29323- ° APPLICANTTO FILL IN INFORMATION WITHIN RED. LINES'- USE, BALL POINT PEN ONLY -
'CITY OFCCPERTINO - BUILDING '-RLECTRICAL '"
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- MECHANICAL'
- BUILDING PROJECT IDENTIFICATION
PERMIT NO. -`
fJ #� ,
G L
BUILDING ADDRESS: •
SANITARY NO.
1 APPLICATION SUBMITTAL DATE
Z Z 90 8 A41 V clus,r
Z�6
OWNER'S NAME:. PHONE:
,^ I -
CONTRACTORS NAM& LIC NO:.
NIC
. • CONTROL N- „
RT/ENGIN'LIC NO:
CHITECN E
ADDRESS: ..
❑a ,
-
CONTACT. - .'v exorvE:
-
?.-BUILDING PERMIT !NPO
'
❑'CoI15U1tenbFees Paid by AppliCaBt (Initial)
BLDG ELECT PLO B MECH
Da'Z
4100
FWH
„O'yU'yU
NQ y
Fl>y>
Z O M ❑
OZ.y. l7
- LICENSED CONTRACTORS DECLARATION-
" I hereby affirm that 1 licensed undo p f Chapter 9 (commencing
with 9 t a 700(acdDif,micar 9 of the Easiness and Professmn,C de seen, live se's
I :
I. force and eBeft ` QyoiO
License Class S 'Lie#
Da1c _ _ Contractor +
.. ARCHII ECTS DECLARATION
I d rand my pl m shall be used as publicrecords
.,
QTY. ELECTRIC PERMIT FEE
_
^ r.
JOB DESCRIPTION
} RESIDENTIAL: '-
-
❑SFpWl, ❑K CHEN REMODEL
❑ADDITION { UMBING REPIPE
-
El ��S UCTURAL .�
�' MODIFICATION
❑INTERIOR t ^' El CHIMNEY REPAIR
IMPROVEMENT. •.' -
- 'I
PER MIT ISSUANCE
APPLIANCES -RESIDENTIAL-
PANELS. - It,
UPT62MAMPS .-s -
Licensed Pf coral - -
201-1000AMPS' s'is,
Liy506U
a
OWNER BUILDER DECLARATION
I hereby affirm that 1 am exempt f th C t t r License La for the
following reason(Section 70315, Business and Professions Cad Anycity orcountySIGNS
❑BATH REMODEUREPAIR DEMOLITION. '
❑OTHER
OVER 1000 AMPS.
ELECTRICAL
tR W y
�Pnort
�Nhe'.
War6
G ❑ O
c
PP�� �
q d0
which magaire, a permit to entworth alterimprove, demolish, nr repair any drocwre
t ce I. q th PPI 1f hpmitl IIsignedrtment
1 tl p v 1h p f N C t 1. L' L (Ch pier 9
(hots ,mngwrthhere ]00(1) 03 fthdorf '' .Cdc)or
that he exert pt therefrom d IM1ebasis f theIle exemption. e p1 Any tion of
is
r l pennitY nr
Sect on 9Ua1 5 by any appl d t for a permu. objects the appl t t cis
not more ohne fivehundred d 11 my employees
the property, onnyempindes with wages rth sole compensation, Business
wiLothe owner work, i. t A144 Bu.i ass
dothewons and thesw furot
SPECIAL CIRCUI'T/MISC.
�•
_
TEMP METER OR POLE INS
".' .
COMMERCIAL
NEW BLDG/ADDITION; ❑ DEMOLITION
❑ `
[]TENANT .r El FOOD SERVICE
IMPROVEMENT
❑OTHER
-
POWER DEVICES
- ..
SWIMMING POOL BLOC
ale
CTB
bender awdoffered
and Code Theo nnthel License Lawdoesnotreply slf ownerof
apply
andProfessionswho
who bndds onmproves thereon, and who does such work himself oared
OUTLETS - SWITCHES -FIXTURES
_
'
property
for
his own emplayees, provided that such improv sold wiure not intended ro cleared for
sale. If, however the building or imp rovemeot is sold within oneyear ofwmpletinn,the
owner -builder will have the burden of proving that he did not build or 'mprove far Our-'
Fire, came.).
, ''
contractors
E)1 of the property am exclusivelycontracting with licensed ed c 1.
censw,m proicat(Sa 9044. Runde.. and Pref. C—.., inCotrctorLi
came Law does not apply to an owner of pronsiny who builds r improves thenpon, and
who contraats nonsuch protectswith. contrat qe) bcensed pursuant io the Cemruner's
.NEW RESIDENTIAL ELBC'TR SQ FT.
^
O
s,SQ. PI'. FLOOR AREA,,
" 4-L
$ISQ.FT.
-
-
TOTAL.
QTY PLUMBING PERMIT - FEE
-
PERMG'ISSUANCE
y,
License Law as - -
I .m exempt under S c. . B & P C for thi, r anon
Lit
... - �1��/
--
Owner
ALTER - DRAIN & VENT - WATER (FA) r
VALUATION"
WORKER'SCOMPENSATIONDECLARATION
%+ I hereby affirm under penalty of Fcrjury one of the following daclararmne
BACK FLOW PROTECT DEVICE
-
DRAINS- FLOOR, ROOF, AREA, COND:'n
❑ I have and will maintain a Certificate ofComenno self -insure for Worker's Camper -
shim es proof vided far by Section 3700 of the Labor Code, far the performance the
,
a s .sued. '
P Irma i i
work have
STORIES
e
TYPE CONSTRUCTION
-
FIXTURES -PER TRAP /�
"
and ill Workers Insurance, required by Section
❑ I have end will
ante ofthew which
Libor Code,&ntbrumanrmanceaftbewlic for
Code
GAS-EA.SYSTBM-j INC.40UTLET_5
rOCC.GROUP
APN
• �
number@ispnmitieissual.
M,Wathe
My Worker's Compensution Insurance Cartier and Policy member are:
Cartiee "' Policy No.: -
GAS - EA. SYSTEM- OVER 4(HA)
CERTIFICATE OFEXEMPTION FROM WORKERS'
^ COMPENSATION INSURANCE
(Tti tion need not be completed if the pemdt is for one hundred dollars ($100)
orle)
- -
GREASEIINDUS'IRL WASTE INTERCEPTOR
-
"
-
ct-6UILDING DIVISION FEES-
'CREASE TRAP
PLANCHECK FEE.
SEWER -SANITARY -STORM EA. 200 IT.
^•
%.
q I
(-'
II it thm "n thpf fth-workr which the pardso-o' oedlehall
not employ any Person any manner sir as to becnmesubjecn_ th Workers Compen-
whom Law, M California Dom -C
Applicant
ENERGY FEE
WATER HEATER WNBNTNEf?CTR 4
GRADING PEE '
NOTICE TO APPLICANT If, after inikintiddiCertificate ofExemption yen Imild
beempa, object to Ne W ka, s Coal, 1 poiskims. of the Liber Code you ma,t
WATER SYSTEM/TREATINC
' °
SOILS PER
WATERSERVICE
flail
U O
LA
U0
i F.y
U
forth iN comply,with such Pmvisinns or this permit ,heli be deemed revoked
CONSTRUCTION LENDING AGENCY
I hereby affirm that thereaconswetion lending agency forth, performance of
the work for which this permit is issued (Sae.309], Civ. C.)x
Leaders Name ,
Lend r nae
PAID ..Dote Receipt# a
NEW RCSIUEN'f1AL PLMB. - SQ. FT.
- W
"p TOL:TA
,.
-
TO
v I tarify that I have read this appl Calmar and manedin the b f rmat m is
emea t I agree to comply withd] city adcounly ordinances andmate laws retire, 1.
building cwnshacbon, and hereby authorize representatives orthsety to enterupon the
QTY, MECHANICAL PERMIT, PEE,-
BUILDING FEE
SEISMIC FEE'S
PERMIT ISSUANCE
ELECTRIC PILL
t
above-mentimed property for inspection Purposes.,
We a msave, indemnlf dkee harmless the CII fCu i t
( ) gree yon p y o Fcr mo....ca
ALTERORADDTOMECH.'
o
h.bil'fe.jdgmems, thatsmal u.,drises which may navy wayinear.gaint said Cily
o equencc of the g t g f this perm t
PLUMBING FEC :q r
AIR HANDLING UNIT (TO 1Q000CFM)
- -
,MECHANICAL FEE
.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI, NONdPOINT
SOURCE REGULATIONS,'.
AIR HANDLING UNIT (OVF.R10,agCFM),
CONSTRUCTION TAX
5L
ee
o pplicanpCor ami ..Dam
' HAZARDOUS MAI'ERI ISCLOSURE
EXHAUST HOOD(W/DUC)
HOUSING MITIGATION FEE .--
.-Sight
�' HEATINGUNIT(TO 100,01011TU).
^
'
Will theopplichnlor fume building recdantstoreorhandle hazardous material
. I d
'
m defined by the Cupertino Municipal Cale, Chapter 912, and the Heabh.nd Safery
Cole, Section 25532(a)?
E] yes ❑N ^' b
Will d aipplica t future building occupant use equ pment or devices which
emit hazardous
e ard.r ebnti n Loomis as defined by the Bay Area All Quality Management
_
District? (]No, e'i .
_
HEATING UNIT (OVER I00,000 BTU)
PAID ' ' -
Data - Receipt #
VENTILATION FAN (SINGLE REBID)
BOILER - COMP dHP OR 100,00!1 BTU)
TOTAL:
BOILER - COME(OVER 104%000BT0).r i,t t
,
+ AIR CONDITIONER
'7'
I have read the hazardous materials regahemenb under Chapter 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL: MECIL' ' SQ PP.
fomra Health & Safety Code, ' S i 25505 25533 and 25534.1 understand that if the
building does r d inumatly have. Wharf, that it is my ren orerbd ity to nomfy the euwpant
oflh requirements which must be mei prior t .-..ace pit Certificate of Owupancy.`-
r
-. TOTAL:
.Owner
ISSUED BY.
or aumonzeda ant' _ Date
6 -
OFFICE,