S 1278APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPI'.RTINO
BUIL DING DIVISION APPLICATION/PERMIT
BUILDING - ELECTRICAL
PLUMBING.MHCDAN'CAE
BUILDING PROJECT IDEN'I'IEFECA'1'ION
PHyryl'I'NO. 1278
J
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
( NUR'S NAME' PHONE:
C NI'RACTOR'S . IL'# JU C- LIC NO.
N/C
CONTROL#
Rill"I'ECTlii GINEER; LIC NO:
A) RISS: 1'7�10 (�'
C
'
❑
CONTACT, PHONE:
BUILDING PE:RMITINFO
❑
Consultant FCCS Paid by Applicant (initial)
BLDG ELECT PLUMB MECH
®/
❑ ❑ 90 ❑
LICENSED CONTRACIURS DECLARAI'ION
1 herrn, mrnn that I on leered ender Eux... ones of Chapter 9 (commencing
QTY
EI.ECI'RIC PERMIT
FEE
JOB DESCRIPTION
PE ISSUANCL
with Section ]IAP)of Divivion 3 of the Hceinrec and ProIcoien, Cole, and my Ecenm is
in full tune Tend yy'c [� I ��
�o
RESIDENTIAL:
❑SFDWL ❑KUCHE REMODEL
APPLIANCES - RESIDENTIAL
Niece.c ns li
Uatn CunuQpy GlO.if< IlgfYiYb
ARCHITECT'S DECLARATION J"Wa V.
1 understand o, plans.hall h used us public accords
C1 ADDITION ❑PLUMBING RE -PIPE
❑MULTI-UNIF ❑S'TRUC'TURAL
MODIFICATION
❑INFERIOR El CHIMNEY REPAIR
IMPROVEMENTDSWTMMING TOOLS
❑BATH RFIIODEI/REPAIR ❑DENUH ION
E] EYTHFR ( IQ. #�
/1- �e����
PANELS
IJPTO2(p AMPS
Licensed professional
OWNEIUBUILDER DECLARA'T'ION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following rcmon. (Section 91131 5, Huvinuc and I'm(ceduns Cede. Airy city nr .oath,
201-1000AMPS
OVER lots) AMPS
SIGNS ELECTRICAL
which regaims a permit to construct, alter. Improve, demolish, or repair any venture
Q\(t.�
SPECIAL CIRCUI'UMISC.
potato it, i,,muue. ahnreyulmsthe applicant forsuch permiuo filea,umintawment
that he is licensed pursminto the provisionsofthe Commctti License Eau, Chapmr9
(cotnnlmcingwom Srction 7000)nl Divinion 3 of@c 9usincs,and Prnfccsinn. Cock),,,
'EEM 1'. MIT fER OR POLE INST.
COMMERCIAL:
that he is exempt therefrom and the basis for me alleged exemption. Any violation of
❑ NEN' BLDG/ADDITION ❑ DEMOLITION
Seen 1 7031 5 by any upplicxm be a permitsome.. the appllato,, o civil penalty e1
t moa than Five hundred dollars (S50).
�Ql. nc nwncrnftnc pn+pcny,nnnymnployms with woge,cas0eirsolemmpcnwtion,
will de the work, and the structure is not intended or offered for.rcle (Sec. 70cl4, Haziness
POWER DEVICES
❑TENANT ❑ TWO SERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POLL 131.F.C'I'RIC
and Profu,;,mms Corr the Contract I Liceme Law docs not apply to an net of
prepery who builds or improves thereon, and who news such work airmen or through
his non mnployas, avoided that such impmvcon,t, arc nm intended nr off mctl for
sale. It, however. the building or improvement is cold within one yeatafrompletinu,thc
OUTLETS -SWI ICI IES -IlX'I USES
NEW NESIOHN'I'IAL ELECT SQ F1'.
SQ. 17, FLUOR AREA SISQ. FI'.
ooner-builder will have the bnMmt of proving that Neild! not build or improve for per-
poseo( ower o
E] 1 ne p p ty 1st, ly t i 6 nen I' 1 tau m
B ss dP I ns Cal )ThCaroni
nh pr1 m,,[
D
T T
cmt .L+`
I oar p- d c, 1
apply I ,f p piny h M1ed
QTY.
PLUMBING PERMIT'
FEE
o contracts f .uchp 1 E' with tet t OI licensed Personal theC rr t 1
wh1 o P
Clem. Law,
� 1 um «rept under Sec. , tl & PC for this mason
SEP 2 8 19 8
PERMIT ISSUANCE.
- DRAIN£r. VENT- WATER IEA)
Owner DateALTER
VALUATbN
By
W'ORKER'S COMPENSATION DECLARATION
IMCKPLOWPROEEC'I'. DEVICE
I hereby altirm under penalty of perjury one nl Ne (..Ilnwing Jcdarations:
❑Ihavt,med ill mairminvCenifiarcof Conscnnnaelf-imenefor Workers Coml'en-
setter, as provided for by Section 37M of the Labor Calc, for the ferfomlance of the
DRAINS- FLOOR ROOF, AREA, COND-
S'roRtEs
TYPE CONSTRUCT ION
work Iia which this Femur is issued.
-II have and will maintain Worker'. Compensation Insurance, as required by Section
FIXTURES - PGR TRAP
3900of the Ld, Code, for the parfonnaecrol he wick for wh ich this prem t is issued.
GAS -IiA. SYSTIT M- I I NC. 40U'TLFI 'S
OCG GHUUP
APN
My Werke Cat and Policy
4 ncc myprya
rl'aGcy
Gomer:�� i��eF Nn:r"KKDoll
GAS -IiA. SYSTIiM-OVHR4(EA)
CERTIFJCATE OF F.XEMPI'ION FROM WORKERS'
COMPIENSATION INSURANCE
(Thiswetlnnnecd not hcamplood ifthe permit is on one hundred dollars ($100)
or less.)
GREASPIINOUSIRI. WAS I I:IN I ERCEPIOR
BUILDING DIVISION PEF_ti
GREASETRAP
PLANCHF,CK FEE
SEWER - SANITARY - STORM F.A.200 FT
I certify that in the performance ofthe work for which this permit is issued.I shalt
not employ ca y Person in any rover �,y tyJ,,:e tM1ito the Workers' Conipen-
ENERGY FEE
WATER HEATER WNENT/iLEC'R
adun
Ateli nm
GRADING VI?li
NUI become subject
fern svb,icctm the Wndefa Giorsor nem oft he Labor Calc, you mutt
ct to the Work IL after making n his Cisioa ao of lLabor ion, you a ouldim,l
vininm
WATER SYSTEM/1'RIiATING
SOILS IYH
N'ATI?k SERVICE
fnnhwhh comply wrtb such pmviaiore ar his pstnnit .Hall rte Deemed revoked
CONSI'RUCI'[ON LENDING AGENCY
I herechy affirm th,adere kaconstmainn lending agency for the perfenmoa,of
NEW RESIDENTIAL PLMB, SQ. IT.
PAID
>um Hcccipt#
the work for which this permit is issued (Sec NEE. Co. C.)
1<nder's Name
11( A1.:
Lender's AddreTames
TOTAL :
certify t
I M1m 1 have rend this application and Mate the the above information is
BUILDING PRE
QTY
MECIIANICALPERMIT
FEE
correct, l agree to comply with all city and county ominancex and stain law. aliningm
building construction, and hereby outharicc representatives of this city m enter upon the
SEISMIC FEE
above-nmetiored property for irnpection pmpoace
(We) agree to save, indemnify and keep hanulma the City of Cupertino against
PERMIT' ISSUANCE
ELECTRIC I I
ANTER OR ADD TO MECH.
Iiabiliticc.judgment,,'ada and.apace. which may in any way acme against said Ciy
ccof tM1is pennir
nacquencc of11
PLUMUING IEE
AI'F'LICAN'I'Ut IT 1 AND WILL COMPLY WITH ALL NON -POIN"I'
SOURC- t' NI �'
AIR HANDLING UNIT(TO 10,00 FM)
#
NIiCHANICAI. I+Eli
AIR HANDLING UNIT (OVER 10.000,CFM)
XA-n-
'Date
CONSTRUCEION 'I'AX
EXHAUSTHOODIW/DUCT)
St nlure til pplicunth'nntru n
HAZARDOUS MATERIALS DISCLOSURE
HOIISINGMI'IIGAHONFEE
HEATING UNIT (TO 100.000 BTU)
Willum npiliccal., um, Imildingoctiqudtswre nr handle haandous material
as defined by the Cupmrs, Municipal Cole, Chapter 9.12, and the Ilealth and Safety
Code, Section 25532(a)?
4117ATING UNIT (OVER 100.000 B'I'U)
[I yes C3 No
Width, applicant or
it infuma edifiedg eause equipment nrdevices which
hanrzmn ainindnaurmamn as defied! by by the Bay Buy Aav Air Quality Management)
PAID
Receipt#
VENTILATION FAN ISINGLE RESID)
BOILER - COMP 0 HP OR 100.000 BTU
DiYtrieR
Cl Yes -1NoBOILER-COMP
TfEI'Ah:
(OVP.k IIX1,1,0 BTU)
AIR CONDI I'IONER
I havueeadmi,hw.afdoes:omnAx acuirernents under Chapter Culi-
ISSUANCE DATE
NEW RCSIDIENTIAL MIiCH. SQ. PT.
fnmia Hea11M1 A SoR•ty Gds, SmionQ55115. 25573 and 25534. I undetManJ thin it"the
building d,er not currently have a tenant. thin it is my msWnsibility to notify the,rcupaut
i
::::::I
,)(the rtyuirtmenu which mu.a be mm prior to issoancc of a Ccnilicme of Occup ancy.
ISSUED BY:
2a
Owner or malba "d zgant Dar
TO AL:
OFFICE /