S 1495APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
PliHTNO
-r
14 9 5
_ BUILDING PROJECT IDENTIFICATION '
v
Bl1LDING ADDRESS:
Z G� �,�-; ho of
SANT ANY NO
APPLICATION SUBMITTAL DATE
9 q�
UW BR'S NA HONE:C
O R'S N LIC O'.
QP 44#,4
N/
CONTROL of
CHITECT/ENGINEER'. LIC NO:
A ORES:'.
3
CONTACC PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
pl,Df; ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTR C'OR'S DECLARATION
)rarer from that l,m Teens d ruder f Chapter 9 Namtneaa
y a pmmuons n P s
wire Scame701l)n(D... aon3nfthe usmecsand Professions Cadauhtd myllmnseis
. iicene class ddfccl.
License Chhss Lia#
p Date ContractorAPPLIANCES
-' .1 11IX]J{`
QTY. e1.eCTRIGPERMIT �. FEE
JOB DESCRIPTION
RESIDENTIAL'
OSFDWL D KITCHEN REMODEL
El AUDI 'TION El PLUMBING RE -PIPE
DMULTI-UNIT El STRUCTURAL
MODIFICATION
PERMIT ISSUANCE
- RESIDENTIAL,
ARCHITECT'S DFCI,ARA'I'ION
1 undersmno any plans .hall be used a, public records
PANELS
a
'UPT0200AMI'$
D INTERIOR El CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑
❑BATA RG�'.Ld2EP!>I� D'DE.MOL TION
❑OTHER F =�\�
Licensed Professional201-IGROAMPS
Oat I ma cU ata fu DECLARATION
1 harcby .(firm onnt I 1 exempt from Ihn CemOamm's License Law for ay
fallowing rhes a (Station 9onst Business and prove. dssinnx Crile Any airy ovcounty
whleM1 requires a permit 1, con[Wd, viler, itnprnve, Aemrixh, or repair any xlmdule
OVER IOW AMPS
SIGNS ELECTRICAL
it pnnrm iu insuance. also rcyuires Wo upplicenl fnrnuch permiuo Ficia,edswtemenl
- floor lm is licensed purroanl to No provlslom of the Contractor v License Law (Chapter 9
SPECIAL CIRCUIT/MISC.
TEM P M E'1EhR OR POLE INST.COMMERCIALr
D NEW BLDG/ADDITION D DEMOLI'T'ION
❑TENANT El FOOD SERVICE
IMPROVEMENT
BOTHER
(corm ting with Section700(oof Di virion 3 Of the Businessland m
d Pfossuao or Code)
( that he is exempt lhemfrom and the basis for the alleged exemption. Any violation of
Station 9031.5 by any applicant for a permit subjects the applicant to a civil peemty of
net more Nan five hundred dol lnrs (S50 ).
[1 1, as Owmer Ofthe properly, or my employees with wages as theiranle compensation,
will smile werk,and We stn¢mreis nm mended oroBemd fatale (See, 9044, Business
POWER DEVICES
SWIMMINGPOOLELECTRIC
and Pmfexsians Code: The Contractors License Law does Out apply total owner of
OUTLETS -Sail I'CI LES- FIXTURES
pmpeny who builds or improver thereon, and who does such work himself or through
his own employees, provided that such Imprn ermal are not intended or oOmeA for
NEW RESIDENTIAL ELECrR SQ FE
-
sa1o, IL howevea the building or improamearl is sold within oneyarofurmplelion,the
SQ,FT.FIAORAREA $/SQ. 1,n
er4 uilder will have the burden of proving that ho did not hold or improve for par-
-
p xe of sevoc
a p
AW
with maxed i-
❑ I, as eweer Of the pmpeny, tem exdnsiand contractingss
/'9
nrtmdow
s
mshuat the project (Sec. 91144, Business and Professions G,IeJ The Contractor Li-
-
QTY, 'PLUMBING PERMIT f
cense Law doer not apply to an owner of property who nrilAx or improves thereon, and
who connaefr for such pr jects with a conWcmr(s) licensed pursuant to the Conmicuous
��� ��1(1-9
PBHMIT ISSUANCB
Lic,ocLow,
❑ I um exemps,title, Sue. ,B& P C for this inroad
• INS
ALTER - DRAIN & VENT -WATER EA)
BACK FLAW PROTECT. DEVICE.
ITY '-'� t`tul.' 6VAIDIMON
Owner Dola
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
DRAINS- FLOOR, ROOF.AREA, GOND.
I have and will maintain a Certificate of Consent to self round for Worker's Coupon-
union, as provided fur by Section 1700 o1 the Ichor Cade, for the performance of the
STORIES
TYPB CONSTRUCTION
FIXTURES - PER TRAP
work for which this permit is island
❑ 1 have and will moinkno Worker's Compamtio r ]a...once, as ed n eed by Suction
3700 of the Labor Code, for the performance .1 fir, work for which this pemut k o,aed.
My Worker's Cmnpensation Insurance carrier and Policy nnmlwr are:
GAS - EA.SYSTEM-I INC. 4 OUTLETS
DEC.
,
APN
Carrier: Policy Ni,:
GAS - EA. SYSTEM -OVER 4 (EA)
CERTIFICATE OP EXEMPTION FROM WORKERS
-
COMPENSATION INSURANCE
(The,oadionnced rellarompleted ifthe a,air is bourne handled dollars ($100)
or less.)
I mrtify'hot in the pcd5umrvoreceofmd work forwhich this ti -r issual, Lball
rat em iln n pc,ma
I Ya Ypers)�ri)tvnymvnner sh� beta �ti sl (Workcrs'Contpen-
of15L.fiiJvle
Applicant
and n 6 �`_�
GREASE/INDUSTRI, WASTE INTERCEPTOR❑!p`MG
(VISION m"I S A
h .:.�w. aj.
W
GREASETRAP -
PLANCHP.CK IrBE
SEWER SANITARY-S'IDRM EA. FT
ENERGY PEE
WATER HEATER WIVBNT/ELECPR
GRADING PEE
NOTICE
NOTICE TO AP. ICANdo, W.'.k If, I sunk h6 this Cenifale of Bx funa, yon a a,(
become subject'. the Workers Compensation providers of the near, Code, you mux)
WAFER SVS'PEMRREATINO
SOILS TBC
forthwith comply with web pmvirionr or this pennil shall he deemrd revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY'
I hereby moral that there is aconxtucllon lerningagency fertile perfamance Of
PAID '
Dem Rccalpl4
NEW RESIDENTIM:PLMB. SQ, EL
the wad for which this permit is i.... (Sec 3097, Crw. C.)
TOTAL:
Lender's Name
Lender's Address
I deftly that I have read Iho, application vnd ,tole Jim the above infmmatian is
TOTAL
E D '
QTY.- MECHANICAL PERMIT FEE .
'
freer. I nsree m ermply with tin city and county ominvnees and state laws rclat eh
building construction, and hereby aulhorire representativesofthiailyuh enlarapon lac
ahovememirneJ pmpeny [ inspection purpoxox.
(Wn).gree m cove, indemnify aril kcep harmless rile Cily of CupenlnO nguinsl
PERMIT ISSUANCE
Ehichm,y
invny way accrue nguin,'said City
wnsuryace of the granting of this permit.
ALTBR OR ADD"fO MECH.in
EEAPPLICA
SIANA
qIR HANUhING UNIT ('I'G 10,11(111 CPMJSOIJItC
INDBRSTANDS AND WILL COMPLY WITH ALL NON -POINT
ATIONS.
L FP.EAIR
HANDLING UNTP(OVER 10.000CPM)
ION TAX
Say core of Applican Imetor Date
HAZARDOUSMAT' 1 .CLOSURE
EXHAUST HOOD(W/DUCT)
HOUSINGMITIGATION PEE
HEATING UNIT (TO 100.000 B DO)
Will lnerppllcant origin, buildb am store ar handle heardemunienal
ns defired by the Cupertino Municipal Code, Chapter 932, end the Heath and Salary
Code, Semina 25532(a)p
HEATING UNIT (OVER 100,000 BTO)
[-1 yes No
VENTILATION FANS INGLE RES I II)
Will the a pplicvnl or Road building Occupant use equipment or devices which
til hazanfare or amlaminaru as definW by the Be, Ate. Air Quality Managemeat
PAID _.
Date Receipt #
BOILER -COMP OHP OR 100.000DTU)
ialicl,
TOTAL:
-
BOILER -COMP (OVER 100,0001FIL)
❑Yes - 0 N
-
AIR CONDITIONER
I have read the mountains al rials requirements 1 Chapter 6.95 If the Cali-
forma Health & Safety Code. Sections 25505 25531 and 2553. I understood proof the
building d oroarratlyh t am. that it is toy n11imehl'ty u
to mildly lheolpant
of the requircmenls which dust he mel prior in issuance of,, ClIirate of Oecuprncy.
ISSUANCE DATE
ISSUED BY.
NEW RF.SIDEN'1'IAL MECH. SQ. FT
on
Owner nr aulhzed agent Date
TOTAL:
OFFICE
2MI DL
ox
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