31460APPLICANTTO FILL IN INFORMATION WITHIMRED LINES ,USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
ECHANICA
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-ML.
P17RMIT NO. 31460 � � � O
BUII.DING PROJECT' IDENTLFICA'1'LON
UILDINGADDRI'SS: -
SANITARYNO.
APPLICAIIONSSUBM`I�TTALLDAT(
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WNER'. NAMIi: 1' I�IiONE:
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❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLpG ELE PLIJ MECII ,
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LICENSED CONTRACTORS DECLARATION
I hereby orf that I am licensed under It..mm�s tar Chipre, 9 Icommercing
with Section 90001 of Division 3of the Business and Pmfea,ioms Cole,; dmyllan,e is
in full fess and eBal.
Live Cl.a Lie. st 10
is-Comrcm
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL,
El
❑ FOWL O PLUMBIKITCHENREMODEL
❑PLUMBING RE-PIPE.
PERMIT ISSUANCE
APPLIANCES-RESIDENTIAL.
D
Z
O O
IARCHITEC'1"S DECLA A ON
I understand my plans .hall rte used as public re caths
-
MULTI-UNIT'. ❑S9'RUCTURAL
MODIFICATION
RIOR ❑CHIMNEY REPAIR
IMPROVEMENT
El REMODEUREPAIR ,O DEMOLITION
A
❑OTHER Ise
PANELS
UPT02MAMPS
Y 6 •.1
pd, 06 U
W a QI F
liveried prnfes,ionnl
OW NER-BUILrt m DECLARATION
I hereby affirm Nat I em exempt marine Communes License Law for the
following reason. (Section ](1115. Business and Ihrfessinre Code: Any city cora county
which requires a .+cro it to ennxuu t. alter improve, Jemah,JE, or repair any structure,
ptrion its ' c uo y 1rc f uch ram n fl Btl mmumalt
hat sedp d, to the prowimmomflimCommuter', License law(Chapter 9
- .201.1000AMPS _
OVlik 10(10 Ah1P5
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC -
9'I:MP. METER OR POI EINS'C
_
x
y,ANIIW BLDG/A DLL141N ❑ DEMOLITION
! -"V
❑TBNrtNT ❑FOOD SERVICE
IMPROV6MFj(i FIJI
❑OTHEk Y4,
a y a
YXI 4th•
y
C❑lots
(vrammamacing withhe❑ ]10) odDivNion 3 oftheH: d Prolimsinin,
"C
Neth t a pt there.. fd N cook f 0- Ikgcl ext pt Any violation of
onoxf
Section 7031.5 by any applicant for a Perot subjects the applicant a civil Penalty of
t more than five hundred dollar; S500d.
uwnermf the property, or my employees with wage., as their Role compensation,-
will du Ne work, enJ theswaum is not intended mattered mrsab, Sea. 70,fL, Business
and Professions Code. The Corttmnnrs License Law does not apply to an owner of
property w[m build, rr impnwas meram, and who dors Ruch work himself rte Wealth
his own employees, provided that such improvements are not intended mr mend for
POWEk DEVICES
SWIMMING POOL EI.HCTRIC ' ,-
OUTLETS-SWfICH1S-FIXTURES
'NEW RESIDENTIAL ELECfk SQ Ff.
sale. IL howcvee the building of improvement is anldwithln one year ofcompletion, the
owner-Id b II have the n f vthat he did no build r cop for para
owe ole) .,
-
SQ. FT. FLCO)R AREA
'
$/SQ. PT.
F11. as f thepropertyexclusively
l t slel y contracting with 1 c nod contratior, to
�i(1{�.Y-,�1{1u�[
construct the parda,l (Sec, 9044 Business and Professions CW ) The C tract rs Li
mr,oc Law does not applyt or properly who builds or improves daterear, and
who contracts for Ruch projects auto committees) licensed pursuant to the Contmeers
^
4O
QTY PLUMBING PERMITjMA) PEE
PERMIT ISSUANCE
License law.^
E3.1 am exempt under Sec. B & P C fronds rtason
-
ALTER —DRAIN & VENT— WATER .
0❑
Owner Date
VALUATION
031 ^
WORKER'S COMPENSATION DECLARATION
1 hcruhY uffnn anger penalty of perjury one of the following declarmionx
L have and will mainmin a Cenificam of Consent to self-insum for Workers Compen-
satin, oas provided for by Section 3000 of the Labor Code, for the performance of the
BACK FLOW PRODUCE DEVICE
DRAINS— FLOOR, ROOF. AREA. D,
STORIEC
YPE CONSTRUCTION
FIXTURES—PER TRAP
'
work for which this permit is issued
❑ 1 have and will maintain Worker's Compensation Imarunce, as reyulred by Section
37W of the Labor Cede, for the performance of the work for which this permit isssucd.
n
My Wor d Com smion m,$r RanPolicy n arc: n
GAS-EA.SYSTEM-I INC.
(>CC.GROUP
APN
GAS—EA. SYSTEM-OVE )
artier:%'/LaLpf�licy Nn.: //7/"/
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CENT( CIDIR OF E IiMPTION FROM WORKERS'
COMPEn,leae ONINSURANCE
(This sevtion need not he vomplatedlf the pcm,it is fonmo hundred dollars (SIM)
or less.) �� � -
I certify that in the performance of Newark for which this permit is issued, Ishall
not employ any person in any manner an an a become subject to Ne Workers' Compen-
Ration laws of California. Dam -
Applicant
GRESF/INDUSTRI. WASTE INT C�
B IL I 'DIVISION FEES
-GREASETRAP
'
PLANCIiBC
I %
SEWER — SANITARY — STORM EA. 200 FT. �'1V_
ENEROYFF rt
WATER HEA'I'Ek WIVF.NTIF.LECTRoss
GRAD G
ff
NOTICE TO APPLICANT,If. after making this Certificate n( Exemption, you should
become subject to the Worker's Compensation provisions of the Luber Code, you must
forthwith comply comply with such provisions or this permit shall he demand revoked.
CONSTRUCTION LENDING AGENCY -
lhereby affrnn that hem is a enmtruction landing agency for the l,eRomnnnm of.
the work for which this permit is issued (Sec. 3097, Civ. C,)
Lenders Name
WATER S YSTEM`FUEATING
SOI
WATER SERVICE '
PAID
D a - Receipt of
NEW RESIDENTIAL. PLM,. ,. SQ. FT.
'
TOTAL:
Lender, Address
1 certify that 1 have read this application and state but 1ne above information is
carted. l agree to comply withal) city and county ordinances and state laws delmingto
building conawction. end hereby auNonixe reprcsenmtiver of thiscirymemer uMm Ne
in save fndemnifyan keephR.
nhrvo-(We) agree
(We) agree to Rave, indemnify and keep hasmlesR the City of Cuputinu against
p
BUILDINGEE 11`
QTy, MECHANICAL PERMIT PEE
SEISMIC
EIPC71i1C PEE
PBRMITISSUANC13
ALTER ORADD TO MECH,
'
Iiabilitiea,judgments, costs and expenses which may in any way acerae against said City
I. consequence of the griming of,hi, permit ,.
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SWR R 'ULATIO
PLUMBING FEE g
AIR' HANDLING UNITOG 10,000 CFM)
- - -
MECHANICALPRESO
AIR HANDLING UNIT (OVER IO,(InO CFM)
'
j1�
CONSTRUCTIONTAX Sit
Sngwturco(ApphcenVCo wnmr�(, 'pare
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD OVIDUCT)
HOUSING MITIGATION FE
HEATING UNIT ITo100,000 BTU)
Will the applicant or tion building ocemp;mt xm, or handle loccommanumdm
,
-
as defined by the Cupertino Municipal Code, Chapter 9.12, enJ the Health enJ Safety'
Code. Section 25532(x)?,
HEATING UNIT (OVER Withal BTU)
• ❑Yes F1 No
VENTILATION FANS I NGLE RBS ID)
��IRaicYr
Will me airIemntorfumre building niche HayseiAir Qualitnt (it y
. nit hazamnus air conmminunts as d<fined by the Nay Arca Air Quality Manegemem
Mage ant
❑Yes �Nm � •
PAID
',Dam Receipt
BOILER- COMP 3HP OR 1011000 BTU
( )
T TAL:
..
BOILER-COMP(OVIIR 100.000BTU) '
AIR CONDITIONER
I have read the hazallous materials requirements under Chapter 6.95 afthe Cali-
fnrriib Health &Safety Code, Sec,ion, 25505, 25593 enJ 25530, 1 undersmmd,lou, if the
building does not currently have at emo that it is my rcspansibihly m nmify the mcupant
ofNe"mocments which ma,, be met labor to issuance of. Cm,ificam of Occupancy.
ISSUANCE DA
ISSUED BY:
NIiW RESIDIiNT1AL MECH. SQ. IT.
Owner or ruthonzed ager, - Date +.
_ t
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OFFICE