29182APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITYOFCUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMITNO. 291 A
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DUppILU''I//NG ADURES�S:
77..� FjQ L.� Cc b�T/�✓D CC 9S �J/7
SANITARY NO,
APPLICATION SUBMITTAL DATE
L^ q
OWNER'S AM& ��II NE:
WRAC1OR'S NAME_ LIC NO:
NIC
❑
^ C NTROLL0
1 1 '
A CHHEC fENGINEF:R: _ LIC NO:
*CONTACT
ADDRESS:
PHONE
4.LYR-�1- /H/s�'✓.L CiC—�'.i -� ���%
❑ Consullenl Foes Paid 6y Appticmt (Inillel)
BUILDING PERMIT INFO
gl.oq ELE PLUMB MECH
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LICENSED CONTRACTORS DECLARATION
1 hmeby affirm dust I w Ikened order I+ov arns of Charter 9 (comm ening
with Soelioo 9gp)nrnfviosm 9ofUCB.oa—and Profekdom, Gal, end my license is
full Trots end cR«I.
I.icrnsc Class Lw.X
Dem. ��ys
1 undcntend my Owl" M to l aslwn c Iecl cod+
QTy ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL'
❑SFDWL HEN REMODEL
❑ADDITION PLUMBMG RE-PIPE
❑MULTI-UNff MODIFICAsTbucruTION
L1 INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT i
❑BATHREMODEL,REPAIR El DEMOLITION
❑ OTHFR
PERMIT ISSUANCE
APPLIANCES-REMDENIAL
PANGS
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Licensed l4nfu"wind
OWNER-BUILDER DECLARATION
I hcl<by uffrm That I R-excmp Gwn the RATIO,rs License Iaw for the
following ¢lase. (S«lesa 10715. Rudw, and Pmfnsiom Code: Any City or crawly
which require a permit to mrawart, alter, improve, wrov ah, or repair any sauerem,
priormiu iasuwlcx, ales rtwie6 lheeppicaum for wch permit to filea,ignd swle.I
that he is IicensM Passional to the Proemiava of the Coslracwra Id«nre Law (Chapter 9
(emonnaeing wilh Section 7010).1Division 3.f he Nosiness andt l'mf«siom Cei
thin he is exenryl lherm efaanal the basis for Ne olkgal essna ion. Any violation of
Section 7031.5 by any, appliwnfor a Permit nubjeals last eppLcant to e civil Penalty of
re alae five hurvlaN aallvx (s5(XII.
as owrrr of the proteny.vmy«rploym with rouges u theirwle compismanoa.
KI work, tied the muctureiaawrmtenauloroRered forsole(Sec. 7W Business
and Pref.i. Code: The Cotnterr s Iaceme Taw does nal appy to an a of
pmpcny an mild, m anpmvra then, and was der,,ach work hlenait or Ihroagh
his own trefluycu, provided Dur anh impavcmcou are mr itcsdcd or oBcacd fa
We. If, however, lar bulldingor improvement is end within one year efcomplction, the
acrbuilder will leve Ne burden of proving alar he did not build or inrpmve for lar-
parse of sa[e ).
[31�
nl cor mes m
1, ax owner of the pnrycny. to exclasi very comeasidng with IiswTo
�W 9 the practice's (.Ser. ]OU. Bm'inru.nd Premexiau Code:) The Conuctor's
c-- Law tiara nut.pply toanown<rorgoPeny who lulldsar improve alantin,end
wan roes«. for loch prgnv witha committeeman.) liceesed Psalms b (he Connectors
Late.
❑ l am eacmp Sec. , B & P C for dds Asan
2(TI-H)k0AMPS
OVERI"AMPS
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC.
TEMP. METER OR POLE INST.
COMMERCIAL
❑ NEW BLD ADDITION ❑ DEMOLITION
�'IENpNT ❑FOOD SERVICE
INIT>aovEMEvr
❑OTHER
POWER DBVICP
SWIMMIN .ELECERIC
OVHJirs-awl S-I'IxrUREs 01
32,
NEW RPSIU IAL SQ 17.
IJ—
SQ. FE FLOOR AREA
-
i"
Clay �� 9199
ESQ. FT.
'
QTY, PLUMB( G IT FEE
` PIRMITISSUANCE
AI.TEN-DRAIN&VENT'-WATER(EsO
_
= eno
w Wok KERS. PEI:SATIONDECGRATION
I hereby affirm under pemlty of perjury one of the following decimations:
)have and is al mama Cenificaw fc.. to xIf-hei for Worker'. Compton-
satin, u pwvNel for by Stake 77(X) of the lssar Calc, for the Perfommerte of the
- work lo- whicb Nice permit is i.sacd.
- O 1 ban and will mwearn. Workers Compcwrion laccan's. a, o'—so by Secure
7]1X1 of Ne Labor Code, forlM prrta,aweeof Ne w,rck for which Nis permit is ustrd.
My Wolds Compemadon howwmse carrier sd Policy numb« are:
Carries Policy No.:
CERTIIBGTE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thi,¢ti,m seed nrX beeoenplad ifNe pmalufw orc WrdrddolW(51001
or �.)
I certify that in Its, Performance of thew nick, for which Nis penal is ia,ted, l shall
ser mini any Peraen in tory tame so m to bermes, cable. n But Worker,' Compeer
Oz anon Lswa of Caliliamia. Dtc
C) Applicun
rjy NOTICE l0 APPLICANT: If, after marking W. Cenificale of E clnition, you shtwld
h^ boe subject Ir the Workefm
1ecm s Copuali
non Prs ovisionof the Inbar Code, yen mus
Q farNwith comply with wch Provisions or on, —it told he deemed revoked.
7 z CONSTRUCTION LENDING AGENCY
L) O Thereby affirm that that. in a construction kding agrncy for dsc perfmmure of
the work for which Nu perrwt Is Neatest (Sec. 7091, Civ. C.)
O FLeener'sNanr
V Leder,AJcime,
y1 cesify Nat 1 have read this applicWos"scle Nat the shove infom antis is
IA const. 1 egret... comply with all City td county adianraa ",we laws mloGng w
V Z Wilding«nurucrion, and scarify nwlmiae acpreacnladvn of this cin to enter apron de,
above-mentianea Paopcny for iinfection purisav,.
(Wer) agree n save, indemafy surd kecp hatrat the City of Cupcnirn agvw
Tubiadea,jdgmeno, mus anal exPenan which may in any way uecme arkmasl send City
in Consryornce M ILK granting or Nis penia
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE: REGULATIONS.
Signuureof AppicentsUmmoscw Use
HAZARDOUS MATERIALS DISCLOSURE
. Will laeapplicam orfwue, Wilding occupant more or handle haaardous mteried
as defied by the Cupertino Muacifa i Code, @aper 9.12, will Irk Health said Safwy
Cody Semon 25571(.)7
_ Yn �Ao
_AmiB Ik appkanI m forces, Wihang «ruptu use equlpmeu on devices which
rnitiuI a la anWtinenl,e, &curd by de Bay Mea Air Cushy Mwagentem
dalim;J
❑Yn [:]No
1 ton and the clamorousnmlvials eequ'ueoros under Chagn 695 d' dr Cafi.
harms HUIIh & Sat Cow. Sectiw 25SP, 2-1577 and 2550. 1 understood dal if the
W ddelt alma Mc mently haat a Irnunr. Nae it is my anpomsibility m wi ify de acapam
of dac rcCpdnenrna winch mut W cot lrimon issvwv'e ole Crnir to of(k'i'.Pwi
bVALUATION
BACK FLOW PROTECT. DEVICE
DRAINS-FLOOR ROOF. AREA.COI:U.
STORIES
TYPECONSTRUCTION
I FIXTURES-PT:RTRAP
GAS -EA. SYSTEM-I INC. i ODDITIS
t)CG GROUP
APN
a
_
GAS -EA. SYSTEMAVER J (EA)
GREASMNDUSIRL WASTE. INTERCEPTOR
BUILDING DIMS NFEFS
CREASE TRAP
PGNCHECK FEE
SEWER-SANITARY-STORM EA. 21X1 FT.
ENERGY FEE
WATER HEATER WNENT/ELF,CDt
WATER SYSTIiMITREATINO -
GRADING FEF.
SOUS FIR
FEE
WATER SERVICE
PAID-'- RneigX
NEW RESIDENTIAL PLMB. SQ. Fr.
,
TOTAL:
'
BUILDING FEE �R
QTY MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE,
I:LECIRIC PEI;
ALTER OR ADD TO MUCH.
PLUMBING FEE
AIR HANDLING UNIT(TO 10.000 C17M)
MECHANICAL
AIR HANDLING UNIT (OVER 10,000 CFS.)
III EXHAUST HOOD(WIUUCI')
CONSTRUCTION
HOUSING MITIGATION
HEATING UNIT (TO IW.OW BTU)
HEATING UNIT (OVER 100100 BTU)
-
PAID
Date Rraiq
VENTILATION FAN (SINGLE RESID)
BOILER-C'OMPOHIOR I00,000BTU)
BOILER - COM P(OVER ((0,000 BTU7
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY: �,yl
- NEW RESIDENTIAL. MECH. SQ.1
-
Owers, erranNadaN ages Due
L
OFFICE