S 1172APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
ISSUED BY'.
OFFICE
CITY OF CUPERTINO BUILDING - ELECTRICAL
APPLICATIONIPERMIT PLUMBING. MECHANICAL.
RUILDING DIVISION i"BUILDING PROJECT IDENTIF3CATION:,'P i ;,• " .
I'Foelpel I ^
L
BUILDING ADDRESS: -
o Lz;�/OWNS
SAENO.APPLICAI'ION
SUBMIT"IAL DATE
'� PITON"
N Rr' S NA LIC NO:
ONTROL#
ARCHIT /GNC LIC NQ
AD R ,
CONTACT: PHONE:
', BUILDING PERMI`FINFO ti
❑ Consultant Fees Paid by Applicant (Initial)
LDG ELECT PLUMB MECH
Opwish
��.
U>U
>pZ W
LICENSED CONTRACTOR S DECLARATION
I booby o1Frm th' 1 I m fc d d p '.' dClu ner 9 (eoytm g
Seci rn ]a00)rfD' is' 3olma Bu nrsvatd Profynx}l'�QcGyl (t41 �ncat
/ @�7/
in full forte and eRa � ✓� Cl CI
Licence Clux tic.#
Date Commanr
QTY "I ttELECTRIC PERMIT 1 r"I PEE-t,t,
"011.n , All . ,... i .t .' �il #- ,' t
.POR DESCRIPTION
RESIDENTIAL,
❑SFDWL [I KITCHEN REMODY:I.
❑ AUDI TION ❑ PLUMBING RE -PIPE
❑MULTI -UNIT El STRUCTURAL
D"IF[CATION
El INTERIOR MN BY
IMPROVEMENT SWIMMING POOLS
El HAITI RE ODEL/RF,PAIK ❑DEMOLITION
❑ OTHER
PLRMII ISSUANCE
APPLIANCES - RISIDFNI'IAL
=y
`�
HITECT'S DECLARATION
1 ndernantl ry plans shall he used as public rectums
PANELS
UPT0200AMPS
F"W
i O
ONwhic
-1
o"
G(rnmmenciny
Licensed Pon ..iohul
OWNER -BUILDER DECLARATION
mpt
I hereby affirm that I am exefrom the Conlm na, License Law for the
following reason (Section 9031.5, Business and Profecninnx Cody. Any oily mcounty
h requires a permit tI I alter, outputdemolish, repair any.vrnure
prior to it, 1o) requires flarcup,lt RrmchP It fintio,racdcancluent
that he ISlicensed PII the provisions --fth Contractors Furtive L (Chamer9
with Section Y000)af Dramm 3ofhe Brxmrmnad Pfofio t,Cndc)nr
that he is exempt therefrom and the basis for the alleged cxetnption. Any violuuon or
201-1000AMP$
OVER II)IXIAMIis
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
THMP. ME' PER OR POLE INST.
COMMERCIAL:
❑ NEW, BLDG/ADDrTION ❑ DEMOLITION
$
dH
3
n to penally til
Sehann 90315 by any ise hundred doll for a pubmat suhleetx the apphca n p y
til mare than arhe pJ farm, emp.
❑LuaownoroRhe property. onnyemplayee,wilheeed i sNenrvle 044,Bsums,
Business
walldnthewrrk, and lite srmcmmatnot rs Livens Law doshotl apply to
and Pmfeshotb Code The Contractors License Law does not work hi s if owner of
property who builds or impmvc thereon, andmu who doessuchn work himself or through
W' DEVICES
POWER
❑'IBNANT ❑ FOOD SERVICE.
IMPROVEMENT
❑OTHER
SWIMMING POOL EL�TRIC
OUTLETS -S ES-PIX'IURES
'
his own etnplayees, provided that such impmvementx vin not intended or offered far
suit. If, however, the building or Improvement is Sold within one year ofeompledon, the
NEW RESIUOA ?LECI'It SQ Pl'.
SQ. FT PLO RNR
\
SISQ. PT.
ner-hhilder will have the burden of pmvi ng that he did not build or improve for par-
1
po f 1 ).
❑ I of the Proper, oxen ly continuing with T' I emadariI
TOTAL.
construct th project (S70,14.Business anti Pddfirs!mrx @m b The C t 1
come Law does not apply to an owner of property who build improves Ives Iherc and
•ri I
QTY
Who Contracts for Such projects vi th o turnarounds) licensed pursuvm onhe Gonhucnors
License Law.
1 am excel t d S , B & P C for this mann
ncr
❑ p n eo.
y�
C1 Ur
PERMIT ISSUANCE
Ownoe Date
ALTER- DRAIN IS, VENT -WATER (EA)
VALUATION --
ALUATIONWORKER'S
WORKER SCOMPENSATION DECLARATION
BACK FLOW PROTECT DEVICE
I hereby nfilm, under penalty of perjury one of rho following declamlion
DRAINS- FLOOR. ROOP,ARHA. COND. -
❑ I have and will maintain aCeaifcme ar Consent muelf-msurc far Worker4x Compcn-
sation, as provided for by Section 39!X1 or the Labor Code, for the performance of the
STORIES
'I' YPECONSTRUCTION
work for which this permit is issued.
FIXTURES -PER TRAP
❑ 1 have and will, tvin Worker' CPmpntsation Insurance• as reyuired by Section
3900of1hq,L'or Ca .fnrlbep tie Ithe work foramen this permit is issued.
GAS - EA.SYS'ILM-I INCA OUTLETS
OCC CROUP
APE
My W Inn In lance rand Policy um ur
Carrier: e-Poli,yNo.:
GAS - EA. SYSTEM -OVER 4(E,)
CERTIFIC E OF XEMPI'ION FROM O KL S'
COMPENSATION INSURANCE
GREASFIINDIISTRL WASTE INTERCEPTOR
BUILDING DIVISION FEFS
need nal M: mn..tried if aha nomad is fomnc Iumdred dollars ($1 00) or It,,.)
Tor
GREASE [RAI'
PLANCHECK PEI:
z
I certify lhatinlheperfnnwnceofthewrrkforwhich this permit is issued, l shall
became xcover la toe Workei,' Conner-
not employ any Indiana, a, amanner sa as Nco
cmirn Laws of California. Dare
Applieam
SEWER -SANITARY- S'IOIIM BA. 700 IT .
ENERGY FEE
WATER HEATER WNF,NT/ELECTR
CRAUINO PP.F.
•�
�
Q
,
NOTICE10 APPLICANT': If, after making this Cerlif n,le of Exemption, you should
become subject to the Worker's Cam tion of Lafrar Gmq t
1 poor t permit Shun you mm
forthwith comply with Such precisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Iherehy affirm ]hat here iso aom0uction lending agency Tenho performance of
the wad for whicb Phis pennh is Issued (Sae. 3119], Cie C.7
WATER SYSTEM?REATING
SOILS THE
WATHIt SERVICE
PAID
Dore e I
NEW RISIUHN'1IAL PLM H. SQ. FT.
Lender's Name
'rOTnl:
O'I'AL:
IsnJcr'spudrcsu
BUILDING FE
SEISMIC FEE
1 terrify that I have end m'. ,qd tad .l t ImaGe chose1' i '.
1I g t only m it y J e) b' dxt I1' Bt
a"IJpgd t i J ih p t f fah ; city l t up the
by
•. ••t i (.. I , .
,QTY.F MECHANICAL?, URI - BEE
:• t' }
PERMIT ISSUANCE
HhoC'I'RIC PEE
e me f ne+lpmp 1 .p, f Pry
'(Wcongree 'omen ify vnd keep hnnnlexc the City of Cupenno agv'ns
AI.TERORADDTOMECH.
PLUMBING FEE
4iex,jhdg la.pVes andws cocwhichmayinany woyaccrueagninst.caidCity
xequenc rf the gra lg of this permit.
AIR HANDLING UNIT (TO [0,000 CFM)
MECIIANICAI. FHH
CAN U (DE RS'TA. DS AND WILL COMPLY WITH ALL NON -POINT
E CI A
AIR HANDLING ON] 'I'(OVER 111,001 CPM)
CONSTRUCTION TAX
EXI IAUST HOOD(W/DUCD
HOUSING MITIGATION FEE.
r A1111lcanJCommclor Dao
'HAZARDOUS ATERIALS DISCLOSURE
HEM I NO UNIT PTO 100.000 BTU)
51) theapplicaut or future bn' ding occupant store or handle haruMous oriental
1 by the Chicago yyy Mumcip 1 Code, Chapter 9.12, tied the I ledth and Safety
'tion 25532(aJ1
HEATING UNIT (OVER 100,000 BTU)
Yen ❑
PAID pale RecciFl#
V HNTILATION FAN !SINGLE. RESIUI
1 he applium nr mince building recapture use equipment or dZ co.s wnlch
.Ions air contaminants as defined by the Hay Aren Air Quality Manugetnent
BOILER -COMP (311P OR Illq[NIII B'I'UI
'
'10'I'AI.:
BOILER- COME (OVER 100,000 BTII)
dew No
AIR CONDITIONER
read the hmaMoua materials mquiremems under Chaplet 6.95 or the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. PT
h & Safety Cade Sections 25505. 25533 and 25534. 1 understand that it the
not currently have tenant, that it is my responsibility to rosily theoccapum
nenkc whntmust home[ prior to issuance in Cerifiwteof Gc,drou y.
wA�
ISSUED BY'.
OFFICE