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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
BUILDING - ELECTRICAL
PLUMBING. MECHANICAL
'BUILDING PROJECT HIENTIF'ICA'1'ION
, PERMIT NO,
�` �CO
J v o
BUILDING ADDRESS:
SANITARY NO,
APPLICATION SUBMITTAL DATE
OJT 01 W b6l M e - APf'LZ- /0
O NER,S ME PHO ^ ���
12 to
CONTRAC'IUR'S NAMEIV
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PPP
NIC
❑
CONTROL#
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AIIC IEC'IIENGINLER: LINO:
ADDRESS:
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CONTACT': I PHONE:
DUILDING PERMITINT°O
❑ COnsUltallt Feast Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONQTY'
1 hereby .Bata hat 1 mo licensed under pm,,W as of Chapter 9 (commencing
ELECTRIC PERMIT
FEE
JOB DESCRIPTION
PERMI'1'ISSIIANCIi -
with Scnion]nfln)nf Divisinn 3oftlie Bmaressund Profes9an Cnde,andl 'license is
in f ullliteeandefer. /14 Q/
RFSIDFNTIAL'
❑SPOWI. C1 KITCHEN kI?MODEL
_
PLIANCIiS— RESIDENT AL
LiccnscClass Lice# V7710
D.an Contrucro
ARCIII'I'IiC "S DIiCLAHATIO Q
I understand my Ideas shldl be uwd al public recuof l
❑ADDITION ❑ PLUMBING REPIPH
❑MUCI'1-UNIT El SI
MODII'ICA'fIUN
Ll INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E)SWIMMING POOLS
PANE L'S
OPTO 200AMPS
Licensed Professional
201-10XIAMPS
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt frond life Commemrs License Law for the
following reason. (Section 7031.5, Business and Professions Cade. Any city a county
[I BATH REMODEDREPAIR (3 DEMOLITION
❑ OTHER
OVER 1(XXIAhtI'S
SIGNS ELECTRICAL
which rayuirea a permit ,o cambact, alter, imprase, demolish, Our repair any stmcmre
SPECIAL CIRCUITIMISC.
prion.its i.ua:ecce, also reyuirc.a llmapplicum fo such permitus life. signal state a,,,
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(cont aims with Section 7000*0 Division Sof the Business .,ad Profdesiom Cnllater
Thal heels exempt therefrom and the basis tit the alleged exom,dica Any vinlutlon of
TEMP MEI' 1]t OR PULE INST.
COMMERCIAL:
El NI BLDG/ADDITION ❑ DEMOLITION
n suhjeaa the up
Safno'ID31.5 by a., appltemn fur uperni pltcaou,, a civil penalty of
POWER DEVICES
II3NAN'1' ❑POGO $CRVICIi
ul nmrc then Eva bundrCJ dolma 1%51X0.
❑ Lm owner ofthe property, or myempinymc with wages as their sole aempvnsudnn,
wd l do Ihewnrk, and the swcture is not intended or offeredfnrmlo (Sec. ]000, Busiress
mud Ponficssioos Cade: The Cont amses License Law daex out apply m an cat of
IMPHOVEMINI
❑ OTI TER
SWIMMINGPOI)I. ELECTRIC
'
OUTLETS—'WI �' .ILXTURTS
NEW RIi)' L ELFCFR SQ IW70
'�
AL
prnpeny who builds or improves thereon, and who does such work himself or thmngM1
his awn employees, provided Ida, such impraveat am not intended Our ulfered for
sale. If. however the building or impmvemem issold within one year ofcompletinn.the
SQ. leE FLOOR AREA
VS). FT.
owner -builder will have me burden of pmving that he did not build or imprtne fm par-
psw of sale.).
El 1,.s owner of the promat um ovel udvely cmurnei ing wil h lanes it enmmcmm to
tlemlmal the project (Sec 7044, Rusiucx. and 11mlbasinna Codc:)'Iba C'nmmcvdI Li-
xo Iauw duce nm npply In un nwm.r,f pmpedy whit holldh nr improvus Ihcmnn, and
QTY, I PINING PE IT
wbn anuruuts lar xuehp Jcetn with nannrnchds) licensed pit rsmmm the Cnntmmnrs
P17RMIT ISSUANCE
Accuse Law,
T out exempt under Sec. . B & P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
ALTER — DRAIN & VENT— WAT ' )
VALUATION
y� ^
SD
BACK FLOW PRCI£Cf. DEVICE
1 hereby affirm under penally oI perjury one of the honest dada itions:
I have and will maintain oCerifcamofConenuo self-insumfor Workees Compen.
onion, as provided for by Section 3900 of the Laba Code, for the performance of the
DRAINS— FLUOR, ROOF, AREA. COND.
STORIES 11
TYPECONSTRUCTION
wad Ga wllich this pemtil Is issued.
FIXT'IIRFS— PER TRAP
1 have and will maintain Worker's Cn alwmvatlon Insurance, as reyuirnl by Section
19811
.Irl Ilhe Lah...Cade, for the perltmnunce nfthe work far which lhi.,cr it leu issued.
My War ry C`mpe uo0 nxurnna carrier
I'alicy No.: �YE]_O 1
cr. Pool, bm.:,:glQryry lff
GAS— EA. SYS' I'1?M. I INC. 40U'1'LETS
OCC, GROUP
QJ N +
V' y
CAS—I?A.SYS'1'I?M=OVF?R4(EA)
'ERTIPICAI l? Op EXIiMPIION PROM WORK17RS'
J
1yst� IENSAHON INSURANCE
nu
R u neetY tTmmall
on less.)
GO'
GREASI%INDUSTRI. WASTE INTERCEPTOR
BUILDING DIVISION FEES
GRF.ASETRAY
PLANCII[CK PER 2 0
I cenify that in nheperfamucaf,hework for which this Permit isi%%md, l shall
nm nmPloy.ny person in any manner sit a es Murata suFjecna,he Wnrken' Comped-
SEW(iR—SARI' —ST :A. IIT.
ENERGY ME
WATER IHATHI ENTI.L.p
46
GRADING PER
aninn I,.xs of California, Data
Applicant t
No] 'ICH '10 APPLICANT': If, after oinking this Cenilicam of I?xemptian, You should
subject m the Worker's Co na;vc,tinn provisions of the Labnr Gila, you muni
'[ 1. BEAT
WATER SYSn
SOILS FEEhcanme
1' .... ov It amply withsuch prnvkin I,or This permit a hill be deemedruvnked.
WATER SEItVIC
CONSTRUCTION LENDING AGENCY
ctum lending agency forme of
I hembyafdirm hauhem iv ucnn.wm
NEW RESIDENT' AQ. MB�sT^^�'
PAID p:ne tp
p
the work for which this permit is issued (Sec. 3097. Civ. CJ
Lenders Name
T L:
TOTAL:
Lenders Address
information is
BUILIANtli Z
I cattily that I have read this application and stale that the above
- -
Caren. l agree to amply with all city and county ordinances and state laws relating to
building construction, and hereby au,huriu represemutives ofthis city to cmcrupem the
QTY. MECI IANICAL PERMIT
FEE
SEI de
PI?HMI'f ISSUANCE'
ALI IAt OR ADU'ID MECO
EI.'( C FEE
above-ammianed prepcny far inepccdnu purpams'
(Wc) agree m saves indmnnify Bind keep bar the City of Cupcnino nsain.a
Ilabilitics,judgmcnl., costo anA expenses wllich lacy in any way uccrueasain.0 sni I City
xcyucna at he narfra,ul his Ian nil.
PLU INC IL?I?
AIR HANIl1,ING UNI"1'('fO 10,fX10 CPM)
MG IANICAL PEP.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1, NON -POINT
SOURCE RIUULATIONS. 6�
AIR HANDLING UNIT(OVER IO.fN10CFM)
CDN$' UCf10N TAX
yl nV g,
FXHAUS`T 11000 WIDUCT)
HOUSINI MITIGATION FEE
NSa tp are of ApplicanVContracmr Dam
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT 110)(saw HTO)
Will,heapplicad or future buildingo:xupamsmre or handle haeardnax mmedal
as defined by the Cupertino Municipal Ott e. Chapter 9.12, and the Health and Safety
Cn n. Nation 25532(.)I
Yes yon
HHATINC. UNI'(' (OVEN RIT" BTIJ)
Dam Receip,N
VEMfILATIUN PAN (SINGLE RESIU)PAID
d
POILY.H—COMI'(711P OR IIN1,01NI IT
,
or devices which
use . Air
Will Tho I,!, co ti Illuu fubrc building rocby fie
mil hurunlouv air cnnmminanly ox alined by the Buy Ama Air Quality Munugcuneni
T&
BOILER — COMP(OVER 100,000 BTU)
Dion.?
[I yes a
AIR CONDITIONER
( have mad lhc hamsdnuvion25505,25533 that Cali-
fumiaHealth gdres&Safety Cads. Sections 255(15, is my and25534.1 an unify ththeifhe
255 requirements under Chapter understand
huildin6 Jas no, currently have a tenant. that it is my respansihiliry m ramify he occupant
ISSUA EUATE�
�,ej
j
,yH\4 HHSIDf:NT1AL. MECH. SQ. FT
Inc awhichtyust}v;met pr ssu;ence ofa Cenifcam of Occupancy.
/'//�6g
'1'A1
i/ea c. k/Q`wYIuQY-
ILoruuJ agent
SSUI?D BY: {�✓
OFFICE