S 1026 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECT'HICAL 26
Pr5ITN0 10
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J "L/�Y�J
BUILDING PROJEC;pIDNN'IIFICA'I'ION - L—
BUILDINGAUDRERS: - , SANITARY NO. APPLICATION SUItMI'I-IA1.DA'TI
3 G '! L�L)
OWNER'S NAMtT PHONE: CO. RACI'OR:S NAME: � LICNO: / NIC CONTHOI,p
•'ARCHITEC'VENGINEER: IdC NO: ADDRP_S d `Q ' �� r— ❑
CONTACc PHONE ILDING PERMIT INFO -
❑ Consultant Fees Paid by Applicant(Initial) BLDG EL,CT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECFRIC PERMIT FEE
I hereby alTreadual 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Section 7011 Division 3ofdhe Buxinesaend Professions Codolnd my license is RESIDENTIAL;
WOO ' ,`nC' PERMIT ISSUANCE KIT
Fut, infullfmce and trent s I Yeas/T'�� ❑SFDWL ❑PITMAN RE-PIPE
t-4 license Clax - Lc.tr •APPLIANCES-RESIDENT[AL ❑ADDITION ❑1'LUMNING RFI'IPE
F- u] Date J D r) T'SDECr
> ARCHITECTS DECLARATION El MULTI-UNIT [_1 STRUCTURAL
OZ�❑ I understand my plansshall heusedas uhllc records i PANELS MODIFICATION
UPT02(X)AMPS El INTERIOR DCHIMNEY REPAIR
WLicensed Pmfes.,used 201.1000AMPS IMPROVEMENT SWIMMING POOIS
s OWNHR.LUILDHR DECLARATION pyEH 1(XNIAMPS ❑BATH REMODEUREPAIk �DIiMO�ION
I hereby allinn tum I ant exempt from the Count.,ar'x License Law for,M1e ,/
iqC O G V following whom.(Section 7101.5,Bminevs and Profession,Code:Any ail,nr roomy SIGNS ELECT RICA], ❑OTHER !2 AY/1
W O F which requires a lerhtit m construct,ahem,improve,demolish,or repair any structure -
primmitsissuance.also nquires the upplicnnt tor.utch permit to rile a signed smmntee, SPECIAL CIRCUIT OMISC.
'j that he is licensed pursuant at the provisions of lha Contractor's license Law(Cloue,9
W ❑O (cemntencing with Section 7md0)of Di vision 3or the Business and PrnfexsinnxCode)of TRMP.ME'I'BIt OIi POI.HINSE COMMERCIAL:
d y M e' that he is exempt therctrnm and me basis for the alleged oxemptinn.Any violation of El NEW BLDG/ADDI'I[ON ElDEMOIA TION
la Section 7031,5 hymryapplonl lora permitxuhlecd lheappliem,to.civil penally of POWER DEVICES ❑TENANT FOOD SERVICE
y
- Pzhilt more than live hundred dulhux($5(N). IMPROVEMENT
tf I,vs owner of the propmy.nr my employees with wages av,hcinole n+mpensmion, - SWIMMING POOLELECIRIC
2 will(it) m
the work,and the sacherc is not intended or hRend for sale(See.7614,Business []OTHER
m and Profevsimn Code:The Camntetnr's L.iaenm Law docs not apply to an owner of OUTLETS-SWI'ICIiCS-PoX'1'L1RE5
g. — propeny who builds or improves demon,and who does such work himself or through
his own employees,provided that such intprove,nents art no,intended or offered for NEW RESIDENTIAL ELECT SQ FT.
sale.If,however the building Orimpoevemenl is sold within oneyem of completion,the SQ.FT.nAR AREA VSQ.17K
c mmehuilder will have the burden of proving that he did urn build or improve for per. -4 '
pose of a le.).
❑ I,as owner of the property,am exclusively contracting with licensed contractors m IOTA(" ^�
customer,the project(Sec.76D.llusiness and Pmfcsaions Cu-;),he Cnmmc.ors Li- {f
come Use does not apply to an owner of property who builds or improves Thereon,=it QTY. PLUMBING PE1'1' rFEE
whocommets formch projects with o commction0licehsW pursuannome Conmetols
License Law. PERMIT ISSUANCE.
❑1 am exempt under Sec. ,B&P C for this mason �"(•
&ALTER-DRAIN VIiNT-WATER THAT
Owner Dam yqN
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(JTECI'.DEVICEI hereby affirm under pemthy of perjury one of Ne following declarations:
I haveand will maintain aCenifataof Consentoself-insure for Workerscmemen- DRAINS-FLOOR,ROOF,AREA.COND, STORIES TYPE CONSTRUCT ION
smion,as provided feat by Section 371X1 of the Labor Code,for the performance of the
work far which this permit is issued. FIXTURES-PER TRAP f
❑ I have ono will maintain Worker's Compensation Imuraoor,as required by Section
37M ofthe LahnrCwle.for the performance of the work fnrwhich this penitis issued. GAS-EA.SYSTEM-1 INCA OUTLETS OCC.GROUP AI'N
My Workers laln_n{ c r er and Policy num to
Cartier: �yI-{yG'�f 9 policy No:(�1� aI`l-9� GAS-F.A.SYS'(FM-OVER 4IRA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRBASI➢INDUS'1'NI.WASTE IMI'IiRCIiP1'OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not he annpldmd if the permit is for one hundreddellum(S pan
'
or less.) GREASE TRAP PfANCHLCK PEE
o I certify had in the performance of the work fnrwhich this permit isiword,Ishall SEWER-SANITARY-STERM EA.200 FI'.
m4con,loymty pernm In nnynunmeroc as In become anhjccl To the Workers'Compen- L'NI3ROV PGB .
Z WKI'ER HEAL W/
NUT ICE APPLICANT',TL inter making This Cenlliam t f Exert , should VIiN'I'/I?LIiC'I'll
Q Applicnm n Jttrnm ma GRADING FEE
tom- suuon Laws o
y ,muds, hnn WA'R?N SYSI'I /I'HIiING SOILS FEE
beconic subject to The Worker's po Compcnr his pmvisihal of the Labor Cale,you must
11.1 fnnhwith comply with eni�h provisions user This penis shall he Jacmdi revoked WATER SERVICE ,
1 Q .
CONSTRUCTION iso onsi LHNDING AGENCY NEW RfSIDBNTIAI.PhMR. SQ.PC PAID
V � Ihenby elfin thin 0ercis'uconiTnetitn lending agency for the performance of Dale ReceiptN
the work for which this Fourth is issued(Sae.3097,Civ.C.)
D" F" Len 's Name TOT
O LU6I derLender's Addrcsv - TOTAL:
1 certify that I have mail this application and slate that The above intonation is BUILDING FEE
u!, cornet.l agree to comply with all city and county ordinances and state laws relatingto QTY, MECHANICAL PERMIT • FEE
I) Z building constaaion.and hereby authorize repnsenmtives of this ciry la sorer upon the [F10',1
SMIC FEC
Ikk
aMrve-mentioned property for inspection pmEvi PERMIT ISSUANCE?
(We)agree m rare,indemnify trod keep hatless the City of Cupertino again, CIBIC FEEhahiliums,judgtnems,costs and expenses which may in any way acme against said CitygLTF:R OR ADD TO MECH.in asequence of the granting mf this pandit MBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONGPOINT AIR HANDLING UNIT(TO 10.0X1(1 CPM)SOURCE REGULATIONS. I/ CHANICALS
'01J /Q•� AIR kIANDLINO UNH'(OVI3R 111,(XX)CPM) NSTRU ONTAX
Sr�gnaturc fApplicandCo me ITp]ate EXHAUST HOOD IW/DUCT) I HOUSING kTTIGATION FEE
HAZ XDOUS MATERIALS DISCLOSURE
Will The applicant or future building occupant stun or handle hazardous material HEATING UNIT(TO I of.do,B'ITH
ea defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(1)'! HEATING UNIT(OVER I0)(,000 BTI])
❑Yesn - VENTILATION PAN ISI NGLH REST DI PAID
Date ReceiptN
Will the applicants fulurchuilding oacupo,use equipment or devices which BOILER-COMP(311POR IfD,DXI ITU)
emit hazardous,air comarmanne s as defined by The Ray Area Air Quality Management TOT
District? BOILER-COME(OVER 1110,001 If'I HE
Yes
AIR CONDITIONIik
11hocrad,hellaza nus mmerinly regniraemx under Chaptu fi95 of,he Culi- ISSU CF.DAT I,
fntnia lTealth&Safery Cn •,Sccdunx 25505,25533 and 25534.I understand that if the NEW NILSIDI3NTIA1.MBCA. SQ.FI'. -
huILIIn6 Aoox nm nimntly rove a wnutli,Thal it ix my uesryasihilltym ooh y the oceupam
n1'TM1e rrqu' mend whiub nwst b purr o-1 ivnuunce nl'u Cen'inretfncc +
".act —xgen
o _OaIr TGl'AL: ISSUED BY:
OFFICE