S 0180 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull ELECT RICA]. P1§UI'No, 0
1
80
BUII,DING DIVISION APPLICATIONFPERMIT PLuhnunc.MECHANICAL
P1§
BUILDING PR(IJF,C-1IDENITIPICATION
2 BUILDING ADDRP_SS: / Lv� ' 1/�& e SANITARY ND. APPLICAI'EON SUBMITTAL DATI?
V 9Sr /V al lea /�/ 200
WNIiR:S AM::^ I' UNE: C(IN fNACfOR' AMI;� L�LV2 oy
As /1 Ei `Y Sof NIC CON'I Nf11.M
0000
nNCHITECT/ENGINEIiH: LIC NO: Al)DNBSS:ilwinw dl,_ yGf LZ ❑
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICEIN12)CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 herol affirm the I mo)flcenrcd under Pr000laos of m
Chapter 9(comencing
O®Z with baccandel o�7 til llv'Iv�n'��+t+.I++hlhc Rosiness and Prufc.dnnx C+Xlc.and myliccnec Lr ElspimNTIAI:
W O I.1iRMIT ISS UANCIi
F�1� in full force and cr _/ n ❑SIT)W I. ❑KI'fC1113N REMODEL
V hittrrse a Lic.a 2a
Q U AYPLIANCCS-HBSIDEN'TIAL []ADDITION ❑1'LUMI3ING RE-PIPIT
F Z W pore lonarmourON
Nab' ARCHITECTS DECIANATIDN ❑MULTI-UNIT []STRUCTURALZ O E2 Z I Aad,,tmnl my plain shell thatied as Public records PANELS MODIFICATION
OZ-0 UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Limmued Prefesioted 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
�Y J OWNERBUILDER DECLARATION OVER["AMPS ❑BATH RHMODEL/HEPAIR ❑DEMOLITION
6 1 hereby affirm that 1 um exempt from the Comradnr's License Law fir the
X O L U following reawn.(Section 7131.5,Im,inesn and Prdensions Caxle:Any city or nm^D SIGNS BLECI RICAL ❑(YI'llliR
I1J 3 4.y
which requires a permit to construct, ❑ p dicir...id,unc,louncy
srucmrc
0�' pre I t '.. requiresth ppl tf such ut 11 asigned.taomenl SPECIAL CIRCUIT/MIST.
} (hath licensed pursuant t theprovisions Of the Contractors L lu (Chapter4 AMMFIA�
1+1=00 (commencng with Section](XXBolDi,mon 3 ofthe Busituss and Profs.:ion,Codel 01 TEMP.METER OR POLE INST.
e.a c W that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION [:1 DIlMOLITION
XIm Section?031.5 by any applicant for a Permit subjects the applicant m a civil Penalty of POWER DEVICE- El TENANT ❑Fool)SERVICE
WE more than fee hundred dollms Won,, IMPROVEMENT
=Q i]I,a%owner ofthe proamys or my employees with wages as their Note compensation. SWIMMING POOL I?LEC RIC
n• will do the work,and the structure is not intended or offered forsale(See.]Oa4,Business ❑OTHIik
W 3 m and Professions Code:The Comm ou'%License law,d+mx not apply to an owner of OUTLETS-SWITCHHS-lq% URES �1
property who builds or Improves Ihuxurn,and who does tach work himself nr through
his own em to w%,Provided That such improvements are nor intended nr offered for NEW RESIDENTI h ?L' 'I'R SQ Irl'.
P Y SQ.FU FLUOR AREA SISQ.FT.
talc.if,however,the building or improvement is sold didiaonelldofcompletion,the
weer-builder will have the harden of proving the he did nrI buil)or improve forpur- p
pnm of tA
ode.). TOTAL: P 1 1)
1,as Owner of the propeny,am exclusively contracting with licensed cnnlmmurs m
construct the project(Sec.]DW,Business and Professions GNeq the Cmonfr urs wase Law draf not apply in an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE JUN 20 REC
who contracts for such projects with a conerforo s)livered pursuant to the Contractors
hicen%c Law. ,R&P C int this reason PERMIT ISSUANCIi
I am exempt under Sec.
ALTER-DRAIN&VIiN'I'-WA ;R 1net '(
Ilam
WORKER'S COMPENSATION DECI.AHA1lON RACK PLOW I'ROTGC'I'.DEVICE
ne'
I hereby affirm under Penally of pe jury one of the following declu mations:
I have and will maintain aCenificateof Concnl mself-insure fffWorkers Compcm DRAINS-FLOORROORAREA.COND' ST(IRIES 'TYPIC CONSTRUCTION
satins.as provided for by Section 3]f10 of the IaMr Code.for the performance of the
work for which his permit is issued. Fl%TURFS-PER TRAP
i]I have and Will maintain Worker's Compensation Insurance.an required by Section
3700 of the Labor Come.for the performance of the work for which this permit is issued, GAS-EA.SYSTCM.I INC.4 OUTLCLS OCC.GROUP AYN
My Weak c' C�g1my� turn Insurancer and Dric pmpy /J
Cuoim, Y!/r!/7- G)4nT/J'sic Policy No.: C�Jt a GAS-EA.SYSTfiM OVI3R4ff?Al
CERTIPI PTION FROM WORKI?RS' GREASIUINDUS"TRI.WASTE:BUT CF,I'TOR
C(lMPUNSAI'ION INSURANCIi ❑UILUING DIVISION ITL'IiS
(This sectionmerd nm he cnmPlowd ifthe permit is Boom,hundred dollars($100) GRBASETRAP
PLANCIiHCK P131i
ties,)
I condytnat in lhepafomeneeofthe work foramen this pcmrit v,ixsaed.Taball SEWER-SANITARY-S'F(IRM BA.20(1 FT.
ern employ any person in any manner so as to bu0me mhjm um IM1e Workers' ENIiHGY FIA:
Co.,.-o.
Z edm laws of California.Dore WATER HEATER W/OI?NT/ELECTR GRADING ITI?
z O Applocam
NOTICE TO APPLICANT:If,after making this Crnifmale of Exemption,you should WATER SYSTI?M/TRhAI'ING
.Nn SOLI ti Fi:li
I-� Femmeh comply
the Worker's imon,Or this scord,dual of the %nod Code,You mora
PXs � li+nhwilh mmplY witlm.eueh PnrvirinnX or this permit shall be Aecrnel revoked. WATER SERVICE?
11 Q
d
CONSTRUCTION LENDING AGENCY NEW RE5IDENTIAI,I'LMH, SV Pal PAID
I hereby affirm that is a construction lending agency for the ponformarecof Dee Receipta
WQ
H the work for which this permit is issued(See 3090.Civ.C.)Iendds Name 'EOTN.:
'HTfAI,:
L1 lenders Address
�s BUILDING PEI?
G I verify that I have mad this application and.nate that the slave information is
.F. ZE crear l aamm comply with all city and county ordinances and state laws elating to QTY. MECHANICAL PERMIT FEE SEISKIRC ITT:
L.) Z building construction,and hereby authorize representative%of this city to enter upon the
show-mentioned properly lot inspection Purposes. PERMIT ISSUANCE! ILLLCI'RIC N:IC
(We)ogre m save indcnmify red keep harmlllCXa the City or Cupertino)against
ImhdBRasJudgmenss,.osis and exPrn.%ex which maylnany any accee it'od City ALTI?R OR ADD TO MUCH. I'LUMIBNG FIiE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT'(TO in"CFM) MCCIIANICAL FEE:.
SOURCE REGULATIONS.
6A
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCI'lON TA%
, go) uecofApplican✓Comreemr Date B%HAUSTflOOD(WXUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant or handle havardous mmedal 111iATING UNITTO I1Xk(XXI NIU)
ns dclmod by the Cupctoinn Municipal Code,Chapter 9.12 rind the Health and Safety
Coro.Suction 2553208,! HCEAI'ING ONE'1'((EVER 100,0XXI BTU)
0 Yes 0 N VI?NTILATION FAN(SI NGLH RESIDE PAID
Date Rmcipla
Will rhe applicant or fours,building Occupant use cquipmem of devices which BOILER-COME'(3111'OR 10.000 BTU)
it hazardous air conomiports m defied by the Bay Area Air Quality Managemm�t '1'UI'AL:
craft
BOILER-COMP(OVBN IM."BTU)
❑Yes ON.
I have read the hvenlous material resimmumn,under Chapter 6.95 d bre Cali- AIR CONDITIONI?R ISSUANCT DATE
foie Health&Sufcty Cdc,Sections 25505,25533 and 25534.1 modemand the If the NEW RF,SIDENTIAL MHCH. SQ.Pal
of the
doe nor cuwhwh mw o tens EuvO-1,try nr.ptI a Co by m ramify lhexarpum
of the myairemm�d which muslMmel Pnnrmlananse nl'u Cenilicnlc o[Ocsvpmcy.
Owner or authonzd agent Date TOTAL: ISSUEDBY:
OFFICE
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••AR above sign desigm B art works art belmg,o SIGNS EXPRESS MFG.CO., Any duplication is prohibited.�r AI.L:RIGHT RESER D."
momCXPR—" nme co. Scale : Noted Drawn by : • ,
EXPREM Date : 5-21-97 Drawing ai
2446 Munn Atnt,sor111�MONTE,cs 91733
ns-063a333 • 810-44340u(Fax) APPROVED BY :
STATE!1G 1852097 • LLL AWKWID/4119586
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**Ali above sign designs&art works aro belong to SIGNS EXPRESS NIPG.CO., Any duplication is prohibited ALL RIGH•r RESFRVED.'•
Y 10885 N. WOLFE BLVD. CUPERTINO _
1 Cxmrai mi:c Scale Noted Drawn g : • '
Date : 6-7-97 Drawing#
8446 MERGED AVE.,SOUTH EL MONTE,CA 91733
818-443-3333 ' 818-443.1615(FAX) APPROVED BY :
U STATE LIC.#552097 ' U.L.APPROVED#E-119586