S 1490 AP.PLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE ITNO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING'MECHANICAL 1490
ItU1LUING PRWECT'IIIENI'IVIU !ON
BUILOINGADIIRPSS: SAN1'TARY NO, APPIACATIUN SU BMI9'I'AL DATE
8l
OWNS :SNAM ya I'ilUNl?: CO '1' ATT R:S M.fj; LIC NO'.
C7J NIC CONTROL#
. ARCHITECT/EN WEIR: LIC No ADD ❑
OC ^ ui .J•
CONTACT` PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT* 1'L`lC MECH
❑
LICENSED CON'TRACTOR'S DECLARATION QTY ELIiCFRIC PERMIT FEE
1 hereby amrnI mat I am ucensal under pnwloons.1 chapter 9(commeacros - JOB DESCRIPTION
M%z with S[nlon]IMMDof Division 3ofthe9nsines.end Professions Code,and lily license is RFSID NTIA
W O PERMIT ISSUANCE
1- in full functional ZO 0it—1Z ❑SPDWL ❑KITCHIiN REMODEL
Quu Lka Liao APPLIANCES-RCS ID17NI IAL ❑ADDITION E3 PLUMBING RE-PIPE
!- W Dae Came.,.,
ARCHITiiC1"S DECIARATI ❑MOUTI-UNIT ❑STRUCTURAL.
F.Nm Iundersland my plans shall hcowduspubliemconlsoz— PANELS MODIFICATION
Z Olin UP TO 200 AMPS El INTERIOR OCHIMNEY REPAIR
F`u7 Licensed Professiarml 201-IW0 AMPS IMPROVEMENT SWIMMING Po019
O BJ Illi "I BUILDER DECLARATION CouloON OVER "AMPS ❑BATA REM
WQ I hereby affirm that 1 am exempt from tM1a Commnnh Lieervce Law for the
iW504 u following reason(Section 7031.5,Business and Professions GMs:Any city or county SIGNS PidtCl'RICAI.
[]OTHER
u+3 W y which mquim,a permit to conswn,shaq improve,demolish,or repair any elrumure `
O.QIto to its issuance,also requires lue.pplicaut f.r oOh pennint filcadgned statement SPECIAL CIRCUIT/MISC.
y
but he is licensed par x..all ,,do.P.vieions of the Cenonctor's Livenst haw(Chapmr9
-400 (commencing with Sen ion 700o)(if Division Sof the Buri ns,and Professions Code)on 'FP,M R MCI Hot OR POLE INS1 COMMERCIAL:
6 40 that he is exempt therefrom and the basis for the alleged contusions Any violaion of ❑NEW BLDG/ADDITION ❑DEMOLITION
�w Section 00315 by any applicant for a permit subjects the applicant to a civil".I,y of POWER DEVICES El TENANT ❑FOOD SERVICE
= tot mom than five handl dalWrs(5500), SWIMMING POOL� IMPROVEMENT
Q ❑I,es owner nfthe propcny,onny empinyms with wages ns their solemnnpcaaution, []OTHERwHl dothe works.and lcltre is not incrdedoralrereJ formle(See 7044,Business
4 m heswand Professions Cede The Camel License Law does not apply to an owner of OUTLET S-SWITCHES-VISIT USES
property who builds or improves thereon,and who does such work himself or through
his own enmloyccs,provided tint such improvements um "intended or offered for NEW RUSiDETO IAL ELECT R SQ PT,
aid.If.hAr,,,,the building or improvement issold withinoneyear.f conal rho 19QAVXfy AREA LSQ.IT.
owner will have the burden of pricing that he did not build or improve for put. C //WW 1
posh of smc.}
❑ 6 as uwnar of the propeny,am excluslvcly enmrucung with IicensW commemrs to 'TOTAL: ���
eongmm the project(Ste.]044,Bruins.load Professions Clal the Combeeno',LL 9 ANS-0
Oenee Lowdoesam apply ton ownerofpmpenywhobuildsor impmvestherean,and R
MBING PERMIT FGE +
who comate¢dor such pool with a aommcmr(s)licensed pnrsuam to the Central
License law. L'RAffI'ISSUA TY Ur laurcn I Jill
❑1 am exempt under Sec. .B&1'C for dillmoon
LTE N&VE TER(MIt Of VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION ACK 1qA .CT.UI:
I herchy al maintain
nada penalty.[of Con tat of the folmwior dockers n,:
❑Ihave all([willfar by eCmi Certificate Coastal roCole,f Conoull of
RAINS-PLOD 1 'AHPA, Il. STORIES '1'YPIi CONSTRUCTION
` xs k r as provided for by Section 3]011 of @e Labor Code,fur the perrnmmnee of the
-11forrwhich will
annual
i,icor). IX'ILR65-PBR'TR -
❑1 halo and will maintain Worker's C'ompensaion Insurance,as mquireJ q Section
37")of the l.ahnr Calgtorthaperl.anancaafthe work for which tholarmlt is isnned, GAS-13A.SY5'f1:M-II '.al OUTLETS OCC GROUT' APN
MY WnrkypQ_ { I pneeq defy icy Ns:numb�sGt¢�'�� e��r'.
Cartier.C'9'6Y o /J{QSLin_ Policy
On her�n4.�JYW GAS-HA.SYSTEM-OVER 4(LA)
CERT'IFICA'TE OF EXEMPT ION FROM WORKERS' GItIiA51%INUUBTRL WAS'T17 d IN I'ERCEITOR
COMPENSATION INSURANCE BUILDING DIVISION Tis
1'Ibisseclion nerd not be cnmplated Him palmar is l'or m..candaddnllas(Sby) GREASETRAP
lir Its,.) PIANCIIItCK PI3C
I certify that in no PerformanceoOhc work for which thispermit is issued,l shall SEWER-SANI'T'ARY-STORM HA.2110 IT
not employ any person in any manner s.as to become.object m the Workers Compen- ENERGY FEM
O ,Z saian Lawxnf California.Doc WATER BEAT UR W/VENT/ELECfR GRADING FEE
Q Applicant
h
NOTICE TO APPLICANT:Under making this CeoBb,de of Exemption,you should WATER SYSTEMG`BEATING
I^ 5 hamate subject to the Workds Compensation Tractional the lahor Ctxle,you must SOILS ITE
WFa fnnbwith cmnplywithsuch prosisinourthopermit,hall bedeemed revoked. WATER SERVICE
Q
CONSTRUCTION AGENCY NEW RGSIDIiMf1A1,I'hMH. SQJrI'. PAID
U QThereby adiw that ievnmxlmnion lending agency[.lite Performance of Dat° ' #
the work fur which this pennil is issued(See.9119],Civ.CJ
0 Lender's Nae
U T
TOTAL:
Nauru
W I.cnAcrs Address T(l'TAL.
I certify that I have lied this application and state that the above informal is BUILDING 14]i
lin correct lagme In comply with all city mal courtynNirunces and state laws relating m QTY, MECHANICAL PERMIT FEE
Jia hnildingcnnact r..ion,nnd hereby mMorize rrprcsematives of this city Not upon the SEISMIC LEE
al
shave-mcmionetl propeny for mepectinn purpose`. PERMIT ISSUANCE
(We)agree 1.save,indemnify and Lecp banal...the City. Cupertino against
Cupagainst ELECTRIC PER
Iiabilities,judgmcnts,costs and expenses which mayor any way accrue against said City AIUHR OR/sOU To MIiC11.
omequence of e mnting of this permit PLUMBING FEE
mg
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POIN'T AIR HANDLING UNIT(TO ILON)CFM)
SOUR( :REGULATIONS. AIR MIiCI1ANICALIEE
OL �/�^� EXHAUNDLIN(i OVIDUCT)
IBdN10 CI M) CONS'INC.MAIN TAX
Signer pplianUConwctor / Omc R%HA W'I'H(IOU(W/DUCO
HAZARDOUS MATERIALS 1 SCLOSURE HOI151NO MITIGATION FEE
Will the applicam.,future buildingexcnpant store lir handle bar anlous material HEATI NG UNIT(TO I fMd(MMI TO TO)
as dedineA by the Cullens.hfunicipal Calc,Chapter 9.12,and the Health and Safny
Code,Sienna 25532(.)? HEATING UNIT(OVER)Oil BTU)
E)YO, ❑N. VENTILA'I'TON PAN SINGLE RES I D) PAID -
Date Rani?X
. Will the applicant or future building occupent use equipment or devices which
emit haoodous air conmmin.nt,as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100.000 IOU) TOTAL:
Ilislrict4
❑Yea El No BOILER-COMP(OVER 100.00013'1'U)
I have read the hazadoos materials requirements under Chapter 6,95 of the Calm AIR CONDITIONER ISSUANCE DATE
fomia Ileadh&Safety Cale,Sections 25505,25533 and 25534.1 undenmal that if dre NEW RUSIDEN]'IAL MECl1. SQ.FT.
of timemens%Inch bust be met p that o is dry ce of a b nificammifOccupaeupam
of the myuimmenu which must be tan prior m issuance ufu Ceniliemt of Occupancy.
Owncrorumhori,ed agent Data 'TOTAL I ISSUED BY:
OFFICE