S0547 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMU ND.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 05471
BUILDING PR(3JF.CT IDF.N'1'IFTCATION
DILDING ADDRESS: SANIFARY NO. APPLICATION SUBMITIAL DATE
1093 LEASES L-1 p\ac G
y'ER'SNAME: PHONE: CONTRACTOR'S NAME: LIC NO:
r �q! r NIC CONTROLN
ARCHITECT/F,NGINEER 'tic NO: ADDRESS: ❑
CONTACT: PHONE, BUILDING PERMIT INFO
�,�, goo-yyo oi�l ❑ Consultant Fees Paid by Applicant(initial) Sr ?L"Y PLU❑tB OH
LICENSED CONTRACTORS DECLARATION QTY -ELECTRIC PERMIT FEE
I hereby fl Intl licensed w p ,Clap, )(entero tg _ J013 DESCRIPTION
Z of ufnnu.nJlvlTwl nnJoftheRunncssn.d Pr fit :C d. 1nyl.c�nc'rc RESIDENTIAL:
'{�ilp_ w- PERMIT ISSUANCE
F04 W F t. . 'DWI. ❑KI fCHLN REMODEL
QUU L,ecnsc Clans Lica APPLIANCES-RESIDENTIAL DITION El PLUMBING RE-PIPE
F-Z W Dmc Contactor
m66 ❑M .TI-UNI I" C1 STRUCTURAL
ARCHITECTS DECLARATION PANELS
~afZ 1 undcrswnd my plans shall M usM as puhlic rooms - CHIMNMODIFIGITION
OZ�, UP T0200 AMPS El INTERIOR ❑CHIMNEY REPAIR
F 4t:ad Licensed tindcsiowl 2DI-1000AMPS IMPROVEMENT E]SWIMMING POOLS
C x C Q' 1 hereby alfinn OWN am BUILDER DECLARATION
E he RATIoor'n Licenzc law for the OVER HIMAMPS ❑BATH RE:SIODELIREPAIR El DEMOLITION
XC)U following Paul(Section]0315.Business and Professions Cods:Any city or county SIGNS ELECTRICAL. ❑OTHER
W C,v which requites a permit m construct.alter,improve.demolish,or repair any strvnure
C,Q prior to its issuance,also requires the applicant for such permit n file a signed chroman SPECIAL CIRCU IT/M ISC.
thin he is licensed pursuant to provisions of the Central License Law(.......
C) (mmmencingwithSmtion 2000)nf Division3of the Business send Pndenniore Calelon TEMP METER OR POLEINST. MMFR
a 0.e W that he Is exempt therefrom and the basis far the alleged exemption.Any violrdio.of Cj
EW BLDG/AUDITION ❑UEh101,IT10N
W 9 vi Section 7031.5 by any applicant for a permit subjects the applicant ret a civil penalty of POWER DEVICES TENANT ❑FOOD SERVICE
Pill more than Eve hundred dollars 5504 IMPROVEMHNT'
gy=p 0 LnsnwmrufdPrm.Eeny,onnyemdoyeezwiNwngesP ffi rsnle Penn Pe anon, SWIMMING POOL ELECENIC
^m will dothe werk,and desnucturekn..,ntmndednrofoiedforsnle(See.7(A4,Ituxinesn ❑OTHER
L 3 rend Prafcxuionn Coda:'The CmErroo is Liemoa Law docs tun apply In tel owner rel' OUTLETS-SWUCHES-FIXTURES
preps rty whn huibL nr improves Iheram,and who dow such work hlmnclfur though
his own mnplayees,roomed that.ouch improvements are not in endedor offered for NEW RESIDES"TIAL ELEC'I'R SQ 1'1'.
,at,.Bt however,the huilding or improvement issold withinone yrarol me,ldinq the SQ.Irl'.FLOOR AREA $SQ.FI'.
oxecT.1milder will have the burden f proving th t he did not build or irproveto p - y
I :owner at the propfmym exclusively contracting wth licensed t to
mnam uM1 p (See 7044.Business d P fie.: s Cash:) C ti .Li-
cense lox does rudappymus mwho builds to imprint hemmn. ad
QT1MBING PERMITT FEE P H
who contracts for such projects with a conimnogs)licensed pursuant o the Connotoex
License Law. PERMIT IS CF
1: crop,under Sec. .B&P C for this Plain. ALTER-DRAIN -WA'1liR(ids) ALDATIOBrimN
Dae ✓w ;..r��
WORKER'S COMPENSATION DECLARATION BACK FLOW PR ICE CnI 'T\R pj(T11y1/
• v and will
maintain
ai under penahy of ofCoyone Uftheinfor for derkar's o
❑Ihavc.ndwill muimnina Certificate ofConzem mself-inxutn for Workers Cumpcn- URAIKS-FLOOR.ROOK. '.A,GOND. S'H)kIIS TYPECONSTHUCI'ION
sation,as Presided for by Section 37W(If the Lubar Cale.for the pedlmnmmc..f the
xork for which thin penin,is isued. FIXTURES-PER TRAP
I] 1 have and will muirmi.Worker's Cempeention n Insurance.a,required by Section -
3NXIoTI[in Lamer Cnde,[unM1c perfnrmnnecofthe work for which till, annn kv,aia . GAS-EA.SYSTEM-I INC.4 OU 111,S OCC.GREECE' AIN
My Worker..Congamo:tl..n Insurance carrier and Policy number an:
Carne[ Policy Nn: GAS-EA.SYSTEM-OVER 4(HA)
CliKOF1CALE OF EXEMPTION FROM WORKERS GREASFJINUl15TR1.WA$'1'131MI'I?HCI?I'I'OH
COMPENSATION INSURANCE; BUILDING DIVISION FEF-5/
fbissntinn need nm Menmpleted if the pemtil is Toone hnndreJ Anllnm[$lar, GREASETRAP
or lexsJ PLANCHECK FEE
ccni(y lhm in the per(..rmovcc oOhe work for whi.h,hispenni,i.ninsucJ,l.ahall SEWER-SANITARY-S'FORM FA.21X)FE
not cmon
ployany persmany manner...az to becomeu
wbjecntbc Wnrtons p
Comere- ENERGY LLE
,z sa,ion laws of California.Date WATER HEATER WNGNT/EI.ECIR
Z O Applicant t #M�E
G LEI?
NOTICE'PO APPLICANT:If,race making Nis Certificate of Exemption.you should WATER SYSTEMITREATING
? hamme,subject n the Wurkcr's Compensation provisions of the WMu Cale,you must E
forthwith comply with such provision, r,his permitshall be dcearmal cIoled. WATER SERVICE
= z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.('LMB. SQ.ET. Date Hcceipta
U O 1 hereby affirm that their is a construction lending agency'for the armarnanec of
G4 F ,he work for which chis permit la I...of(See.3197.Civ.C.)
Laval Name TOTAL
Lcndcr's Address TU I'A L:
1 candy that I have read this applicalmo and state rho the above io(orn ation in G FI?.
h
....u9.I agree m.o Illy with all city and county ambient...and state laws wahtGngm Q MECHANICAL PHRMIT FEE
V z buildingcnn.tructlnP.and hereby umherire representatives of thin city to enter ulxnt the PI?
Fr uhnvc1111al.tned property far Inspection fampexcz. PERMIT ISSUANCE
(Wc)ogre:to save,indemnify and keep Imrmlesn the City of Cupertino against IC I PH
List
Iiubilities,judginentn,costs and expenses which may in any way ucemcaguinnt said City ALTER OR ADD TO M ECI I. NG I':,
n,famca of the granting of the,p snot..
APPLICANT'UNDERSTANDS AND WILL COMPLY WLTH ALL NON.POINT AIR HANDLING ON IT LTO IIk1XX)CUM) ICA MI EISOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,110 CPht) UCI"ION'FANamantre of Applicunt/C..muchn Date EXHAUST HOOD(W/DUCD G MITIGATION ILL,
HAZARDOUS MATERIALS DISCLOSURE:
Win H r,aldicam nr furore building ofempamnonor handle hemmed,mamrial HEATING UNIT CTO 100.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Sec,im.25532(0'f HEATING UNIT(OVER 100,000 13 EU)
E)yes []No VENTILATION FAN(SINGLE RE.-SID) PAID pate HceciplN
e,a mit haeWill,he applicant or future building occupant use equipment or devices which BOILER-COMP CHP OR I(Xh1XX1 BTU)
ardous din esmouni ams as defined by the Bay Ano Air Quality Manom
geen, TOTAL:
Di,arim4 BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
Ihovercml lhehnz.ard.P,materials nPolisntemlender Chapwr 6,95..E the Cali- AIR CONDITIONER ISSUANCE DATE
tori.HeAh&Safety Come,Seeeions25505,25533 and 25534.1 understand that it(he NEW RESIDENTIAL,MECH. SQ.FI'.
building does not currently have a Icon,that it,,any nNeer,ihdity m many tlm rceapunt
of the requirements which must b,met prior to knuanee of a Certificate of O¢astray
Owner e,uuthmized agent Date TOTAL: ISSUED BY:
OFFICE