S 0934 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERPINO BUILDING-ELECI'RICU- I11} 11TNO. O
934
BUILDING DIVISION APPLICATION/PF,RMIT PLUMBING-MECHANICAL l`�
BUILDING PROJECT IDENTIF'ICAT'ION
SANI'T'ARYNI APPLICAI'IIIN SCHM1II'II'AI,0AI 1,
BUILDINGADDRESS
10(01 �O
OWNERS NAME: PHONE CONTRACTORS NAME: LIC NO: NIC CONBOLh
AR T'.T/ENG E 1 LIC No ADDRESS: ❑
s� - N BUILDING PERMII'INPO
CONTACT: PHONE:
S►O'Z7j ❑ Consultant Fees Paid by Applicant(Initial) nLOc _FC1 PLUMII MECII
G {V
LICENSEDCONTRd code'9DECLARATION QTY2UPT02MAMPS
LECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm the 1 am licensed under provisions of Chapter 9(commencing RESIDENTIAL
0�ZO in fall BaccaBl1Bffect.visionJofthe Beninese and Professions cote,and my license is PERMITANCE —
C�F i full force and effect. ❑SPDWI, ❑KI'TCHCY REMOUI[I.
4UV Licenet,Claes I,I1.9 -RESIDFN'I'IAI- ❑ALOE'HON ❑PLUMBING RI I'1PI;
Fab Date Contractor
NN ARCHITECPS DECLARATION ❑MUI]'I-UNIT MOLIFIURN.
~a,I Z l understand my plans shall be used as public records MOUIPICATION
ZOZy� PS ❑INTIg�W{1OR ❑CHIMNEY R17PAIR
IMPl47V fE 'f C]SWIMMING POOLSW Licensed Prof...m d PS qq /w/OWNER-BUILDER DECLARATION MPg ❑ItA'lll RIiMODIiL'IRICPAIR ❑DIiM(lhIT10N
C < I thereby a0imt that 1 am exempt from the Contractor's License Law for the
xL g a V fallowing reason.(Scroll.7031.5.Basincss and Profe..an,Care:A,city o'county SIGNS ELECTRICAL
41+W
y� which peiconsumer. p demolish, p y a alum
0
prior t ': k 1 stn pplc of hPe n flsigned.t lament SPECIAL CIRCUIT/MISE.
'hat he [faconealt the provikituiv alth Contractor%L (Chapter 9
Wei p lmtmnammgwth Sat m7fNX0 of U'v'eonI cI the Busnvns,:d l roR"im.s Cock)... TEMP.ME p t OR POIIi INS'I'. � IINI
t1 al
cc
that he is exempt therefrom and the basis for the alleged exemption.Any violmion of ❑NIiW IfLDG [[)11111144tltl4`! ❑DIiMOLITION
W^m Saran 703I.5byanyapplleantfar.parom,,ubjatn the appliis macivil pea yof POWER DEVICES hNANF ❑FOODb-RVICH
not more than five hundred dollars($500). IMPROVEMENT
SD01.o.nwncrofthe progeny,army employees with wage%as their sole ntmpcnemian, SWIMMING POOL ELECTRIC ❑pl'111iR
N will do the work,and the structure is not intended or offered lir sale(Sec.7IH4,I{usincsx lU'CLC'r5-SwITGIIES-PIX'I'11RE5
W and Pmfcaions Care: 1'he Commans
Command License Low docs not apply n:aur nwnvr o
ell property who build,or in,pnrves themon,and who Joss such work himself or through NEW RESIDENTIAL CLIiCTR SQ 1'1'.
his own employees,Provided that such improvement.art not intended or u0cred for SQ.IT.FLOOR AREA SNQ.len
sale.IL however,the building or improvement is sold within one ycaaf complrion.lhe ■y/C/���
owner.milder will have the burden of proving mat he did not build or improve far par- V 'I'�
pasenfmJc,). 1OI'n1: V (�
[1 Lax owner sur he property,am exclae vcly a,mmcdng with liccmed cnntn et m
onstmet the project(Sea.9(W.Business and Profession.Cocc)The Contractor's Li-
censelos,ill.not apply to an owner of Property who builds or improve.,memo..and QTY. 1' 1 1 PERMIT FEE
who contracts for such projects with a cora ur000 licensed pursuant to the Communes
License Law. PERMIT IS. C'
l ath axe tender Sea ,13&P C 1'nr this reason
ALTER-DRAIN& "1' W 'LE VAI.UA'HON
n Dae �•
RKIiR'5 EOMI': SATION D[CLARATION tlACK FT.OW PROTECT'.UB IC 23 �
1 hereby alBrtn under pen 'jury one of the OJbsving declarations
I]I have and will mainmina Ceniricae,(Consentm self-insme for WnrkeGCompe.- DRAINS-FLOOR,ROOF.AREA.COND. STORMS 'TYPE CONSrRUGI HAD
scion,as provided for by Section 3]1X1 of the Labor Cure,limbs pc,A n vm,e mf the
work for IsInO this pennil is I...ed. H%TI1RIiS-I'IiR l'RAP
1 have and will maintain Workers Compensation Insurance,as required by Section
37MaloneWbor Ccue.(orlhe per(ammncenfmc work for which this permit is i.sued. GAS-EA.SYSTEM-1 INC.J OUTLETS OCC.GROUT' MINE
My Worker's Compensation Insurance carrier and Policy.umber arc: GAS-EA.SYSTENFOVER 4 WA)
Currier: Policy Na:
CURE'IFICAI'E OF E%EMPHON FROM WORKERS' GRF-ASEIINDUSTRI,WAS IN'FERCCPIOR
COMPENSATION INSURANCE
BUIL LING DI ISIIIN PEES
THtis annual need not he completed if the permit is Intent,hundred dollars($100) GREASE'I'RAP PLANCHECKI :I: 1 '
ar lass.)
Imniry Palin meanymannrsit the laccom subjectch to the ons issued,Copn-I shall SEWER-SAN]TARY-S'I(sRM EA.2(X1 Irl'. ENERGY FF.
nrn nnploy any peau.many manner at as m Become subject m the Workers L'ampen-
Oz rntimn l.tlwxmrcalirmrnla.nett, WATER w;n'mR wrwiNTna.lacrR cpnulry :E
O Applieam
z y NOTICE P1 APPLICANT If,ager making'hi.s Cerifieate of Exemption,You should WATER SYS'IoM?REKI'ING SOU-S 1'1:
a' became subjat to Inc Wekcrs Compensation pmvisinns of the lama Cela you must
r fnnhwimComply withench provisions or pemtit shu116e deemed revoked. WATER SERVICE
0] PAID
a
CONSTRUCTION LENDING AGENCY NEW RCSIDI?NTIAL PLMB, SQ.Irl'. Dm Rcccipt p
UQIhereby affirm that there is a conxwation lending mgcncy for the per0:mtance of
the work for which this permn is i...of(Sec.3097,Civ,C.) TOTAL:
01-' Umabex Name 'TOTAL:
U Lender's Addle, BUILDING EE
LLIa verify Pat I have mad his application and,,are dal the ab."imammdn.is
,-... rn correct.lattice a emaply with all city and county ordimmeex and state law.moaning W QTY, MECHANICAL PERMIT PEE SEISMIC 1 aE
U ,Z buildingennswcti.n,and hereby nuthmixurep.,cournsesmfthieclty u:emurupmm the
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE ELECTIE 'Plili
(Wt,)agree m save,indemnify and kap nay in an the y ac of Cupertino against
liabilities,judgmenos,nsw and expenses which may in my xuy acerae against said City METER OR ADD TO MECII. PLUAIBI .PEIi
in osequence of the granting of this permit.
APPLICANT'UNDEI S'T'ANDS AND 1,COMPLY WITH ALL NON-POINT AIR HANDLING UNI''(1010,000 CPM) MI;:HANICA I:IIE
SOURCE I':GULA' NS. 11
AIR HANDLING UNIT(OVER IB.HWCFM) CONSTRUCTIO TAX
SQA Date EXHAUST HOOD(W/DUCH E OGSING MITIGA'ION FEE
HAZARDOUS MnIERIALS OISCLOSURF-
defined
Will the apflleumnr fiuure hmillog occupant slnmarhundle hu'aurdou.nmterial HEAPING UNI'1'(TO I Narita)11 TU)
as by he Cupertino Municipal Code,Chapter 9.12,and he Hwlth and Safety HEATING UNIT(OVER 110.01X)BTU)
Ct-0c,S
arm
Core.
❑Nn VENTILATION FAN(SINGLE!RESID) PAID
Darn Receipt N
Will the nppi cantor future huilding aeeupatn me cquipmant or dcvlres which 1301LIiR-COMP(3HP OR 1110,1X10 BTU)
mit hoaashm,Bir cnntnminar,au defined by the Bay Arm Air Quality Mnnagemenl
Daniel! BOILER-COMP(OVER IOfIJMX)BTUI
Dyes Fl No
AIR CONDTI'IONER ISSUANC i DAIT
1 have reed the hazardous Bas 255 requirements under Chapter ota or me Cali-
fomiu,does ne Safely Cala,Satins 255115.25513 and 25514,I undeoumd that if the NEW RESIUIiNTIAL MECII, SQ,FC
huilding does net currenny have Icmnn.lbnl it is my rasq:nnlhility to notify the ns'.vpam
of he mquircments which must be mm prior Io issuance nl a Cenilicme nl'lkcupancy.
Owner or indicated agent Dae 'r OTAL: ISSUED BY:
OFFICE