S 5498APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILIIIND. ELECTRICAL
BUILDING DIVISION APPCICATIONAIERMIT PLUMB NO- MECHANICAL _
Bun:nmr, rRo.u;cT HH?NTu� lcnrum
PlIt�IINO.
J -1597
BUILDINCIADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
OWyER$fgj�lE J(JG PHONE:
CONTRA OR.SNAAfIi:/� Jrr'�G -CN
NIC
❑
CONTROL#
ARC/CII/IIRECTRNGINEER: LICNO:
ADDRESS:
e--
CONTACT : PIIONIi:
BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG li iC' PLUMB MECH
MZZ
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Oh
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F I:FadLicensed
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4i 3 LL y
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F'� Y
Q❑Lan
9p
UCF,NSED CONTRACTOR'S DF.CLARA'HON
I herehy al'rrm Ihm 1 ma teamed nicer pmvinl.. ..r Chaplin 1) m.,�n,n alit,
wlllt Seclimt 9000)nl nn3nfthn Buslnessand Pralexsinnn CnAo, unU til IkonncL
in full faces nd utfs,,Cf/O U �
-iccnnc CLl ontr
male a, S 1 Kr
Contract /
QTY. ELECTRIC PIiRMI'I' FhF:'.
JOB DESCRIPTION
L:'Dlvi.
RESIDENTIA
❑SFnWL ElKITCI HEN REMODEL
[]ADDITION ADDITION PLUMBING REPIPE
❑MUTAl-UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEIJRI:PAIR (] DEMOLITION
[]OTHER
PERMIT ISSUANCH
NT
APPLIANCES - RESIDEIAL
ARCHITECTS DECLARATION
Innder,landmyplans.hail beused aspuhliencemd,
PANE LS
UPT02MAMPS
Professional
I head y ufrrm inOWNER-BUILDER
, I r, e.emp Efootman,Connote License Law manic
following reason. (Section 703 I.S. Business and Professions Cale: Any city or county
which regnires n permit m conslNcl, eller, impms'e, demnli.h, Ur repair any slNs'lure
prior m in issuance. also requircahe applicant for such pertain,, file a signed statement
That he ElicenseJ pursunmmlhe provisions of the Contractor',license Law lChapter9
Ieommeneing with Seclinn]U)d)af Division 3ofthe Buvinesn and Proessinns Cale)nr
That he is exempt therefrom and the basis for the alleged exemption. Any violation of
l,alliken the applican,, a civil penaltyof
Section )031.5b,an,,d Pll,wdlmepmmt
nor n ore than live hundred dollar, (5500).
owner nfthe Pnmeny,mmyemmendeswith wages
ned hasltheir (Sve. contpe7044. oi,inen,
el5ec.aan,owne,aa
nm,License
will JC lhowon,
hc11he
201-1000AMPS
OVER I"AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
/ TEMP METER OR POLE INS'1'.
COMMERCIAL:
❑ NEW BLDGIADDITION ❑ DEMOLITION
❑TENANT OU SERVICE
IMPROVIiMI'
❑OTHER
POWER DEVICES
SWIMMING IKJOI. ELECTRIC
C(aland
Law dd.....l
.all I '.i( Ic: II C t- t L L J t pl lyt wncr d
Caramel-,
OUTLETS -,SWITCHES I'I%TITRES
pmt ty '11:., ,th n J I d :' kl If Illnlyh
his t ply pl I d II't : h' pm L. t' t d t D red Ino
sale l Lbmwcvm,lhcboddmgot im,nmeme.I kind within one year ofcu npleainn.0¢
NEW RESIDI'm Al,III ('!'R 5(I rf
SQ. Irl.. FLOOR AREA $/SQ. F1.
c,landi cr vvdI h: ve the hnNan of proving that he did not build ur improve [nr pur-
grscofaJeE.
I, an owner of the prvla,o tan exclusively contracting with Ileessed commmo, m
,
TOTAL:
construct the projem (Sec. 7044, Braman and Professions Csde:)'Ihe Conuant-v Li'
seal law donation apply In unnwner of progeny in ho builds.,, improves thereon. and
clor(s) IiecusedpurNann the Contractor's
whocommets forsuch projects with mcommn
QTY. PLUMBING PERMIT FEE
PM �f , q
PERMIT ISSUANCE
License Law.
l an excntplunJer Sec. ,B& 1' C fn this reason
[/
ALTER - DRAIN & VENT- WATER G:A)
VA1.&TTQN
ff//
Owner - Date
BACK FLOW PROIECE DEVICE
WOR KER'S COMPENSATION DECLARA PION
C�T.
•
Ihereby tilirot mile, penally of perjury one of the following Jeeltal ions:
�I// '
(have and will NvintainaCenircme el Cnnsenun self-insure fir Worker's Compem
satien, as for b Section 37M of the La w, Cale, for the dormadr, of the
pn,vhu r, pe
work for which Nis is issued
DRAINS- FLOOR, ROOF, AREA. COND.
STGRIHS I'C Ty ECONSTRUCT[ON
h IIVU
FIXTURES-PER TRAP
sonlai orlon' his Pura it Sssued.
r,{"7 hive and will ntaimaar Woolen CompCane o the w rkfor which
700 of the huhor C,,do, fnnhe podnrmvnca of the nod for which this punnh ie issued.
OCC, GROUP APN
GAS -EA. SYSTEM-I INC. q(IUTt,lsf5
Myswis Cn-mBr] trot ) q{and Policyao
Cmdei9 amu'/� 'LryOro'+=1' Policy No/y`aa"Z� '7111&
GAS -EA. SYSTEM -OVER 4(BA)
,
CIIRITPICA'lli OP HXEMITION PROM WGRKIiRS'
COMPENSATION INSURANCE
CREASUINnIJSTRL WASTIi IN'I'IillCl!PIY)Il
BUILDING DIVISION I131?5
(This section need not beamnplmedifnheperion isforonchvndmddnllnr,(Elan)
nr less.)PLANC{Ir:CK
_
GREAS12TRAP
Plili
1«city lhm in the perfnmtance.,!abet work fnrwhichthispermiL ixc,awl,]shall
become object the Workers Campers-
oat employ any persin any manner so as m ti
on
SEWER-SANITARY- STORM IiA. 200 EI'.
ENERGY TLE
WATER HEATER WIVI:N`UFl.FC1'k
WATER SYSTHMn BEATING
WATER SERVICE
GRADING FET:
Oz
z Q
cA
a;
Lk1
aQ
az
4. 0
fL Hthe
� L)
>+ a
Ln
G o7s
claims laws of California. Date
Applicant -
NOTICE 10 APPLICAW.- If, after making this Certificate of Escmptior, you should
beenme subject to the Worl,cen Compensation provisions of the Whir Cash, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
ONLENDING AGENCY
CONSTe is� construction
that isacomSee 309ending agencySlo�e perlormance,,!
I hereby hs,
work Ibr which this permit is issued (Sm. 31M'I, Ci, CJ
Lender's Ndnre
SOILS IFF,
PAID Date Rtt'ei
T
NEW RFSNENfIALPLh18. SQ. FI'.
Lenders Address
TOI'A1,:
BUILDING THE
I anify Ih:n l have mud This npPllrnlimn and surae that the above information is
correct. I ogree m comply with all city an,[ couny nrslinmma nnA same Wws filming m
hui1A'mgconnlNetlon, and harchy tmttonle represenenivesulduk city or anlm'upoltabet
QTY. MECHANICAL PERMIT, FEE
t
SEISMIC FEE
PERMU'ISSUANCE
ELLCI'RIC I'IiH
al cou,ntioa,,d,a cl ly fir ln,pecdon pumrvnc,.
(We) agree m save, indenmlly and keep hmmless the Oly of Cupenlno ngainet
PW MBING PP .
Ilabililie.v,jadgnwma,eoYe:mdespesne. which may in any way secure against xnid City
in miueciance of the gmaling,,I rix permit.
APPLICANT LINDIIERS "N AND WI LL COMPLY WI'I']I A LL N ON-POINT
S Uio—r%�'/�J' A'T
AUFFIR OR ADD TO MECH.
AIR HANDLING UNIT (1010,000 CFh1)
MF.CHAN .AL FTE
AIR HANDLINGIJNIT(OVHR 10,Ixd CFM)
CONS' UCTIONT'A%
Signature n pplicanVC,,ntmcmr �✓ Date
HAZ RDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(WIDUC1)
HOU. ITIGATION FEE
HEATING UNIT (TO I od,m) BTU)
Will the applicant or future building occaptinl store or handle laroudous mmenal
as defined by the Cupertino Municipal Code. Chapter 9.12, and the llcullh and Safety
Code, Section 25532(a).'
HEATING UNIT (OVER I10i B'I'In
E] Yen 0N
Will the applicant of finer, building occupant use equipir l or devices which
emit s air contaminants as defined by the Buy A= Air Quality Mnnaganent
PAIDpL a -
Dove Rt ei
VENTILATION PAN (SINGLE RIS IIP
NOILER -COMP (3NP OR 100,000 H'I'U7
BOILER- COME (OVER 100,000 ETC)
ict?
District? o
F1 Yen ❑Nm '
AIRCONDITIONER
I hrrvc real the huennlons mtnerialare awdcrClm mr[s45 of this Cull-
yninmcn p
ISSHAN F: DATE
NEW RESIDENTIAL. MUCH. SQ. Fn
facia Ie:Jlh & Slay Code, Seaionx 25505, 25533 and 25534 1 maletso nd that if the
bnilding des nal currently have a vena ti,Lhm a is Ny responsihility Io.... lily the,nxtTanl
offal requiwmmals which must be met pn,,r to issuance of a Cenitlane ol'(kmynmq.
TOTAL
��
ISSUED BY: \_I�/,�
Owncrmauthnri,d agent Dale
OFFICE