-1`I ♦fes /C�N(T `IR �_��
TIw1 B14XI.-E�' _ S�uN p/ 5TD7 trey 5 11C S- �Q NIC C'ONI'kOLp
C (�'f 61 LIC NO: ApDkENtiS:F"- II/rl.Rl'�✓ TC ❑ 2
-I f1-t1-f-1� CO UNiJE'RSl �l� Loi CS 3 3
CONTACT. PHONE: ;z-• -HUILDINO PFRMrr INFO
A RK"r FA K TOd,;,4eir CSt°J}.q 6 ❑ CnnsRltant FecS Paid by Applicant(Initial) HIAc RISC' PLUMB MECH
(
LICHNSED CONTRACORS DECLARATION QTY. - ,itl?LECTRICIf.RMIT FEE
I berchy drrn that 1 mu Incised J 1 f Cn la 9( ng '! 306 DESCRIPTION
OI Z with Stein.70fXJofDVvne tof@e Ru ..and Pmfee.r eCodeundmy licnse'sRESIDENTIAL:
Fob in loll farce and elffic, PERMITISSIIANCE
ytW-+ 0 SFD W 1. 0 KITCHEN Its"ODFI
¢'UU Licmixe Class L,# APPLIANCES-RPSIDEN'I'JAL OADDI'HON O PLUMIUNG It LPIPIi
F Z C Dalc Cenlnu'ler
F7m ARCHITECT'S DECLARATION PANELS El MULTI-UNIT ElS'I'RUCTURAL
ZOr-Z lundemmnd myplan-baa denied.,public record, MODIFICATION
OZ�-Q UP T02(q AMI`S ❑INTERIOR [D Cl HMNEY REPAIR
F 6 L c wherehyl v ^-nl-Iu00AMPN IMI'ROVIiMI?N'I' OSWIMMING IN)OLS
�; OW'NI[R-BUILDI3N DI'CLARA'I'ION OVI7R 1000AMIS 0 PATH REMODEUREPAIR 0DEMOI.H'ION
uflirm Thal I am exempt from Ne Contractor'.license Law for the
�a a U following reason.(Section 0131.5,Busines and Professions Code:Any city or countytiIGNs ELIiCTRICAI. ElDaHER
fU�LLO F"
.1 60, q ' . a p 'u .I t It p d lib P', y.tncere
al 1 I' 4 'ppl If 11 ILII - b Halo,, SPECIAL CH(IUI UMRC,
f, iN+ lhv h 1 P n ll p.....mo,oche C I l License I (Chap e )
9X (e ening with Section 900)of Oivisin3 ofthe Business and Proessurs Code)or '1 LMP METER OR POLI'INS'I'. COMMERCIAL
a 6 C that he is e.aempt therefrom:ted the basis lin the alleged exemption.Any viMmion of 0 NEW RLDG/ADDI'TION 0 DEMOLITION
X0
W N Section7031,5by an, obtainforarenin wM1Jects me nprlicam mucivil penally of POWER DEVICES ❑IMPROV ❑POW SERVICE
f1r� mm�re than five hunJrcd Aullum l850t11
❑=C 01,as ownendlbc pmperry.or my empinyce.with w.gds us their sole nnnpcnsvtion, SWIMMING POOL HLECIRIC 0THER IMPROVEMENT
22 p. 'diskette work,and lhemmetumi.snam intended arotrered for sale(Sec.]D1i,Business 00THER
6 3 m
and Professions Club.The Co muche's License Lou dnea not apply nl an owner of (rtl'1'LFTS-SWITCHES-PIX'IURES
pmpcny who huilJs Ur improve,thereon,and who docs sneh work unused m lhrouyh
his own empinyces,provided than such Improvement,ole nal In(midel ,,onRcrcd fir N13W RESIDHN'I']AL El HCI'I1 SQ FI'.
sale.If.however,the building or improvement is sold within one year ofeempletion,the SQ.FT.FLOOR AREA $/SQ.ET
ows net builder will have the burden of proving(hut he did not build or improve for put-
0 I,as own,of(he mUp--ny,and exclusively Cummeloo,vol l Ilcemcd Canlmgnnl b, IOTAL.
mnlmn the project(Sec.7094,13ucines,loll Pedfesion,Civic:)The Colorado?,Li- -
,e hw,docs net apply it)an owner ofprolndy who hnild%or improve,thereon.and QTY. PLUMEINO PERMIT FEF
who contracts for wah prolmtx with a nomneln,E)licensed pursuant to the Contlaetore
License law. PERMIT ISSUANCE
❑ Ism ewript lender Sec. ,B&It C tar thi"ceen
Owner Date AUTER-DRAIN&Vl;bD-WA'I ER(EA) VALUATION
WORKER'S COMP HNSAI'[ON DECLARATION HACK FLOW PROTECT.DEVICE T
I berchy a0irm under stonily or ImOnr,one of dm G Mowing dechlratinn A l%
❑ I hoe and will monlaina Cenitieatcol'Consem inmll'.insumMrWnrkor',CnOpen- DRAINS-IIDDIt,ROf)P.Alt IIA,CONO' S'10 1?Y 'I'YI'E CDNtiTIt UC'TION
sa(ion,as provided far by Sec(inn 3]00 of the Labor Gluten for the Pcdormance of(Lc
ork for which thin,crit is mo d. FIX'I'DOES-PER TRAP
❑ I have and will maintain Worker's Cmnpensation Insurance,as required by Section
3700vi(be Labor Code,far l lepe,morunvol the work lar which duk,cnnll is ie sued. GAS-EA SYSIUM-1 INC.4 OIl'i1.Bl'S OCG GROUP AI`N
My Worker's Conmon.maion hounumee ca...e,:ted Pulioy mma,le,ere:
Carrier: P.Inty No.: GAS-EA.SYS'1'Phi 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDDSfRL WASH INTERCEPTOR
13LJII•DIN DIVISION FEES
(To,"clio incl and he completed it he Pdreel Moron,hundred dollars($Ifs)) GRFASHTRAI'
or Iesc 7 I'LANCI IECK PF.
Ioworry Jusehat in themin perfionaan,artlanceofi,to bekforwMchthis perthe it Wrkms' dmxmo- SEWER-SANITARY-SD)RM EA.200 FIE I shall
not employ any person in any nsannennas mhecrnne suhjecno the Workers'Compcn. ENlikfiV IBE
ration laws of California.Date WATER HEAIFR WNUNT/IiLHC'rR
C Appllcanl 1 GRADING F1
y NOTICE TO APPLICANT:IL after making Ibis Cenlfimne of EaemTIion,you shoal WATER SYS'I'EM/TRUA'1'[NO
become subject bl the Wori Compensation provisions of the Labor Cbde,you must SOp S IT
timhwith comply xith teed provisions nr this permit shall M:Jeemal revoked WATER SERVICE
Q
VLL CONSe is ac(..tractIN0 AGI3NCY NI?W RESIDI:N'TIAL PLMII. SQ.1'L PAID
Q Ifar,hi h,hi thanhcrc i sadon.um lien fbadmgageney burahe pefiberm ccof
JIM work for xhich Ibis pemril is kstied(Sec.3119],Civ.C.)
P. (<nd,,Numc T(of.:
a
C) W ,color's Address TOTAL
I cdi il,lbs(1 Lave read llik applicatlon cold sane lbal me above inforrnmi ne ist BU DING FE I 1.
to mil c: l agree locomply win all city and county ordinance,and state laws relating to Q1 Y MECHANICAL PERMIT o ' FEE
VZ building construction,and hereby nlahorimrepow,mmivesefthis cityeco thuMmnt the SEISMIC IFE y
abovomennonW properly far inspection pumases PERMIT ISSUANCE
(We)agroc e oboe,indmi U,and kccp hamJos,the Cil,o1 Cupertino i aired EI.HC'I'RIC FEE 7
luhilides.judgments,emu and ta,descv which may in any way accrue against said Clly AI:I'IiR OR ADU TO MHCIL �a e'1 O
in Cis+ PLUMBING FEE
consequence NthegS JAN SIbispenml. _ /
APPLICANT TINDERS"I'ANDS AND 1V11.L COY1P1-Y WITH ALL NONPOINTAIH HANDLING UNIT TIO I0.000 CI7htl
SOURCE REGUhATIONS. MHCIIANICAL PEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION]AN
SignamecoUpplicant/Contractor Date EXUAUSTHOOD(W/DUCTI HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore ar handle dinedous material HEA'HNG UNIT(f(l 100,000 BTU)
as defined by the Cupemoo Municipal Code,Caper 0.12,and the 1lcallh and Safety
Code,Sections 255320P HEATING UNIT(OVER 104),0410 BTU)
0 Yes ON. V5N1'[LAI'ION PAN SINGLE RESIDI PAID
One
ell the upplicom to ruuu'c building occupant Ilse nrylpmenl or devices which Recei Pa
unit hawNons ar emarminum x as defined by he Ray Arca At,Quaid,Mara gamenl 13011.ER-COMP(3HP Ok 104000 B'fll)
❑Yes ❑Nn - BOILGR-COMP fOVF.k 100,000 PTLD
AIR CON D 11 TONER
I have lead the hamNons materials letloimmenls n elm Chapter 6.95 of the Cub- ISSUANCE DATE
forma Ikmtb&Safe()Cele,Salmons 25505.25533 and 25534.1 undenland that if the NEW RESIDENTIAL MHCII. SQ.FT. 1 4 U
building does not currently have a moan,that it i,my responsibility to notify the occupant 3-
9!!!O///
of the equimmont,which must he mel Prim ini maybe of Certificate of(kcupaney-
Ovoummiathon,c]agent - Daae (PIAL 1 ISSUED BY.
OFFICE