99100087APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY • IT_ �Ioi I DOOR
OFFICE
CITY OF CUPERTINO BUILDING. -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS -
t cku
SANITARY NO.
APPLICATION SUBMITTAL DATE
6 y8_p
OWNS q I ONE: .
IRIr/\l/`'- ,;L� 59
CONTR DR'S AM�: LIC NO'.
N/C
❑
CONTROL.M
\RCHITECT/ENGINEER: LIC NO:
ADDRESS: - - 1,
3 (�
CONTACT: PHONE:
BUILDING PERMIT INFO
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+1'� avf- ��
❑ Consultant Fees Paid by Applicant (Initial)
HLDO ELECT PLUMB ME.CH
❑ q,-- � ❑
LICENSED CON'TRACTOR'S DECLARATION
I hereby arum that 1 am licensed under provisions of chapter 9 (commencing
with Sectim700m.fDivisi n 3ofthe Business vnd Pmfessint,Ccdeandmylicenaeia
in full foreeand offer,.
license Cl s Lic. p!
Date Contractor Rhelt—SIMIA
ARCHITECTS DECLARATION
I understand my plans shot] be used as public records
QTy. '' ELECTRIC PERMIT FEE ,
,
100
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JOB DESCRIPTION
RESIDENTIAL:
C -I
SFDWL �fITCHP.N REMODEL.
CADDITION El PLUMBING RE-PIPH
Ll MULTI -UNIT ❑STRUCTURAL
MODIFICATION
ElINTERIOR [I CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
El BATH REMODEL/REPAIR [2 DEMOLITION
❑OTHER
�
PERMIT ISSUANCE
gPPLIANCF:S-RESIDENTIAL'
PANELS
UP T02(IOAMPS
Licensed Professional
OWNERBUILDERDECLARATION
I hereby affirm That I vm exempt from the Con¢acmr'e Llcansd Law for the
following reason. fSection'JW L5. Nosiness and Nmfeasinnr Cnde: Any city or county
which regnims a peril to moslmcl, eller, improve, demolish, or repmr any onnum
friction,iswine,.ho,"mire;fic.pplicantfmaichperohn, file aslgoed doormen)
lhathe is licensedpurwin t.lbe pro,kinnsofthe Chromium, License Law(Chapm,9
201-IOWAMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
OF
SPPAIAL CIkCUI'I'/MISC.
TEMP. METER OR POLE INST.
CO MERCIAL:
NEW BI.DG/ADDITION C DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
DOTTIER
iC�Oa
7 cI V.
V•
^y
1 d
3
j
' ^
(commencingwilh Serum 90tad)olDivision3hf dic Bminateand Profvsdlhm Cale)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
m
Section by any applicant for a permit subjects the applicant a civil penalty of
nl mom Than Five hundred dollam ($SW).
dothe worMthe pm deny.nrmyemplended wlBtered for sale044,usiness
will To marina, andthehe (mre is not intended Law
Code The Comraereo License Law does sol apply d, via owner of
no, apply to weer of
and property and who docs such work
property who builds or improves
who
Idea offered
POWER DEVICES
SWIMMING POOLELELTRIC
OUTLETS-SWITCHES-PIXTURGS
t such i,
his owe or fo
are not intended or offered for
provided that such impros e
SQ. PT. FLOOR AREA
SISQ. FT '
however
sale. If, howevu, the building or improvement is sold within one year of completion, ha
sold w
owner-builderwill have the burden of proving that he did not build or improve for pur-0)
ILJ
-
pnvoutside.).
❑ I, os owner of the property, am exclusively contracting with licensed eommetors m
'
onxmucl the project (Sec 9044, Business and Professions Cnde:) The Convacmrs G -
se Law dons sat apply ro an art of property who builds or improves thereon, ons
QT LU
who contracts for such projects wish art mwmnga)Ilceosed pursoammthe Contrnemre
with
Lw.
License Law.
Ellam exempt under See. ,B&PCfhr this reason
PERMIT ISSUANCE
Ism[
r IN - (
Owner Date
- VALUATION
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the folihwing declarations:
LE W
D
DRAINS- FLOOR, ROCP, AREA, GOND.
I hove and will moimninvCerifenmof Consent to self -Insure for Worker's Cmnpen-
done, as provided for by Section 3700 of the Lab., Cade, for the perfo deduceof the
ST S TYPE CONS'1'kUC9'ION
work for which Nis permit is icsucd
-FIXTURES-PER TRAP
C I have and will maintain Workers Compensation Insurance, as required by Section
erm�itiis issued.
3100of the LeborCodc. Intake performance ofthe work for twhihiclitthhisppe'Tim, W Is
Cnl9pe I�µpce ams Pnf yNcsnT_;;ny
ame, gee C
CY
'GAS -EA. SYSTEM -1 INC. 4 OUTLETS
OCC. CROUP ANN
'CAS-EA.SYSTEM-OVERITA) ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE,
dead not be complemdiftlaeparrou isfor onehundreddo0ars(8100)
or less) �
O
�
GREASVINDUS'I'RL WASTE INTERCEPT
N 'C 39
CREASE TRAP
I certify that in theInTrouranceof the work for whichthis permit i, issued. l shall
not employ any person in any manner so as m become subject m the Workers' Compete
SEWCR-SANITgRY-S'TOkM EA.2W FT.
ENERGY PEE
Z
2
M
cation Laws of California. Date
Applicant I
WATER HEATER W/VENT/ELECTR
GR.{I�CNTT4 8 ju
v V
NOTICE TO APPLICANT. If, after making this Carnivore of Exemption, you should
become eabje i m the Workers Compensation prov' sof the Labe, Codo, you rote,
WATER SYSTEIATREATING
SOILS FSB
WATER SERVICE
a
DLender's
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forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that There is o construction lending agency for the perforance of
the work liar which this permit is issued (Sec, 309], Civ. C)
Name
rPAID
NEW RESIDENTIAL PLMB. SQ IT. B
-
'TOTAL:
-
TOTAL :
Lders Address
en
BUILDING FEE
I army that 1 have read this application and state that the above Information is
correct. ] agree in comply with all city and county ordinances and same laws relating is
bung construction, vnd herehy aulhnrize repreeenletiva of this city In enter upon the
- - - -
,QTS• MECHANICAL PERMIT 'FEE'
SEISMIC FEE'
idesomolimod property for inspection purposes. -
(We) agtce m save, indemnify vnd keep hvrnlcas the Chy of Cupertino vgninat
PERMIT ISSIIANCP.
ELECTRIC FEE
-
lichilities,judgments, costs and expenses which may In any way acerae against said City
m.,amencenf the gmntingof fid,,crmia.
ALTERORADDTOMECH.
PLUMBING FEE
AIR HANDLING UNIT CTO 10.000 CPM)
MECHANICALFEE
APPLICANT UNDERSTANDS AND WILL COMPJB WITH ALL ON -POINT
SOiRCE I� +yQULATION$t / /I/ I
AIR HANDLING UNIT (OVER I(I,OW CFM)
CONSTRUCTION TAX
-����',(���J �A "I.� �
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Signvwre ofgppdivvnUChntmmnr D e
HAZARDOUS MATERIALS DISCLOSUR
CXHAUSTI IODD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,000 BTI))
Will the applicant or future building occupant store or hen a huzaNnus material
as defined by the Cupertino Municipal Choc, Chapter 9.12, and the Health and Safety
Code Section 25532(x)7
HEATING UNI'C (OVER I W.OW IT )
-
E]Yes ❑No
PAIDTION
Data.Receipt#
VEN'T'ILAA CAN (SINGLE RBSID)
Will the applicant or future building occupant use equipment or devices which
mit hazardous air contaminants as defined by the Bay Area Air Quality Managemem
BOILER -COMP (3HP OR 100,000 BTU)141.
Banner?`
❑Yea, ❑No
BOILER- COME (OVER 1001001 BTU)
AIRCONDITIONER
1 have read the hohazardous material, requirements onde� Chhpmr fi.95 of Ne Call-
famia Flealth & Safety Code Sections 25545, 25533 and 25534. I understand that if the
building does not amend It alemtint that itis my responslbilityt nhit'y the ocapa I
ISSUANCE DATE^, �5
� CrJ Y
NEW RESIDENTIAL MECH. SQ. ET.
of the it esu which mU eoLC•rll' Ieof0empancy.
B
,
%
ISSUED BY: '6C
Ownerormannrieedigenl - Data
TOTAL:
OFFICE