S 2676APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING -ELECTRICAL ------
PLUMBING - MECRANICAL
PERMI'1'NO.
S
2676
IRA LDING DIVISION APPLICATIONAIERMIT
LICENSED Cf RACI'OR'S DF LARATION
1 hmehy amort mm 1 am closed under previsions of Chapter 9 (commencing
wlllt Senion]Ofq)nfDivlsion3s lhu lAtxinc<s nnJ Pro(eesinns Cale, unA my license ll
m bt 11Horn and effect.
Liccnasc Clxrs LILM
Dale Connector
QTY ELEC-rRICPERMI'F FEE
JOB DESCRIPTION
JjJj$IDF.NTIAL:
[ISFDWL ❑ KITCHEN REMODEL
]ADDITION ❑PLUMBING RE-I'[P17.
]MULL LUNIT ❑STRUCTURAL
MODIFICATION
[I INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT QSWIMMINGPOOLS
❑ HATH REMODEIIREPAIR Q DEMOLITION
❑OTHER
J
TERM1'1' ISSUANCE.
AI'I'LIANCES-RESIDGN'I'IAI.
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BUILDING PROJECTIDENT'IF'ICATION
PANEL
UPTO200AMPS
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ItUILU1NG ADDQ[S5:
ZBI-IIXMI AMPS
OVI:1t PRI AMPS
SANITARY NO.
AI'PLICA'lUBM
NOVM�ITAI, )ATG
/r'tiFi,c��
�oz�
'I PMI'. MIGIFORPOLBINS'f.
I'
li G/ADDITION ] DEMOLITION
[I FOOD SERVICE
IN OVEMENT
QOTHER
3
qg
( - LIC Nqe J I , ALIDNI'ytiSti • - _ „ - / 1 ❑
I- I ,
11(•/F/•'
❑ Consultant Fees Paid by Applicant (Initial)
In DO F.LECIPLUMB MHCH /
IrhC/ rL~Y/ IlrKl/
Matz
WOO
Fad
�UU
LICENSED Cf RACI'OR'S DF LARATION
1 hmehy amort mm 1 am closed under previsions of Chapter 9 (commencing
wlllt Senion]Ofq)nfDivlsion3s lhu lAtxinc<s nnJ Pro(eesinns Cale, unA my license ll
m bt 11Horn and effect.
Liccnasc Clxrs LILM
Dale Connector
QTY ELEC-rRICPERMI'F FEE
JOB DESCRIPTION
JjJj$IDF.NTIAL:
[ISFDWL ❑ KITCHEN REMODEL
]ADDITION ❑PLUMBING RE-I'[P17.
]MULL LUNIT ❑STRUCTURAL
MODIFICATION
[I INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT QSWIMMINGPOOLS
❑ HATH REMODEIIREPAIR Q DEMOLITION
❑OTHER
J
TERM1'1' ISSUANCE.
AI'I'LIANCES-RESIDGN'I'IAI.
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CIII'1'ECPS DECLARATION
til h: he used res public records
cr I� a
PANEL
UPTO200AMPS
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1.%c�i<e 1' fesstnnal
ION
1 hereby afErm �1 a 1 am le [BOER D[ia in I Nc Can?mc m i License Law for the
billowing reason. (Section 7031 5, Business and Professions Code: Any city or county
which requires a perm, to consumer. altar, improve, demolish, or repair any structure
priorm hs issuance, also requires lite uppliennl for such permit mlilcnxignml stmmnem
ZBI-IIXMI AMPS
OVI:1t PRI AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUI'I'/MISC.
-
y,
do
1d � o a
Ise
E=0
F
L 3 el,
ul he I, Licensed untainut be do, reskinnsnf the Connectors Llceno, Law lChapter9
(ean....encing with Section 71101gofDivis nn9uflM1C Hneincex nnA l'ndandnns Code) nr
That he is exempt therefrnm and the liters or the alleged exemption. Any viol error of
Similar 7031.5 hyanyapplicam for m vanotodderts rhe applicam to a civil penalty of
announce than five hundred dollars (450x)).
Q Las owner of rhe propcny. nrnry entployms with wages as their...ecompmeamm
will Jo the wudrod the structure is not intended oroRered for sale 71W,Bu<imv
and 11..he.roions Code: The Cramer v License Law uses our apply ,I an owner of
property who builds or improves Ihcaan, and who docs such work hireelf or IAfmgh
It,, own camik,ces, provided Thar such itipamenent, aro not intended or offered for
wle. If. however, the bulldingorintpmvcmem is sold within one year ofrompletiom,the
'I PMI'. MIGIFORPOLBINS'f.
I'
li G/ADDITION ] DEMOLITION
[I FOOD SERVICE
IN OVEMENT
QOTHER
PUWI?R DIiV ICES
SWIMMING POOL ELECTRIC
OUILI?r5 -SWITCHES-FIXTURES
NEW RESIDIWFIAL ELECTR SQ 19f
SQ. Fr FLOOR Ak1iA
4I4Q. Fr.
owncohmlder will have the burden of proving that he did nor build m improve for pur-
poxe of sale.),
proper y, sen exelnsivel cnntrunln' sell, licensed mnumm�rx m
]1, us owner of rhe t Y 6
'I'O'TA L:
constmut rhe project (Sec. 711,14, Eminess and Professions Cudc:) The Canvocbsr's hi-
sc Lawdoes not apply m an owncrnfpropery who builds er Improves thereon, and
�(//•`e
QTY PLUMBING PERMIT FEE
who contracts for such projects with a commalmon lic, nseu pursutm m the Contractor's
PIiRMI'I' ISSUANCE
License excu
❑IamcamPl undcr5ec. .tl&PCfile his on
AI TER - DRAIN & VE - - WKI'ER IEA)
Owner Date
VALUA'T'ION
WORKERS COM I'ENSA'r10N D
BACK FLOW I'R E Ii
fdreto Norab
I hereby affirm under penalty of perjury one of rhe fallowing Jcalnnvians:
l haveand will maintain a CmrilicanordConsent. self-nere Raw .. lor's Carmen
e,ioam m provided far by Section 371X1 of fe, Labor Cres, Int Oe perliamureenf the
work fur which this perch is ilorcol.
DINS- FLUOR, ROOF, AREA -O
RIES 11 'YI ? CONSTRUCTION
�� ��
NX' ISS _ PER TRAP
Q have and will ear maim Worker's Compensation Inmmner, c required by Section
371N1(t the Labor Code. forthe orrtiam:mce arthe work for which this permit isissuad.
My Worker's Compensation Insurance carrier and Policy number am:
Camel Policy No.:
OCCROUP (] AEN
MAR 4 19x79
CAN -IIA.SYS7'EM-1 INC.4 OU'IL. S L
GAS-IiA.SY. RMdVER4(FA)
GREASIVININSTR WASTF.INTfiRCIiITOR
CERTIFICATE OP EXEMITION FROM WORKERS'
COMPENSA'I'[ON INSURANCE
BUILDING DIVISION I EES
OR BASE IRAI'
nor he cnmkted it rhepermit is harem, hundred cultures IW)
(]III,section need a
ar less.)
' ANr'tit:(`K FPP �I
SEWER - SANITARY -STO EA. NNIIT.
%.
z Q
ti h
;
aQ
Uz
U O
kz�TOTAL:
(~
0 L%
'�'I pedp,�
�. V)
U z
I certify rhe in rhe perfromame of the work for which this permit in i>sued,Ishot]
va'fairly ony prion in any mannerist a to become subject,, the Worker,' Compoe-
s:niun Lnwa of Culihmnla. D:ve
Applicnnn
I:NHROV FEE
GRADING HE
WKI'EIt IIFA'I'EIt WNEN'I'/M.EC 't
NUI CH 10 APPLICAM': IL a0er making this Certifcalc ofa lincmptiun, you should
bell as subject m the Worker's Compensainn provisions of the toast Calc, you must
forthwith comply with such provisions or Ibis Permit shall he deemed revoked
CONSTRUCTION AGENCY
ennumetion len,agency ,eche Performance of
Iherchy off rm that The. here isix.din
the work for which his Permit is issued (Sec. 3097. Civ. C.1
Lender's Name
WAl ER SYSTEM/IRBATINC,
SOILS FEE
WAI GR SERVICE
PAID
NEW RCSID[MIALPOA B. SQ 1
Date Receipt If
Tf]rAL:
lender's Addmxs
BUILDING FRE.
/
1 ecnify Ihtn I hove scud thin upplicnainn and xtme lout Ibe above infnnnmian is
aonem. l twee m same, with a l chy and county oolimmcex and slate lnw.<rcladns in
erehy arim represemmives of this city to spm enter the
building cnnslowmer,mal hmho
_7
QTY. MECHANICAL PERMIT' FEE
t
SEISMIC FEE
PERMIT ISSUANCE
±Lpentic FEE
/
ti
shave -mentioned property for as,oker purposes.
(We)agreemuve, InJamnif Ike' harmless aha Cit fCn linnu Diner
y am p r n per s
OR ADD TO MECL
liabilities,judgments. coeds and uspmms which may in any way accam against said CityL'rIE
imcomerionceofthegmnrvgor lmspennit. I
PLUMBING HE
AIR IIANDLING UNIT(TO Iq(x1fICPM7
MECUANICAL PE[
APPLIC ( ' UND qST ' AND WILL COMPLY WITH ALI, NOWPOINT
SOUR, : t,Ul 6
AIR HANDLING UNIT(OVE,R I00x)CFM)
CONSTRUCTION TAX
Signumr of ppliwntlGmma- Dom
HAZA )IIS MAIPIRIALS DISCLOSURE
EXHAUSTIHOODIW/DUCII
HOUSING MITIGATION THE
IIIiNI'INC. UNIT,(TO I(100)(I It'll)
Will rpc applic ani hture huilJmg nccupam ntnrcor hunJle 'I I. material
.emir
as defined by the Cupertino Municipal Core, Chapter 9.12, and the Ileallh and Safety
Cod,, Section 25532(a)7
El Yes Lyse
Will the applicant or fdure building occupant use equipment or devices which
havNous air contaminants as defined by the Bay Area Air Quality Management
HEATING UNIT (OVER I(Mim) B'rU)
PAID
-
VENTILATION FAN (SINGLE RCSID)
Date Receipt x
BOILER- COME(3HP OR 100,000 BTU)
'TOTAL:
7
BOILER- COME (OVER EptypoI R,TL
District'!
El Y.
AIR CONDITIONER
I huuc real rho harmloux nnmcriulx rulniremems under Chapter h95 of the Cali-
liai a Ilc.alt Sn • C d , ..Bons 255115, 25533 and 25534. 1 imalo ouul rhe dthe
hilildia� u nlcrjan6lhat it is nryreslwnxibiliry to nmilythm¢vvpanl
ISSUANCE, DATE
Nil I' RIiSIDENPIAL MECII. SQ. IT.
of if /arprinnn issuance of a CeniGarle of OVentwney.