S 1375 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'I'INO BUILDING.ELECTRICAL Pli lI NO
BUDDING DIVISION APPLICATIONIPERMIT PLUMBING.NIECIANICnI' - 1375
BUILDING PROJECT IDE:YI'It'ICATIUN
BUILDING ADDRESS: SANITARY NO. APPIJCN[ION
SS�UBMITI"AL DATE
WNiR:S NAME: R.0 al'HONE: CON"THAC TOR'S NAhtlj. 1 LIC NO: `� v
Qr ' 26 _ Re.kD SOOq
NIC CON THOLp
ARCIII'lr-EC'1'IENGINEER: LIC NO: 1 )RE S. ^ ❑
C0/q I'/ACT: �Q^rvl�/ Is&-196D ^ Vl IUILUING 11FRMl'I'INFO
�f e�" x / a I'J C/Jn `r ❑ Consullam Fees Pail by Applicant(Initial) BLDG ELE PLUMB MECH
//✓ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT F E
1 herchy affirm mm 1 am licensed under pnwieim o of Chapter,9(co arrear ng JOB DESCRIPTION
OmZ with Section 7S01of Dlvidou 3 ill'Ins Hunincssnn I Prolnuions Codd,and my lluemc is RESIDENTIAL:
1,- PERMIT'ISSUANCE
CSF in tnre)anJ effect. C�\���n ❑SFDWL ❑KITCHEN REMODEL
aUU hicew las Lic.M Dei kl
�zw Dam $' Cntnnmtor l.L� APPLIANCES-HIiSID1iNTIAL ❑ADDITION ❑I'LUMNING RE-PIPE
la. ARCIII FECr'S DITI-1 A lord [I MULTI-UNIT [I STRUCTURAL
F�an I'ANEI ti
Z O yZ I undentanJ my plans sM1nll be useJ as public records MODIFICATION
OZ-O UPT02B)AMPS IN']PRIOR ❑CI I IMNEY B17PA1R
i2 1z al l.menscl Profcsrional 201-1000AMPS IMPROVEMENT ElSWIMMING POOLS
�yCL S Q
OWNER-BUILDER carr DIiR DECe Coal.ON OVER 1000 AMPS ❑BATH RIiA10UIiIJREPAIR ❑DEMOLITION
1 hereby u(Hmr Ilett 1 ran exempt faun til)DECLARATION
License Lew 6r We
3 G U t'ollowing mace..,75'0100 7031.5,tlmim:n and 11 bastards Code:Any city or count, SIGNS ELECTRICAL ❑O'I'l1ER
� a t- which rcyuirc>a permit lu<onsmn,alter,impmve.Demolish,or repair any umnurc
; prior to its issuance,ahem, ires theapplicatn Ruttish Farm,I.file a6madstvtaoem SPECIAL CIRCU I UM ISC.
(commencing
o miscwmcd Secure
70th)7000)of Division 3 the eBusinst nd Pres Luo(Chupru9
2.a: ea thin h mncingo,a Sectloatimaddf Division3of theege rxernd Pm An,i Cale)or TEMP.MITER OR POLE INST. COMMERCIAL'
Sao 5 that he is exnnpr amv aplm and tar basis for the alleged emmpnen.Any violation of ❑NEW BLDG/ADDI'T'ION []DEMOLITION
�-m not 703L5 by 111 I!r- Iw tsubjectsthapplicant "Fpr Penalty I' I'OWI:H ULVICIiS ❑'1'ENAN'I ❑FOODSERVICE
Dol than't hundred dollars(85W). IMPROVEMENT
WZG 01 f n il Irony Y PI y . lh g - 1x1- pe .-f SWIM MING POOL ELECTRIC
S w'111 tha wn A.and tlt Luhxstet nt Idor ollvedGrl (Su9(M4,Bns nen ❑O'111ER
It 11
1H
3 w nnJ Profnsiuns Cale:The Cnnrmcmh Licenu law Jets nm apply ro an sinner of Ol1TLE15-SWI'ICHF_S-PI%TURES /� —C�
propc'ny wM10 huilJs ar i;npro es tncrcnn,snit who Jsnz wch work himself or lbrmght
his own employees,providul that such Intprevcmmdls arc not intended or oltned for NEW RESIDEN'HAL FL1.C'JR SQ EL
sole.IL howeveq the builJing or improvement is udJ within nn)Year of mmplction.rhe SQ.FHI1,00RAREA $ISQ.PC
owner-builder will have the burden of proving that he did 007 build or impmve for put-
Few"I';de), '10'A : A
El 1,an owner of the property,ant eschei,cly contracting with licensed cmumoors to
construct the po jec,See,70,14,Basin—and Pmmourne Gde:)The Camme.nJe Li- 410
e %cLaw does nor apply a;anownerofpropuny whobbddsor mprosmmcrestrnd QTY. PLUM/
LUM NG PERMIT FITAO�
who contracts for such projects with a:'antmcmKet licensed political to the Contractors Iy�
License law. PERMIT ISSUr ��
}
Fl I am exempt under Sec .B&P C fonhi.masou C�/y e 8
Owner Date
AI:1ER-DR L`
& WATER(EA) VA, N
• s
WORKERS COMPENSATION DECLARATION I{ACK FLOW PR( '.I e ICI r
Cyy
I Ecrcby;Jllrm wWer pcnuhy u(purlury ono of rhe following dcdumbon ///�, 7
❑I base unit will maintain'CenificamntCnnsenan sdf-insum for Wdrkcr's Compen- DRAINS-FLOOR,R F REA. 'D STORIES TYPE CONS'1"RUCTION
whorl,as provided for by Section 37M of the Labor Code,lin the performance of the
work fin which th is permit Is idod. FIXTURES-PER(RAP
❑1 have and will maintain Worker's Compemation Insurance,as required by Section
3700 of the Labor Cale.rile the performance of Be work for which this permit is issued. GAS-RA.SYSTEM-I INCA d1YOX
OCG CHOIII' APN
My Wnrkcrs Cumpcnani0n Inwruna:urrzier and Policy nunnccr um:
Cunicr: Policy Na: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF 17XEMIMON FROM WORKERS'
COMPENSATION INSURANCE GREASb/INDUS'I'Rh WASE IN I HNCBFI OR
1'1'his section need nJ nbe complcreJ it the is fnronc hundred DIVISION FEESJ dollars(SIM) -- ---
orleas.) GREASBTRAP PLANCHECK FEE
I e,any thin in t m any ornansc'Phe woek lot which this,he W is L soCompl all
nor em In SIiWER-SAN]'IAHY-STORM 13A.8N11:I'.
p yany person many manor'( /� object Workers'Compen- ENERGY PEE
O z. emiun laws n %ln.Dare `� / su WATER HI?/TER WNEN'1'/F.hGCTR
Zpff
z Applicant GRADING FEE
rN. NOTICE IO APPLICANT':IL alter making this Cenilicate of Exemption,you should WATER SYSTEMn BEATING
a > become subject m the Workers Csnnpensation provisions of the tabu Code,you must SOILS FEE
Fkl IbMwith comply with such IF swons or this perlit shall be Jeemecimsoced. WATER SERVICE
d
Uz CONSem n.,raNLENDINGAGENCY NEW RLSIUEM'IAL PLhf SQ. PAID
V O l h)rchy0iIfe,hanbercisv issued
len ding agency for pr'rforzn;race of U:ne Rncip7a
4.C) Underk liar which rM1u pumri7 in inmcd(Scu.31007,Civ.C.)
Q Lender's Addr GTAL:
YV LcnJcr'x AJdrcns TOTAL
W1 certify that I have orad this application and ,at,that he voAc information is BUILDINGFEE
Z) amen.l agree to campy with all city and county ordinances and sure laws relating to QTY. MECHANICAL PERMIT FEE ^
V z building construction,and herebv authorize repm%entatives of this city to enter olam the SEISMIC FEE 4.
above liculinnM Property for inspection purpose. PERMIT ISSUANCE
(We)agree a mlen ac,indemnify and keep hanthe Ciy of Cupertino against ELECTRIC FEF.
Iiabilities,judgmentc,costs and expenses which may in any way acme against said City ANTER OR ADD TO MECII.
ntryisnlmmec of the granting ill this porn it PLUMBING FIiIi
�icANT iNUERS9'AN ANU ILL COMPLY WD'H A.L NON-POINT AIR HANDLING UNIT(TO IO.t1W CFM)
S R ERT /NATIONS !EIAID -
Will
AI.P"E
AIR HANDLING UNIT(OVER 10,000CEND TR TAX
g amm o(APPlica CORDO ate EXHAUST HOOD OV/DUC-) U IGATIONFE.E
HAZARDOUS MATERIALS DISCI. Sll
Will the.applicant or future building occupantstore or handle hvmrdore material HEATING UNIT(TO 100.1X10 BTU)
as defined by the Cupenino Menicipal Calc,Chapter 9.12,and the Health and Safety
Crile,Section 25532(x)? HEATING UNIT(OVER 100.11110 B I))
❑Ycs ❑No
VlifsTlLATIO,u FAN(SINGLE RLSID)the appliuun inforum building by the B y A ea Ate Qu)r Manan which 1}te Remt
mithumrdnm air ummminunu as Refined by the tiny Area Air Quality Munugwnevr IR)ILEH-COMI'(311Y OH II111,gN1li'fU)
District? 'e AI,:
E]Vies Fl No BOILER-COM P(OVBH IIX),IXX)HT'U)
I have mail the havanlmn numrind myulmnrcros under Chapter 0.95 of Ne Cmt- AIR CONDITIONER ISSUANCE DATE
bum.Health&SAO,Code Socriom 25505,25533 and 15534.1 understand that if the NI3\V RIISIDHN'1'IN.MECII, SQ.IT.
bss
uilding Jive nal mrrendy huvc a Ie.ant,the,itis my m\pordhibly m tardy rh):acupvnt
of the myuirermams which mart he mer,prior to issuance'if.Cmilicae of(kcupzncy.
Ooncrrn aadim ts]agent Date 'ILIAL:
ISSUED BY:
OFFICE