S 2671APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY ii A. j n
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
_ .BUILDING PROJECT IDENTIFICATION
P PERMIT NO,
Q n C
J G v 71
BUILDING ADDRESS: //
//��
SANI'I RV NO.
APPLICATION SUBMI'CIAL DTAE
J
OWNER'S NAME: PHONE:;
/��r A/97 /
C.i Ff �C� `f
WN ACTOR'S NAME: LIC NO:
J / /
n�� yLiO359
NIC
❑
CON ROLA
ARCHITECT/ENGINEER: LIC NO,
ADDRESS -
5,91 �
De
CONTRACT: PHONE:
�j� y p
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BtLj)CCj ELECT . PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION-
1 bereby affim, that Ina, ueeneod ander provision, of chapter 9 (commending
QTY ELECTRIC PERMIT ' FEE:
-
JOB DESCRIPTION
PERMIT ISSUANCE
' with Sncnon9000)ofD,o,mr3onho Brearssmld&ofooman,Cam, andmy license is
in full force lqt
1 Liecns a LIC.N O 5,9
1 Dvtc s, Conaacmr
RESIDENTIAL:
❑SFDWI. ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBINGRE-PIPE
❑ MULT[-UNIT ❑ STRUCTURAL
MODIFICATION
APPLIANCES - RESIDENTIAL
I ARCHITECT'S DECLARATION
1 understand any plans shall he used as public records
PANELS
Liwtxed Professional
Ois,I at I11LD[C nth, ItA'f10N
Law for the
I hereby ,form Thal i am exempt from mo Ce,mam, u : An,
Code: Any city or county
1 following remoa permit
9 onstre Easiness and Prel de o demolish, or reach structure
j wart, requiresma permit toam."Icl. tutee improve, daermit
UP TO 200 AMPS
UP
El INTERIOR SCKIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
❑ BATH REMODEUREPAIR El DEMOLITION
❑ OTHER
OVER 000AMPS
SIGNS ELBC'IRICAI.
SPECIAL CIRCUIT/MISC.
t ed
that he is admuhnlequithe lheapplieanfiduc for Cchpermi. to ,Law signed statement
that hC i, IiceneeJ purouummthe pmvieian, of the Cnnuctor's License Law Chapter
TEMP. METER OR POLE [NST
COMMERCIAL:
(commencing wish Section 9000)of Division 3 ofthe Business and Professions Code) or
that he is exempt therefrom and the basis for IM1e alleged exa epdnn, Any violation el
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7031.5 by any applicant fora Permit subjects the applleam to a civil penalty of
not more than five hundred dollars ($5110).
le cpensation.
El 1, as owner of the progeny, or my employcc,wimwageso, Iheir,oom
will do the work, and the succmre is nm macr del proffered for sale (See. 9044, Businces
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
OUTLETS -SW IT Cl LES -FIXTURES
and Professions Code: Ilse Contractor's License Law dors not apply to an owner of
properly who builds or improves theroon, and who does such work himself or through
his pan employees, provided IM1at each improvement, um not intended or offered far
NEW RESIDFN'TIAL ELEC'IR SQ hT
SQ, FT. FLOOR AREA
S/SQ. PT.
sale It, trust the building or improvement is sold within one year eformpletioa, the
owner-huilder will have the humlen of proving that he did not build or Improve for par -
face bf sv1eJ.
❑ 1, as owner of the property, am exclusively contracting with licensed cmntmters to
TOTAL: ,
ransomer the pumas (So,. 9044, Busire,, and Professions Cosi the Contractor's Li-
waseLawdoesnotapplytoanownerofpropenywhobundsorimprovesmercem.and
ho commucts for such propel, with aarmaddra) licensed Pannell to the Contractors
QTY. 4pLUMBING PE
.
PERMIT ISSUAN E
License lmw.
❑I amexcmptnndcr Sm. ,B&PCforlhismasen
ALTER - DRAIN & '-WA'I'I7RdaA) y
BACK FLOW PROT .1 EV 11111
Owner Dnle
VAIUA'FION
5O
WORKER'S COMPENSATION DECLARATION
affirm,�(
I hereby code penalty of perjury one of the Inbreed, declmanons.
[:I I have and will maintain a Certifieame ofConsento sel6imare for Worker's Comfort
00 of the Labor Code ler the perfpnnance of me
k1'oswhich
worcadge,.: provided fmuni ,,mad,
permitis
U J
DRAINS - FLOOR,R AREA, COND.
STORIES
-
2
TVPE CONSTRUCTION
��
PIXTURHS- PHR'fkAP
d�ave i
will maintain Workers CO
orker Insurance, by Sector
Labor Code, s, flh,me
Le h his Dann
My Work Loan n"ap ,ah pmucc anrit'sehewnrk for d—orhis permit is issued
CurrWorkeG'x CJ I�� �=%C a. Pnlcy No.ynuanbcr aro:
CERTIFICATE. OF EXEMPTION FROM WORKERS
GAS - EA. SYSTEM- I IN S
OCC, GROUP
A
O O 17
GAS - EA. SYSTEM -OVER 4(EA)
COMPENSATION INSURANCE.
(This section need not by completed fthe permit is for one hundred dollars(5100)
Or less)
GREASE/INDIISTRL WASTE, INTERCEP'10
sBCiLDING�5(VISI FEES
a Zen
GFEASETRAP
o-
PI sCHECK THE
SEWER-SANI'PARV-STORM DA. 20(1 tT.
certify Ihxt in the periormvnee of the work far which Im, permit Is issued. I shall
not employany person in any manner so as to become wbject In the Workers'Cpmpery
ERGV FE[ -
WA'ft?R IIEA'fER W/VENT/ELECTR
cation Laws ofCalifornia Date -
Applicant (
GRADING FEE -
NO'rICB'f0 APPLICANT: If, after making this Certificate of Exemption, you should
become r Fjoct to the Worker's Compeasmion previsions of the Labor Code, you must
WATER SYS HISIG BEATING -
SOILS FEE
forthwith comply with such pa,fo ma or this permit shall he deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
1hereby afOrm than there is a conduction lending agm,cy for mper
e fnnords, of
NEW RESIDENTIAL PI.MB. SQ, PC-
1'A[ a
Date ReceiPlM
the work for which Oats pemJl ix insuel (Sep 3099, Civ. C.)
Leaders Name
TOTAL:
Lender's Addme,
TOTAL
I troops mut l have read dr, application and,d ne and dis above mimmation is
BUILDING FBH 71
QTY., MECHANICAL PERMIT FEE
correct. I agree to Comply with all city and aunty ordinances andstate laws ranting m
building canstm mount. cad hereby vamonee rep r..mo lives Of thio city to crow upon the
SEISMIC FEE
ebovomnentonetl pmpeny for inspection pvmmes.
(We) agree mav
our, indemnifyharmless the and keep hatheCity 01 Cupertino again:
PERMIT ISSUANCE
ELECTRIC FEE
iabilities.judgmems, costs and expenses which may in any way acerae against said City
In consequence of the granting or this permit.
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (1011k000 CFM)
MECHANICAL FEE
AP I CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SO EREGULATIONS.
a0� h.n
i /Data
AIR HANDLING ON] F(OVER IO.OW CPM)
CONS' 1' RUCTION TAX
Sigh. roof App aiiontr nr
HAZ OUS MATERIALS DISCLOSURE
EXHAUST 11001)(W/DUCT)
HOUSING MITIGATION PEE
HEATING IJN[T(TO 100,000BTU)
Will me applicanit bmre building is par tore orhzndlefectudmus material
vs deliaed by IM1e Cupertino Murletpal Code, Chapter 9.12, and IM1e Health and Safety
Code, Section 25532(.)? -/
Yes
-
nr devices which
Will the applicant nr future building y the m usa co Air
emhhazmdous air contuminnnfv as dcTlnod by me Ray Area Air Queliry blanvgemem
Districi
HEATING UNIT (OVER ]FLOW H'IU)
PAID _
Dam Receipt it
VENTILATION PAN (SINGLE RBSID)
BOILER -COMP (3HP OR I00,000 BTU)
Vex
UOILER -COMP (OVER 1001000 B'Flp
AIR CON DI'FIONER
I have read the homNous aadmiahreuirements ander Chapter 6,95 of the Cali-
4 P
thatifthe
fomiv Hculth& Safety Cyfurvecters 25505, 2s my resd25534.1undersy the
buildingtic omurtenlh
rfylhenccupanl
ISSUANCE DATE
NEW RESIDEN 'FIAL MECH. SQ. Ft'.
ohne ren ,cols wnRn man ne me ono i„anaee mracenuirote oroeeap ,x
Brenntenamihatltiemyce,"fainatilate
ISSUED
Owner nr ,,rodagc r— 4 Date
TOTAL:
OFFICE