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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - IfLECERIOAL
BUILDING DIVISION APPIACATION/PERMIT PLUMRING MECHANICAL
BUILDING i'RojEc1 inE rriv'ICA'PItvs
PE MITNO.
2254
BUILDINGADDRESS:
10U� G7
SANITARY NO
APPLICATION SUBMITTAL DATE
/Z - - -4,
OWNER'SNAME: PHONE:
0 -
CON'I'It AC'I't)IRSNAME: �f LIC NO
2 S /.VA'1 rI*TaO �U1�3Z
N/C
❑
CONTROL#
Ij ARCIIITCCHENGINEIR, LI , -
ADDRESS'. _
coNTncT rt1GNE:
❑ Consultant Fees Paid by Applicant (Initial)
-- - .BUILDING PIiRMI'1'INPO
BLDG RLECI' PLl1MR ME❑CII
❑ ❑
LICENSED CONTRACTORS DE(11.ARATION
I hereby arrrm that I nth neewsaa anger nmvi.mn, of enamrr v aolnmenailtg
with Section 7000 of DM,mr 3 onha nuxinexs mat Proficoians cone, and my liana In
'n full force unJ Itl, O �3'�
Lianc CP. Lic.M
Dam � ^ Cnnvvepor W
QTy'
ELECTRIC PERMIT
_
f °EId ^'
JOB DFSCRIPTION
RESIDENTIAL:
RESIDENTIAL
[:j SFDWh ❑KI'fC1f IiN RF.h10U1i1.
GADDITION 0PLUMBING RA;
❑MUI:F6lJNll' OS'I'RUCI'URAI.
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVIIMENT SWIMMING POOLS
❑ BATH RI MODIi1JRHPAIR El DEMOLITION
❑OTT ICS
PER MIT ISSUANCE
APPLIANCES - RESIDF.N -AI.
ARCI11,1E,1 "S DECLARATION
i unaemm�J my plans Shull R usrJ ns pnhlic recoNs
PANELS
UP710200AMPS
Lteeosaa Pn,lceninnt
OWNEm exempt ltifr m the RATION
1 hereby .(Seth mm 1 am exempt from the Con....s C s a Ali, a Lbw for the
which nwi ngrunnn.lsa t 9onstr t. aiiensmprovel derradx Codc:Anyuity nrccture
which reyuircs a permit re conswm, pplic improve, h permit t or e a sir n d structure
that "i, ha"smcenlxin require thcappliis o f .Col pen LBlcasigaw,(Chemem
mm he Is Iiaersal Sectionollw of D..inns ofthe C'nntnmsedd Prue Law,Cosh)r)
that is exempt Section 76(g)) and of Dlvlfor thealeged examptin. Any vi Cosh) ar
that he is exempt thmefmm and the bass for the alleged ecmppinn. Any violation of
Seetim: 7011.5 by any upplirl nt for u permit inflects the appliemn to a civil penalty of
not mare Wnn Eva hundred dollnrn W N0.
❑ I, vsownerofinepmpengonnyempmy eeswilhwagc >asmeiranlccatnlwmation.
will do me wad, aria th- hol"no n rim irtonaed... o fared lit sole (Sce.7044, Bnarl
and 11 froiann Cale: The Contractors Licial I.aw does rim apply to rot owner of
property who builds or improves thereon. and who does such work himself or though
his own employees, provided that such improvcmenls arc urn awarded m uttered fur
sale. If. however. the huildingori:nprovcannot ix xok! within one Until complctimt,Nc
wricobuilder will have the burden of proving that he did not Wild or imp toa for par
pone It sale).
❑ L ns owner of the pmpeny. unr exelmivcly contmdid, with deviled conrucmn m
construct the project (Sec. 7M4, Business and 1'nd'essions Qxle:)'Ihe Contractors Li-
xe Low daa, m apply manownerofpropeny who huildenr improve, Nadon,and
who umaads l'or such p lads with u commdnrts)lirensml p.,,at nophe Commdor's
License law.
❑IUm exempt under Sec. , H & P C units reason
201.1000AMPS
OVER 1000AMPS
SIGNS RLEC'IItICAI.
SPECIAL CIRCUIT /M1115C.
_
�l-
'LEMI'. METiiIi OR POLE INtil'.
COMMERCIAL:
NEW IILDG /ADDITION ❑ IIGMCl1.ITION
I3NANT [:1,0017) SERVICE
eMIiN "1'
0
POWER DEVICES
SWIM M [NO 11001, ELECTRIC
OUT LETS - SWITCHES - FIX 'ILRE5
NEW RESIDENTIAL ELECTR SQ ET.
Pf. F1J3DR AREA
$ISQ. PI'.
TGI'AL:
QTY PI. UMBINGPERMIT
FEE.
PERMIT ISSUANCE
A13FR- DIdAIN &VENT -WATER U!A)
Owner Dote
VALUATION
' )
p
o k
WORKERS COMPENSATION DECLARATION
I heeby u0nn unJar punuliy ofpurury one of the following AccLlmdno:
❑ Have and will maintain aCeniicateofComarllosell imareRt Workds Camper-
anion, os provided for by Section 3000 of the Lml Code, Poe the offornamce of the
rk I'orwhich p hisper:nh is i s xd.
bill) have and will maintain Workers Cmnpcnci ion Insurance. is required by Section
37mlaf Nelnbm Calc. fa Ili pwrfomtm cofthe work for which this permit is issued
My Workp y�p�y ty�) �qyl rand policy :lyl hyr)ps _ Q
CarriesC _txfl KGIU U Danrr Policy No:uj k��fn17I01L
CERI'UICATE of EXEMPHON FROM WORKERS'
COM III iNSKI'ION I NS If BASE: [I
(Thu-,tion need rim ba mmplaed ilNc permit is future hundred dollury IS I IN0
orlms.)_
IccnilyAm, in the pcdontanccol'Ihcwotk lbr such this,init islwed, l shall
not employ any person in any manner n h t m Worker,' Compcn-
sarinn Laws o CallsI' .Dam 7 6_ a
Applicum U
NICK FLOW PROTECT. DEVICE
DRAINS - FLOOR, ROORAREA, Ct ,fh�\�1111
pp p1�
/ /lt
II �t STORIES
'IYPi?CONSTRl1CT10N
FIX'I '11121;5- PI!It'I'I<AI'
I I'_,
GAS- I[A.SYSTEM- IINC4OUTLEFS
[D
021993.
OCC.GR(IUY
APN
GAS - FA. SYSTEM OVER 4 HIA)
GREASE/I NDUSTR1. —A TE LATER FITOR-
' (� Ii I-
11 lylaal S BUILDING DIVISION FRIS
GRI:ASL 1kAl' Yf1FrI
F TIN-
YLANCHIiCKFEIi
SHWlilt- SANI'T'ARY- S' I' ARM EA. 200 PI'.
ENERGY ITE
WATER HEATER WNIiNT /EI -ECI'R
q
p Q
GRADING PT:E
N(TI'10E'10 APPLICANT: IL niier making this CeniEcme of Exemption, you should
becone subject to the Workers Cmnpensmion provision of the Labor Cmic, you moot
f..l1wiffir Fly will xmhprnvininnsur dais permit mall he deall"d revoked,
CONSTRUCTION LENDINGAOENCY
I herehyaffmtlhattherci nnconsaction lending agency for 'he l art'oddroo, of
the wort: for which Its permit is issued (Sec. 3007. Civ. C.)
Lender's Name
WATER SYSTI3M/IREATING
S01LS FEE
WA'IIiR SERVICE
PAID
NEW RESIDENTIAL PLMN. SQ. FT.
Da - Receipts
n T(YFAL:
Lenders Addrres
Tt
BUILDING FEE
I reni fy that 1 have road Ili, application Etna sale mat Im above iwformaaan is
sect. I agree to comply with all city and county ordmunces and saa paws relating to
haddlm eonmation,Ind hcrehy math ... reprernarive-anfthixcitymmn'r upon the
unovomenllumd p,,i,,Iy fair inpatient purpascx'
(We) agree to sae ,indemnify and keep hamdeA the City of Cupertino against
l inhilifle,judgnenlx , a Is anJcnprnscs whichuc, unary woyaccmmtgaidd id Chy
in uto,ill of grit g' "'pa'"
AYI'LICANI'U' li NI AND 1' WITH ALL NON -POINT
SOURCE AT S. O
1��45� 1
- t
01 y. MECHANICAI. PERMIT
FEE
SEISMIC FEE
PERMIT ISSIIANCI!
ELECTRIC FEE
At,] 1711 OR ADD TO MICH.
PLUMBING PEIi
AIR HANDLING UNIT H' 010,000 CFM)
MIiCHANICAI. FIIi
AIR I ONDLING UNI'I'(OVER Ik(NOC1SH
CIINSTItUCT1ON TAX
Signore of AppbcanUGnt r Dam
HAZARDOUS MATERIALS DISCLOSURE!
VOINheupplicom m nurc mildingtecupmnemmor Imudie hamolom malerial
as defined by the Cupertino Municipal Cade, Chopper 9.12, and the Heyhh rind Sakty
Cn I,. Seek.... 25532u)'I
❑Yes Fl No
Wn the air cortm Ur ind, a defines b, he u,ac ea Air ar Maas which
emit hnreninns air contnminanrs as defined by the Ray Area Air Qualify Munagemcnt
DianwtI
❑Yes ❑NO
I have read pile haramors mmena, requirements under Chapter 695 of the Cali-
IbminIludth & Sal 'nyCore. Sanwa, 25505, 25533 and 25534. 11 demand that HI It,
building dossnmcunemdybaveammod,thvt it is my mi,sal it It, notify the aecapan
of the requirements which amt fee met In to issuance alt CertiO<me n[(kxvpvncy.
EXHAUSTHOODONMUCH
HOUSING MT' I'IGNI ION FEE
HEARR ING UNIT ('10100.0H) If HE
FIHNI'INC, ONE r (OVER 100,III1) It ED)
PAID
-
VEIL UNZ'ION FAN (SINGLE RESIDE
Dam Rcccipt 4
BOILRR -COMP (7111) OR IIHI,I71N1 B'TU)
^
BOILER --COMP (OVER llkl,IXq 9TH)
AIR CONDII'ION17R
ISSUANCE DATE
(7JI 9
121—
ISSUED lit':
NEW RHSiIAHN'I[At, MECH. SQ.Ff.
TOTAL:
Owner ar mandated agent Dam
OFFICE