30864APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIPFRMIT PLUMBINGBUILDING PROJECT IDENTInCATION -MECHANICAL
PE""/IT N030864
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BUILDING ADDRESS:
V
SANITARY NO.
APPLICATION SUBMITTAL DATE
OWWt'SNAS PHONF_'
�N !
iNGINEE LI O: ✓ILII
CO CTOR'S NAIAHz LIC NO:
121Zol//ii
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CONTROLx
CONTACT PHONE
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ElCauultanl Fetes Pald by Applicant (Initial)
BUILDING PERMIT INFO
BLDG Fl ECf PLUMB MECH
Mix,
V �j
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LICENSED CONTRACTORS DECLARATION
fT
I thereby erm that I am licen. i uMv povui«u of CT.pier 9 (mmrneeciny
with Sectiun'tW(F. Division3ofthe Duxinesstand Pneeuiom Codc,and my ucevci.
on full fora a W cRw�
Ties. Clan Lie. x
Da Co., �
QTY' ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
DSFDWL DKITLTiEIJ RF1.fODEL
DADDU70N ❑PLUMBING RE-PIPE
0MULTI-UNIT ❑STRUCTURAL
MODIFICA]'ION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
D BATH REMOMLrREPAIR DDEIvIOLPHON
D OTHER
PERMIT ISSUANCE
APPLVtI:CtS- RESIDENTIAL
F
C) Z
ARCHITECTS DECLARATION
I undntaW emy plana shall be, after] ax Public rme. .
PANELS
UPTO200AMPS
an ul
�j •]
U
3 C gV.
=OLj
.Q.1
tyytyyy
CLOS
�f 4'
lil�rn
F�Q❑Lome
LLS
6 3
Liud Pm
nofeav^ad
oWNLmciennDEREECe Cmi ON
1 herthy , Sw can I em eBavine fmm the Conlon; os Lichen.¢ y aircraft,
cr the
following Icuae. errm t 7031.5. euol�. herdave. cleiona h. or ,r city m county
winch r�Ylrtaa alsocri iitt «repaira11Ynomert
l so toagts theiahn, info for
fri«mIuiswaart rilForwwtoithe lhovisioso fm wchpamit lnfkesiaw ochptfr1)
that Wislicewit pweonnnnlh) 4 Division 3 theta Business
L kmw Lew (Civic)f
(romnrncing with Salinn](1W)of Division Sof Bte Budrcu tad Professions Code)nr'
fast Is, is excmq Ihvefmm and the buu for the allepd cromViian. Any vi^Wion of
Smticm 7031-1by an,.,,Ii.t for a Pemdl whjma the ap0licam to a civil prnalry of
(SSW).
nt 1. IN woefron lovehundood pro,et,, or
omoftheme,Imsy,or myot moyeev with wegamlheirsole(sU, BunmeatI
will Prolow«k,aW tieheC. isroty Licensor Mfcrtdf«.0 s(Sec.an ofB of
and Pmfesaie, v Code: The Cmtrurio License, of law dace a apply s m owma a
pnT my whit Wilda or imPmvc Thereon, oto who does such wink himself «ems1 f M1
bio own employee, pmvldd than such weft Nsaw w are as iyeanded m nRued for
side. Wiltho boo ItarventuwM wiNin«aymrr mole ,cfee the
woner-tower will
waer-wild<r wm here the bunRn or �nvinl than ne did ria wile «imlanve r« wr-
Fl1,Nade.).
D 1, IN owner of dz Pmpmty, un enelunivdy nmlroding with licensed mmncwa or
... the, .j DSDPBig...
T. and Pmfeasiona Code:) The C^nlrianom'a U-
ve law loci lama apply to an owrcr of Bantam who wilds or impoI lhvmn,aW
whocmtrons f«aoN Projecn wish ecmtracmrts) licensed porumol
tor e Coatractm'a
w.
cm'toers
D Iw Licensead S. ,B&PC f«this reason
38I-IOW AMPS
OVER IDMIAMPS
SIGNS ELECTRICAL
SPF;CIALCIRCUR/A11SC.
TEMP. METER OR POLE INST
COMMERCIAL:
D NEN' BLDGIADDRION D DEMOLITION'
DTBNANT C1 FOOD SERVICE
CYFHER IMPROVEMENT
DOTTIER
POWER DEVICES
SWIMMING I'WLELECfRIC
OUTLETS-SWITCHES-FIXNRE
NEW RESIDENTIAL I!Il!CfR
SOFT. - A EA
43
APIR {!
C11 Sir II NI)
i
LSO. FT.
'-
QTY, PLUMBING PERMIT Fq
PERMITISSUANCE
ALM - TRAIN & VENT- WATER (FA)
Owner nuc
VALUATION
WOR K ER'S COMPENSATION DFCLARATION
1 hereby aliirm u Wer Penalty of Perjury on, of the following &clave ins:
I baso, aW will maimaina Cmifinteof Comrnl loaelf-iosurcfor Workm's Canpen-
sstim, m pmviJW f« by Semon 3100 M ds labor Code. f« the per o., of the
work for which this permit ie Lmed.
M I Love mal will maintain Worker's Crmpenaolion frmmace, m requited by Section
3100 M the labor Cade, for the perfo ,crf the work for which this perim, is aeued.
MyW'orkcra Comprnwtim I.. curia tad Policynumbcr arc:
Carrico Policy No.:
CERI IFICATEOF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE
(This region scoffmr W mmplaed iflK Permit it for. hundod dollen (SIM)
or
I enify'loW p
imcrfrmW
moueofmc,orktw
fohieh mi, permh is isaueal, ishall
av employ any Pcoson in any manner w m to b same ol
wbject to e Workers' Compcn.
Z swim Laws of Glifarnie. D.46WtelDEATER
z O NOTICE
OT( E
y NOomc van APPLICANT: If. Co making thin Certificate tof Eailvor, Civic, , y should
F-' normawattiy the WIrth:crro Cocinsor Nimait" tvthe Lehorirnkeytw mus
forthwith comply with such povuian or ON perWlrball to decood rtwkcd.
Q
� CONSTRUCTION LENDING AGENCY,
r- Z Ihcrehy affirm lhauhert i.amnswctitn lending ogrreyfm the Pcrfmnuvee of
Ile wok f« which this "' is iuual (Sec. 3091. Cr, C.)
Is ' Nude
MACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOF AREA, CONE,
STOg)Fg
IYPF. CONSTRUCTION
FIXTURES - PER TRAP
GAS -EA. SYSTEM-1 WC. 4 OUTLETS
OCC. GROUP .
APN
GAS - EA. SYSTEM -OVER 3 (EA)
GREASEIINDUSTRLWASTE INTERCEPTOR
BUILDING DIVISION FEES
G AP
PLANCHECK FEE
SEWER-: NITARY-STORM FA.2W FT .
ENERGY Il_E
W/VII.'f/FJF,CTR
GRADING PEE
WATER SYSTPM/IREATING
SOILS IR:P;
WATER SERVICE -
PAID
NEW RESIDENTIAL PLMB. SQ. FT.
Due Rccciptl
TOTAL
p U
(n
V Z
1<ndei s Acores.
I certify that I wve it this.,licalim oarsman than the eMrva inGmm" m is
sono .lagrectoccnmly wilhtll city andveanty mdinutma etW wtc lawsreloingio
Wilding a'«uvunien. atd hereby authorize rep hoito,s of his city'° ever upon the
.bore-mrntiotd poopet, f«inspection amara'ns,
maty eep h—lca the Cil, of Cupertino against
I Wel agreem.vvve. In&and k
Iiabiliies,jodgmrnu, case std cxpens wldch nay in any way acme against raid City
in crosequcrce of 0e yami.g of Ihia permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS.
�I V
TOTAL:
BUILDING FEE '
QTy, MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC ME
PLUMBING FEE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT(TO 10,BW CFM)
MECHANICAL FEE
'
AIR HANDLING UNIT(OVER lf.1.1 CFM)
CO.S'ST1tULTIONTAX
tgnamze mf Appli t/C « Doe
ARDOUS MATERIALS DISCLOSURE
Will the a,,4icenl In foram huiding «cupum store or h"Ic hverdw material
IN darned by the Cupertino Municipal Code, Cluipler 9.12, and the Heaflih said Safety
Code, Salion 25512(a)P
E] yes Fl No
'
NTLI the applicant or future Wilding occupant use ryr i,ament «devices which
call hvudourfor forsomnanu m&ftod by the Bay Arm Air Quality Msaa,.mt
ptuncvy
Dyes DNo
1 have t,III de Wase ars m-r•nalsAIR
oryuiremmts uakr CFwpa 6.95 of de Cdi-
fomia Httllh & Safery Crdc 5¢li«u 25305, 21533 atd 25533. 1 uWmurd (het if the
W Urs, dca Mt curremly have a levant, that, is at, ocxpom'ih Ivy or notify ole IccuPtnt
of the mlramern a which mon 4 rrct price too.o ofa Conifcatc of Occulwscy.
MHAUSf HOOD (N'NUCU
HOUSING MIIlGAT10N FEE
HEATING UNIT ITO IIM1.UUp BTU(
HEATING UNIT(OVER 100.00) BTU)
PAW
VPNfILATION FAN (SINGLE RES M)
Game ReccilN #
BOILER- COMP DHP OR I WAW BTU)
TOTAL
BOILER-COMP (OVER IW,OgI BTU)
CONDITIONER
ISSUI NCE DATE-
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. IT.
Owtler or aulhreizN ogcm Dame
TOTAL'
OFFICE