S 2105 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PI: 11 NO.
BUILDING DIVISION APPLICATIONIPF,RMIT PLUMBING-MEC,HAaNICAL 2105
BUILDING PROJECT IDEN'T'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'I'I'AL DAT[
ICb?a� u.�;A►Jz->� moi.-vt� -/ � ��
O EyILI-N'S NAMIi: � THONG: CONTRACI Olt:ti NAME. LIC NO:
�'�if1�TI1A-�97 N/C CONTROLIf
-ARCH[TECUENCINEER: LIC NO: ADDRB..: ❑ i7 1
�� G-ZznB "JIl S�1V)51 ST.
CONTACT: PHONE: BUILDING PE IT INFO _
-ffrs-se'��-�- ❑ Consultant Fees Paid by Applied.,(Initial) 11Lr ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTYELECTRIC PERMIT FEIi
I hereby affirm that 1 not bw orroander protisiobs of China, r.Rummencing JOB DESCRIPTION
M�Z with Section Division 3 afthe Businessland Profesvi cCode, dmylicense,.s �� t�T RESIDENTIAL
WO, wa PERMITISSUANCE JN/
b Z in full Tutee ani '. �L/L,.{ ❑SFDWI. ❑KITCHEN REMODEL
�U u) License Clnsn Lic.p=xL1 /�1 APPLIANCES-RES1DEN-HAL ❑ADDITION ❑PLUMBING RE-PIPE
Z(y Date - Conrado (j���'(
I•n6y � ❑MULTI-UNIT ❑STRUCTURAL
7,� RCHITT:CI-S DEC[ A ION PANELS
Zpm"' landes""m fit plans sM1all sed us a orals MODIFICATION
OZ`4 UPT0200AMPS ❑INTERIOR ❑CHIMNI: REPAIR
F4 201-I'N0AMPS IMPROVEMENT C]SWIMMING POOLS
iYgd OWNER-BUILDER DECLARM ION OVER Ors)AMPS
❑BATH REMODEUREPAIR C]DEMOLITION
hereby uEmn Ill.,I um exempt from the Contracmh License Law for the
U Billowing taxon.(Sethi 731.5,Business and Pmdessii Cale:Any city or county SIGNS ELECTRICAL OTHER
41 W LL y which requires a permit to construct,alter,improve,demolish,or repair any shallow
; primloitsi....needs.reyuirex theupplicvrn for such permit,,Filesign,J stmnnen' SPECIAL CIRCUIT/MISC,
f p. that he is licensed pursuant it)the provisions ofthe Commclm's License Law(Chapter 9
W X00 (commencing with Section 71010 of Division 3 of the Business and Professions Code)or I EMP.MET ER OR PULE INST. COMMERCIAL:
d p, IY 'hot ho is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑Ol?MOLITION
W m Section'/OJ L5 by any applicant fill. .,.t subjects the apPlimmit a a civil penalty of POWER DEVICIS TENANT ❑FOOD SERVICE
t more than rive hundred dollars($500) EMENT
SSC ❑ 1,us owner of the progeny.fir my employees with wagesaztheir sole compensation, SWIMMING POOLE 'C'1'RIC
F- will Jo'he work,and 0esuudureknot irdcnd,cmal'fcredfnrnole(Soe.x1144.Emile,
W3 m and Professions Code:The Contractors License,Law does not apply m an owner of UUTL1iT5-SWIT IES IX'1'URES / )
progeny who builds fir improve,daemon,and who does.such work him ulr or through
his own employees,provided that such metalemends am not intended or offered for NEW RESIDFN l ECPR SQ IT.
sale.If.however.the building or improvement is sold within one year of completion,the FT. NAREA 5/SQ.IT.
wnarboadc,will have the burden of Noting that he did not huild er improve for Nur.
pas,of sale).
❑ has owner of the property am escluaively contracting with licensed earma:lon to AL:
construct the project(Sec.0044.Business and Pofesions Cale:j The—a—tors Li-
nseLawdoesnmupplymanownerofpropertywpmhadd.m improvoidoncon,and Q'TY. PLUMBING P. IT FEE
who contracts for such projects with a commdnr(s)licensed pursuant the Contractors [
re law. PI7RMIT ISSUANCE .-J-0
❑lame It under Sec. .B&PCfotbis re'
ALTI:R-DRAIN&VENT'-WATER(EA) VALUATION
Ow
WOR OMPF.NSATION DECI. ATION BACK F10W 1'ItOI'IiC I.DEVICE nn
Ihereby nundcrpcnalty ofperjuryone nfthe alhowingdecl:uminre: � Q V
❑Ihave ni'J will muinminaCrnificme of Con.aenl to ulf-invure for Wnrkcr'x Compen- DRAINS-PLOOC ROOP.AREA,GOND. STOR ?S TYPE CONSTRUC IOt
I" sudor,as provided for by Section 37X1 of do Labor Crnto,for the po fotmanee of the
work for which this permit is issued FIX'1'URF_S-PER IRAP
❑ Ihave unJ will maintain Work npensa'ina Insurable,as required by Section
PIXl of the Labor Code T p ace of the work for which this pemait is issued. GAS-EA.SYSTEM-1 INC,4OU'I'LETS OCCC P APN
.My Wo "�v..plctcd
olicy number arc:
CurtiNw: GAS-EA.SYSTEM OVER 4(EA)
:RTIFIROM WORKERS GREASEINDUSTRLWASTE INTERCEPTOR
RANCE B ILDING DNISION FEIS
phis ac tion madmit is Tatar hundred drllun(S Nd GREASETRAP
or less.) PLANC E .li / 2 Z
I cenif fie.,ionic pedandemsedfam work forwhich this pem'it is i...ed,[,hall SF.WER-SANITARY-STORM EA.20FT.
not employ any person in any manner se as in become subject fit alio Worker.'Cumpem a "R Q
Z saline Lawsof Cuhfnum.Dam WATER HEATER W/VENT/ELECfR GRAD FEE
•7 0 Applicant -
t"-1- NOTICE TO APPLICANT:If,after making this Cenificam of ExemOILS Exemption, a.should WATER SYSTENUTREATING SI iE
E~ Mcome subject to the Worker's Compensation prussic ns of the Lxbm Code,ymr n.,1
fonhwithcamply all such povitinnsur this penni'shall be deemed revoked WATER SERVICE
0
7z CONS'I'RUCTION LENDING AGE NEW RESIDF.NTIALPhMB, SQ.FC PAID Date Receiptp
U O / IherebyalFrm not there'- mgagency for the perfu fire or
work for I ($e ) Civ.
r LeeapUr,
nAN TOTAL: r7o
Wdrsd
T A O
I certify Nm 1 have rcaJ IM1is application and sole that the aMn nBamamirn is BUILDING I'1?E e U
F" IIIc roc'.I agree to comply with all city and carry om,.nances and.ante rows relining m F
QTY. MECHANICAL PERMIT
U7
G building cons0uc'Ion,and hereby nutherine representatives oftles city to enter upxm the '
aline-mentioned property for inspemon purposes. PERMITISSUANCE EI 'E
(We)ngree la sane,iudeannify anal keep bunnless the City of Cupertino against 6
Iiahilities,juJgments.mmsand expenses which may in any wvy vccmc ugainm wid City ALTER OR ADD TO MECH. PLUMBING FEE
in omicni ace of inegrant,.ng of his pemtil.
APPLICANT UNDERSTANDS AN -OMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO IBUCFA) WAIN , .E 4 It 70
SOURCE III ATI, .7
AIR HANDLING UNIT(OVEN I(I,BIXI CFM) CONST RUCTION TAX
ag .anmactnr Dat EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATGRIAI S DISCL ORE
Will the applicant or fuauu building ocmnpan'mom ler handle foliations material HEATING UNIT(T0100.000 BTU)
a.dc,Sv by the Cupertino Municipal Cute,Chapter 9.12,and IM1e Health and Safety
as de Sed by the Cupet `amu,mi HEATING UNIT(OVEN IIN),(p0 BTU)
C]Yes VhNTILATION PAN(SINOhE RESIDp ` s PAID s? ateReceipt#C
Will the applicant ar Fumrc building wcupam are cquipmcm or device,which BOILER-COMP(JHI'OR lflo,(XX)BTU qp
+� emit haraNnus air commninrnn iso de tied by the Buy Area Air Quality Management TOYAL: 119
J
Dion"1 BOILER-COMP IOVHR 1'0,01X)BTID
❑Yes
I huvetead 0eha,adous mmedals myuirements under Chvperb95 of We Call- AIR CONDI'1'IONIiR > ISSUANCE DATE.
kronor Iieal la&Safety Code,Secdons 25505,25533 mad 25534.1 melmo mil that!fill, NL'W RESUMNI'IAL MECH. SQ.IT.
building does not causally have a tenant,that it is my responsibility to dolly the accident T
m be mel n n issuance of a Cedar,1 11 ev -' cupnnc
' t rN TOTAL: 7. � ISSUFD11V�e' -
OFFICE