30560APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT' IDENTIFICATION
'
BUILIIINGADDRESS:
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SANID
OWNERS eL �'�/�/� PH _/��
CONTRACITIR'S NAME,. WC NO'.
ARCHITECTS DECLARATION
1 urduuard or plan. shall ha oval es public rads
BIC
SRCHIIEC'LENGINEER: LIC NO:
ADDRESS:
❑
CONTACT: PHONE:
�' C I �, I A . 'L� /1 /.7�
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❑ Consultant Far Paid by Applicant (Initial)
OVER J"AMPS
BLD
❑
�aZ
!+W O
�UU
�Za
I here, ffnm thus 1 em ficemed ulldcr,
thereby and Preeneef Core,e(comma«tug
with Smrebun effibo iJiuun3ofthe Bu irw add Pmfessimr Code, and my licenseis
iafullf Cl urd u(fcef
Date Clem Lich
Date Convect«
QTY ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
Z
ARCHITECTS DECLARATION
1 urduuard or plan. shall ha oval es public rads
-
PANELS
OZ -1
[. 4 (qq'
((yy 11'' YYLL''11 Q
>(a 6 U
LLLL17 O
wNSPECIAL
a C O
!U N
ZQ
UP TO 200 AMPS
Ltan .l Pmlcuinnal
Ce CommaON
OWNER- exempt Beer
1 M1arthy affirm th�l 1 um exempt fmm the Convceturs Li«vre Law for the
following rttunn. (Sediw "I0J1.5, Business ard Pmfcssions Gdc: Any city «county
which me uires a Doe it 1. moomct, sm,, imgove, demolish, or repair any moque,
pri«to its Issuance alw, myuimt the applicant fee rush femmeo file a sigrcd statement
thathe int a- punrxnuo pmvisums of of teBustclvrelncPmelaons Codmr9
(come, is exg with Smdwern and me, basis n 3fur di tueeged cwand Professions vi Cede)«
thatSac io it examb Imy sof and for basis ler tM alleged ammant to Any violeuon of
be, don, by anyopplicamfnsvpcnnid rubj¢ts the applicant macivil perxldy of
nal nrxc Then Ova hualN dollars (SSIXB. '
❑Lea uwrmr u(Qte prorycnY,«my nnpinyecs with wvgcs as dhcirwlemmperuai«n
will do ere wag, and the structure is not intended «effered for sale (.Sea 7fN4. Business
ard Profoaimx Calc: The Crntrdcmrs License idoes mol apply to an owmf o[
prepi wits, builds or muDvocr dnreon, and also dues wch work himself «thrwgM1
201-1000AMPS
OVER J"AMPS
SIGNS ELECTRICAL ,
CIRCUIT/MISC.
TEFIP. METER OR POLE INST/
ir
POWER DEVICES
SWIMMINGPOOL
OUTLETS -SWI - RES
his own employees, pmvwoJ that Inch improvemend arc int intended ur efo red ler
NEW RESIDENTIAL BLECfR FT
tele. If, Nowcvm, lee IsaiMingorimprovemem is sold within one yen of urmpldien, de
tuner-huilser will have the burden of,avo ng text he d'td nut build m improve fee pur-
ryne of maJ.
❑ 1, as meter of the prgteny, am exclusively contracting with llcensN eontraaors Bi
conrorom tee project (Ser, 7M4. Busiress end Profusions Coda:) The Cootessme x Li-
QTY, PLUMBING PERMIT
sa Lew dra not Tply loan owner of pnpeny wen Wilde «improves fo reon, and
waw eonwea for wch projects with a enntmatm(s) licensed pursuanno the Conweter's
PERMIT ISSUANCE '
License law.
O l am exempt under Sec. ,B& P C furl but motion
ALTER - DRAIN&VENT-WATER (EA)
Owner - Dena
T
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of pie ury om of the following dmlamtiom:
BACK FLOW PROTECT DEVICE
DRAINS- FLOOR. ROOF AREA, COND.
IMve and willtreinlain aCenifcmeofCmsem to wlT-imumfnr Worker's Compen-
Wien, v pmvid i for by Section 37W of the Who Coda for the rerfemtnrce of the
FIXTURES - PER TRAP
work for which thit turmoil is isaoeJ.
❑ 1 have and will maintain Worker's Compromemi n Inmrmsee, as mywrd by S.iou
37W of the Whor Cade, for perform—of lha work for which thin permit t, issued.
GAS - EA. SYSTEM-] INC. 4 OUTLETS
My Worker's Compensation Ins«vec cinder and Policy cumber arc:
GAS -FA. SYSTEM OVER 4 (EA)
Contac Poltey Na:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE/INDUSTRI, WASTE INTERCEPTOR
nrlxv) (This rection need not be mmoclW i Dee,,soonra mono hundred dol 1.1$ I gin
GREASETRAP
OZ
O
I certify don of the,, uposen ceofthe worlt her which thispmunit iamtud, I shall
not employ any pawn in am, manner.so as to becomes, subject t. the Werlmo, Cmnpen-
®firm Law.. of California. Data
Applicant
SEWF,R-SANITARY-STORM EA.2W
WATER HEATER W/VENT/El-li
Vj
a;
NOTICE TO APPLICANT: If, after reeking this Cenifcme of Excmprion, you dmuld
become tuhjml to Ea Work'er's Coe,mall pmv,00srs oftrd Lubse Coda, you mart
comply with wch pre,,obeI or this parent than he deemed revekM.
WATER SYSTEM/1'REATING
WATER SERVICE
aQforthwith
' V 0
CONSTRUCTION LENDING AGENCY
Thereby affirms that them u, a corestructi«lending infamy famy fthe m
pidommoe of
NEW RESIDENTIAL PLMB. SQ. FT
Q. L-+
the turd for which this perm, is issued Pdm.3(Nz Civ. C.)
.O U
].
y
Lemere Nana
L,nclef; Addme,
I cetify that 1 blee mnsd Nis applicntien and state dW the alnve inf.m. is
TOTAL
.
QTY. MECHANICAL PERMIT
to
V Z
coir«t, l agree to comply with all city and county«doomema android, laws mating to
building construction, and hcrchyvmlmnu mpre.rnlmivcn of this city m ebur uPm lhc,
PERMIT ISSUANCE
alowe brammtul proDedy for in,seetien peopaux .
(We) at do mea, indemnify and keep hmtnksx tha City of Cupenlno again,,
Iiabilitigjudgmenu, cosus ard expense, which may in any way aeurest Umnd said City
in mnwluarce of the granting of she, permit.
APPLICANT UNDERSTANDS AND W11L COM LY VI 'H ALL NON L T
SOURCE REGULAT )NS.
ALTER OR ADD TUMECH.
AIR HANDLING UNIT(TO 10,000 CFM)
AIN HANDLING UNIT(OVER 10.000 CFbll
/�
EXHAUST HOOD OVMUC7D
Sig um of Applin Co car roe
HAZARDOUS MATERIALS DISCLOSURE
ABATING UNIT (TO 100,000 BTU)
Will devppliam or future huilding eventuate stere or hardlc hmvdoua material
u definul by the Cupertino Municip.l Cale, Chei 9. 12. surd the Health end Safety
Code. &mdo o 255]2(.)?
HEATING UNIT (OVER 100,000 BTU)
❑Yes 'gRe
VENTILATION PAN !SINGLE RESID)
-
Will the vppllcom«fuum building occupvm ore equipmam err
cdevices whip
crit hvwuiwa me contaminants ants as defin 1 by ere Bay Area A, Qualidy Meragement
BOILCR-O MP(HP OR IW,OW BTU)
Dr rico
❑Ya INo
BOILER- COMP (OVER 100,000 BTI)
AIR CONDD'IONCE
I larva rad the avzNows ma¢n.ls ber,momcnts order Clutprer 695 of the Culi-
NEW RFSIDF,NTIAL MECH. SQ. FT
Tania Health & Safety Calc, SttYloos 25505, 25533 ard :5511. 1 ualmuaal dot if the
Wilding docs m e.ndy have a Ianmd, thus d ie my neynrxib lny tr tinily Ilse ceeupant
of ilk reRuinemcma which mad hamet wYr ufa rrrc, n(a tsnif.:arr. e(A.,.mArw
'OFFICE
YeN"'"NV 30560
'NO. APPLICATION SUBMITTAL DATI
(6?c
orvlxoL
BUILDING PERMIT INFO
PLUMH MUCH
❑ ❑
❑ BATH REMODELREPAIR ❑ DEMOLITION
Cl OTHER
COMMERCLAL'
❑ NEW RLDGIADDITION El DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. FT. FLOOR AREA jlSQ. ET
FEE
SEP 161996
trlr
1 1VALUATION
if l.Ur 4r,o HlU
STORIES TYPE CONSTRUCTION
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Rccaip p
TOTAL:
BUILDI E
FSE SEISMIC FEE
A
XA ON FEE
Date Rectifier M
TOTAL:
\ISSUUUAA\NNCCED/ATE
ISSUED BY
JOB DESCRIPTION
RF.
IOFNTIAI_
❑SFDWL
❑KITCHENREMODEL
[]ADDITION
❑PLUMBING REPIPE
[]MULTI-UNIT
El STRUCTURAL
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODELREPAIR ❑ DEMOLITION
Cl OTHER
COMMERCLAL'
❑ NEW RLDGIADDITION El DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. FT. FLOOR AREA jlSQ. ET
FEE
SEP 161996
trlr
1 1VALUATION
if l.Ur 4r,o HlU
STORIES TYPE CONSTRUCTION
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Rccaip p
TOTAL:
BUILDI E
FSE SEISMIC FEE
A
XA ON FEE
Date Rectifier M
TOTAL:
\ISSUUUAA\NNCCED/ATE
ISSUED BY