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CITY OF CUPERTINO BUILDING- ELECTRICAL
BUILDING DrvIs1oN APPLICATION/IaERMIT PLUMBING � MECHANICAL
BUILDING PROJECT IDENT'IF'ICATION
YEIW\IT NO
V 1901
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
` 3 M1�2 2� C!l
G N . �Mf� /I_ - PH� NE v
CONT 'Rr�(.-1'(l :S; AME:_ C3*
xfLil/i1�T/YA)
NIC
❑
COM"ROLN
ARCHITECT/ENGINEER: LIG NU'.
�l $I0S: �
W ISAJI)m
CONTACT': PHONE: -
BUILDING PERMIT INFO
HLDG sL[ PLUMB MECH
❑ Consultant Fees Paid by Applicant (Initial)
❑ ❑ ❑
LICENSED CONTRACFOR'S DECLARATION
1 hereby affirm that I um licensed under provisions of Chapter 9 (commencing
with Seaion7")ofllivision3ofthe Bueinessand Professions Cede. Jmylicensais
fi� !.. /m
in toll form node Tui. SY et l�-
QTY ELECTRIC PI3RMIT FEE
JOB DESCRIPTION
RESIDENTIAI,
❑SFDWL ❑ KITCHEN REMODEL
FERMI"I' ISSUANCIi
APPLIANCES -RESIDENTIAL
License Conn.,., n l'ii 1 6:447 /!ri
Dam Cnmrnctor��..._-.r��
❑AUDITION [:1 PLUMBING RE -PIPIT
❑MULTI -UNIT ❑MODI�URAO
MODIFICATION
[I INTERIOR El CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
ARCHITECTS DECLARATION
: 1 umleremnd my plain shall brawl as Public rw:rds
PANELS
UP 1021X1 AMPS
Licensed l'mfessiannl
201-I(xNlAMPS
1 OWNER -BUILDER DECLARATION
I hcrchy atlired that I um exempt initiative Craftier's License Low for the 1 following reamn. (Section W31.5, Business and Professions Code: Any city or manly
❑BATH REM )F. IR
❑❑ OTHHk
OVER IIxx)AMPS
SIGNS ELECTRICAL
which requires a permit to construe], alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such pramin to file a signedsmtement
that he is licensed punuont to the provisions of he Contractors License Law Chronic, 9
T' v
SPECIAI.CIRCUIT/MISC.
COMMERCIAL,
(commencing with Section]aXb of Division J of the Business and Professions Code)or
that he is exempt therefrom and the basis fur the alleged exemption. Any violation of
Section 90115 by any applicnnl for a pentyl subjects the applicant o v civil penalty of
TEMP METER OR POLE IN.
[INEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOODSERVICE.
POWER DEVICES
am mom than five hatumd dollars ($5IXp.
C] 1, asewtteroffle impeny, ormyempicyces with wages as their sole compensation,
n
will do the work, and the sanctum is not intended noticed far sale (Sec. ]0F1, Business
3 and In fir slums Cadet'rho GnnmaOr's Licemn Law does .,it apply m ml owner ,I
PAPROV EMI!N I
❑ GTIiIiR
SWIMMING POOL E.LEC'I'RIC
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENT]AL ELEC!'R SQ IL
property who builds or impnmes them... and who does such work himself or Ibdough
his own employees, provided that such improvements art not intended or offeml for
sale. If. however. the building lir improvement is sold within one year ofcnmpleaion, the
owner builder will have the burden of proving that he did not build Or improve for par-
SQ. FE DOOR ARG
P A I D
LSQ. FF.
T L:
poeeofnnleJ.
❑ h us owner of the prolen$ am exclusively contracting with licensed conmaom to
orsvnet he pn�jecl(Sea .70OL Business and Pmlessions CO]I:) no Contradius Li-
law does not apply m ml owner of pnpeny who builds of improves thereon,and
�roc AND
QTY. PLUMBING PERMIT FEEJIM
who contracts for such pm)acts with a contractors) licensed pursuant m the Command's
A
PERMIT ISSUANCE
License Law.
ul- ukri CI}IUlu
I; an exempt under Sec. ,B&P C for this.,,,
ALTER -DRAIN & VENT- WATER WA)
VN.UNFION
Owner Date
WORKERS COMP17NSATION DECLARATION
BACK FLOW PROTECT. DEVICE
I hereby al'Ihnt under penalty of perjury One of the following declarations:
❑Ihavc undwill maimainaCenifcnm of Conummeelf-ensure lhr Wnrldn, Cmnpen-
DRAINS- FLOOR, ROOF, AREA. COND.
STORIES
'TYPE CONSTRUCTION
cation, as provided for by Section 3100 of the Labor Code. for the performance of the
work for which this permit is Issued.
FIXTURES - PER TRAP
El I have and will maintain Workers COnlpeasmion Insurance, us myuired by Section
37W ofthe Lamar Coallp,+,tt1for the Performance ofthc work�mrrWwh+cich/t�his(P/jrmilieissucd.
GAS - RA. SYSTEM -1 INC. 4 OUTLMS
'
OCC GROUP
AI'N
GAS - I!A. SYSTCM-OVER 4 (EA)
/
Carier��No^IIS? �/ Il..T a Policy Noleand yES.�/1QJ.J—}L_
WAS'I'F. IRFERCEITOR
CERTIFICATEOFEXEMPTION FROM WORKERS'GRGSI%INDUSTRL
COMPENSATION INSURANCE
BUILDING DIVISION FEES
GREASETRAP
PLANCHECK FET!
(Ihir,welion need not be completed ifthe Permit is for enc hundred dollars(SIM)
Or less,)
SEWER-SANITARY-S'TORMEA. 200FT.
ENERGY FEF.
I cenify that in Neperinrmvnec oflhewmk mrwhich this woral is issuad, ]shall
not employ any person in any manner ser as to become subject to the Wori i Comps^-
WATER HEATER WNENT/ELECTR
GRADING FEE
action Laws Of California. Uale
Applicant s
NOTICE TO APPLICANT. If, after making his Ccnificem 'If Exemption, you should
' become subject the Workers Compensation provisions of the Labor Code, you must
u
WATER SYSTRM/TREATING
SOILS EEE
PAID
Dine pt p
fonhw'nh comply with such provisions or this pend] shall be deemed revoked,
CONSTRUCTION LENDING AGENCY
1 hereby dRthi that ]hem is i ned aconstruction lending agency for IM1e performuncc of
i the work for which this permit is lssueA (Seo J(M)"I, Co,C.)
Lender's Name
WATER SERVICE
NEW RES IDEN'FIAL PLM O. SQ. FF.
TOIAI;
TO'i'AI. :
Q Lerdde, Address
Is I certify that 1 have mad this application and slate that the above information is
0 correct l agree m comply with all cilyand county ordinances and slide laws rel^ling lr
builiingandoc ion, unit herebyamhorimm,roesenlatives oflhixdty loaner -Plot the
QTY. MECHANICAL PERMIT FEE
jE=R1
PERMIT ISSUANCE
above-mentioned grope for inspection games.
vgrcctdmtless the Ciry of Cupertino againstliabililics,judgmer :rots and expenses which limy in any wxy ac<mc against suit Ciry
FEEn7
ALTFRORADDTOMECII,
rFEli
nwqucon, th &roof m This permit.
APPLI I :RS ND AND WILL COMPLY WITH ALI. N -For T
AIR HANDLING UNI'I'('IO 10,000 CFM)
MECIIANICAL
501' CE RE Ul. TIO S,
AIR HANDLIN6UNIT(OVER IR,(x1BCFM)
CONS'1'Rf ION'I'A
d mmmm Dam
ca1A
EXHAUST HOOD(W/DUC1
HOU SING MITIGATION F'b'
RDOUS MATERIALS DISCLOSURE,
ll the applicant or future building rccupam store ar handle lmmNous material
H17A'I ING ON] I'(TO 100,000 BTU)
as deOned by the Capetian Municipal Code, Chapter 9.12, end the Health and Safety
Cal^. Section 25532OH
HEATING UNIT (OVER 100,000 BTU)
VEN'1'I LATION PANS INGLE RESID)
❑Yes C1 No
PAID
Date Receipt If
' Will the .,Jr.., ,, furore building..,at um cyripmem or devices which
mil hazardous air connotations as defined by the Bay Area Air Quality Management
BOILER-COMPUIPOR 1W,"BTU)
TOTAL:
District?
C]Yea No
BOILER - COMP (OVER Hatton 13 U)
-
AIR CONDITIONER
ISSUANCE DATE
I have read the hazurdaus merands requirements order Unfair h. 95 of lire Cali-
NEW RESIDENTIAL MECH. SQ� FL
fore^ Ilealth & Safety Code, Sections 25505, 25533 and 25534. I undetslumd that fiche
building does no¢urrently have a tenant, that it is my respmsibilay to notify the Occupant
Of the reyddenmam which most be met Our to issuance of a Cenifieam of Occupancy.
'IOIAL:
ISSUED BY:
Osbadmimhndzedagenl Dole -
OFFICE