S 1072APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
CITY OF CUPERTINO BUILDING - NI.ECTRICAL
BUILDING DIVISION APPLICATIONMERMIT UTUSIIHNC- MECHANICAL
BUILDING PROJECT' IDENTIFICATION
PISI I'NO. '7
J 1�
BUILDING ADDRESSOWNER'S
4
AP PLICATION SUBMITTAL. LAIF
NAMME :' VHUNIi:
(� I r
CON 1RACIORS NAME :
'
ISANI
CON'I'It01.#
ARCHITECT/I ?NGINEIiR: I,IC N(]:
ADURESS, .f� .
14 59
CONTACT. PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INTO
RLOG el. icT' 14511 MUCH
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LICENSED CONTRACTORS DECLARATION
1 hereby affimt that 1 um licensed made, p . rf Chapter 9 enmm g
with Section 9010) of Division 3 t fthe IL s mes s' d Professions Cod, and my fce tsv a
in full force and cho V LDi
Liccnsc Class �� 1 D Lich `�s�I f
rannr��
Date w- 4.1TECT
QTy
�� ELECTRIC II RM I'I' r i, +I''t�PBE
_
JOB DESCRIPTION
RTSI DFNTIAL'
❑STOWL ❑KI'I'CIIEN IIEMODIiI.
ADDITION E] PLUMBING RE- 1'11'8
❑M111.TbU NI 'P [I STRUCTURAL
MODIPICA'fiON
❑INTERIOR 12 CHIMNEY REPAIR
IMPROVEMENT ED SWIMMING POOLS
❑ BATH REM ^ODF.IJRIiPA1R DEMOLITION
❑OTIIF.R
rr
PI IIMI'1 ISSIIANCI
_
AI'PLIANCLS— ReSIDENI'IAL.
1 jCI S
A 41T'P,CPS DECLARATION tti((.�
��
I understand my plans sM1all be used as public recnN. —� '
Licensed Professinnul
OWNER- RUILDER DECLARATION
I herchy all lose then I nth exempt from the Comrocmr'c License Law for the
following requires Sa�dnt IDnstru Business and improve, ce +lose Coca: AnY city orcnnnty
which ts lemad f construct, - p doermb repair any wcutre
pr t tissuance, n1 9 stn nppl tf such permit file tmemcnt
-
PANELS
Oil TO 20B AMPS
2(11 -1100 AMPS
�s
OVER IOW AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUI'I' /MISC.
X0C
m ..y
=oat
SSG
tai!
that he is I clawal puldion(a, the ponveremovot th c f to " License Law (Coop....
(commencing with Section](XXB of Division 3ofthe Business and Prof..ioo Cede)or
that he is exempt thcrcliom and the basis for the alleged exemption. Any vinlabou of
Sect 70315 byiny applicut far a permi(inh,iec,s the a,bland in. Old pnimil of
mom than Five hundred dollars (SS(XB.
I, ac owner of the progeny, nr my nuglnyees with wages as their sole ntmpeman n,
to ll du the work. and the sbunum is Ideactenduloribbred for sale[Sec`?=4 whmas
and Profexsions Gds: The Conavemr's License law does mat apply ,, me net of
protein, who builds or improves thereon, and who does such work himself or through
his own emglayees, provide,] that such Itop rovmnems are am intended or offered let
m1c.If. howeverJhe building or improvement is sold within one yearofcompledon ,the
COMMERCIAL
❑ NEW BLDG /ADD' ON ❑ DEMOLITION
ED TENANT ED FOOD SERVICE
IMP V' 1
❑OT '
TEMP. MB I' ER OR POLE INS' I�
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS— SWI'ICIIES — FIXTURES
NEW RESIDENTIAL ELEC'IR SQ Ff.
SQ. hI'. I +IAOI{AREA
S /SQL FI'.
owner - builder will have the lotden of proving that he did not build or improve for pur-
'L'O'YAL:
ryve ofsole.).
1, ns owner of the progeny, am exclusively command, with licensed contactors Io
construct th project (Sce. 90OJ Business and Pmfiessions Cod) The Contractor's Li-
contuse ].use d not apply t n fproperty h builds r 1 lame W
who contracts [ .suchprjeas with acc)n ctrt(s)bcenvedp tt the Cma coma
License Law.
I,i I �Y
V
OCT 24 R���
QTY. t t;, 'r PLUMBING,kMMITJ ,)
t -rEE'
f 1 EMIT ISSUANCI.
I am cxnnpl amity Sal . It & P C as thin rnnon
_
Owner Date
ALTER — DRAIN &VENT— WAIHROiA)
Pff Ut- UUrEffJJN 10N
WORKER'S COM PENSA'HON DIiCI.ARATION
I herchy affimt under panalyofpenury one of the topmost, deelimtions:
BACK PLOW PRMECT. DEVICE
.❑
STORIES
TYPE CONSTRIICI'IOR
e and will maintain a Certificate of Consnuosch- insure for Worker's Counter-
I liv e
sation. as,roMi l Ibr by Seution 3701 of the Labor Coda fnr the pc bjeelacc of the
work for which this permit is issued.
DRAINS — FLOOR, ROOF, AREA, COND
ITS LURBS — PERT RAP
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
9701 of the la i,Code,I,or the perfonuanceof the work fnr whichthis g dood, rslssucd.
CAS —EA. SYSTEM -I INC. 4091 IAUfS
OCC, GROUT'
AI'N
My Workers Compensation Insurance carrier rand Policy nomncr ate:
Comer Policy No.:
GAS —EA. SYSTEM -OVEN 4 (EA)
GItF.ASIJINUUS'I'RI. WAS 'Ui1Nl'ENCEI "I'OR.
CERUFiCA'I Ii OF EXEMPT ION FROM WOR KERS'
COMPENSATION INSURANCE
BUILDING DIVISION PEES
This section need not be completed ifthe permit is forone hundreddollars (5100)
or Ices.)
GREASRTRAP
PLANCHF.CK IEB
SEWER — SANITARY —STORM RA. 200 F1'.
ENERGY FIJI
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I certify that in the pertnrramd.ofthe work far which this permit is issued, [shall
not crude, any person in any manner so.s to Mtmic su njem ur floe WnrAmv Cooper-
satins Laws of Cad �g.. 1) 11 �,L — -
Applicant G 0
WATER IWATER W /VEN'UELECfR
GRADING Irlili
NOTICE TO APPLICANT': If, she, making this Cenihc.4; , mYR` rtum. you should
hnenmesubjem m the Workers Compensation prawkiuns of the Labor Cod, you Iona-
forthwith comply with such provisions. this permit shot] be decmeJrevoked.
CONSere is a'IONue;ior OA agency
k far nor that there isaed(See mmlendm agency for the performance of
the work fnr whim this permit is :slued (Sec. LN], Civ. C.7
Lender's Nume
WATER SYSTENE'l REATING
SOILS FEE
WATER SERVICE
PALO
NEW RESNENTIN,PLMR, SQ. FY.
❑an. hu t#
TOTAL:
I'OFAL:
Lender's Address
is
BUILDING FE
1 certify that 1 have read this application and state that the aMVe information
currccf.I.gon, Io contp1, with all city and enttntyoudinucesotd state In. relatingm
building construction. and hereby aothmize represenwtive% of this city '()enter upan'he
QTY. MECHANICAL PERMIT -Ito
PEE''
SEISMICFE
1117RMIT ISSUANCE
ELIiCI RIC E
'—'
olnwe- mentioned property for inspection purposes.
(Wc) agree m save, I donna fy and keep harmless the City of Colsomm, against
liabilities, judgments, cnets unit expenses which may i a any way accme against said City
Aconsequence of the gaming S this permit.
UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
ALTER OR ADD'1'OMECH. .
PLUMBING III[
AIR HANDLING UNIT ('1010,OW CFM)
MECHANICAL .E
SOURCE REGULATIQNS.
SOURCE
-
AIR HANDLING UNIT (OVER 10.(KKICFM)
CONS'f RUM H NTAX
,O ry1
Signature �fApplubmC ^te
EXHAUST H000 IW/DUC'1')
HOUSING MTIGA'OON ITH
HAZARDOUS MATERIALS DISCLOSURE
Will the upplimnt nr l imam buildmlal,drean sure or handle hteanlnas awtadid
os definW by the Cupertino Municipal CoJq Chapter 9.12, and the Health and Safety
Code, Section 25592(.)9
HEATING UNIT (10 IIXLWfI BTU)
ORATING UNIT (OVER 101,000 BTU)
VENTIhA'PION FAN (SINGLE RIiSID)'
❑Yr, ❑Nn
-
PAID
Dote ccigf#
-
Will the applicant or future building occupant use equipment or devices which
t hmrar]nus air nmtaminamts as defined by the Buy Area Air Quality Maregentom
BOILER —COMIC OHP OR 10X.(00 BTU)
TOTAL:
Diarict9
E3 Yet ❑No
BOILHII— COMP(OVER 811,00 BTU)
AIRCONDITIONER
re p
Ihuve read the M1emrdous ntuleriWSre 's under Cha ter (�YS nI'Ibe Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FI'.
forma & Safety Cade, and 25514.1 understand thin Rise
2s
m notify occupant
that o is my tespon unity t
ea aclea ,that i
g Ands not currency have a,
gdoes my
al
bed p CenIy bo
of the nquircmen's which must Mmat priormiasuanee nloCenlficoc nl'(NCUpuney.
the
.
., ,TOTAL:
ISSUED BY: t
Owners, outhrei"I agem -. Doc
OFFICE