00020020APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY - C
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
111111 LUPI. Vn(l IF(' I114'viuvICAi N
OFFICE
AHCHITECI'/E LIC N(1:
-
ADD 5:1-1C � �
CONTACT': PHONE:
❑ Consultant Fees Paid by A plicarl (Initial)
BUILDING PERMITINFO
BLDG: IiLECF PLUMB MECx
S/'o o So
Cr71Ell ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 herchy affirm Lha I an licensed under pmvisinm of Chapter 9 (commencing
nSectinn ]IxX))of Dims' qoI the Buvinessnndl'mfmcion. Cnde,undntylicen.cin
col ^ ^
nfullfe.maJellca. 3s6 Ile /
License Class Lica
DaleContractor
QTY ELECTRIC PERMIT FEE
JOE DESCRIPTION
RESIDENTIAL'
OSFDWL O KI'I CHEN REMODEL
OADDPIIGN OPLL/h1BING RC -PIPIT
OM111; 1'1 -UNIT OSl'RUCTURAI.
❑INTERIOR OCHIMNEYREPAIR
IMPROVEMENT OSWIMMING POOLS
[I BATH REM PAI ODPCMGXyX/�LIL
OOTHIiR Q.�f�+i�y
OCZ
y100
5WF
aVV
F Zty
[,=)coMODIFICATION
z0000z-0
rr r3.F'sW
C Q
%p W V
d
1+131+. y
`W Oe
I'IiRMI'1'ISSUANCIi
APPLIANCES-READEM'IAI.
ARCH( I'ECTS DECLARATION
IunJeand my plans shall ire used as public recoMs
m
PANELS
UP TO IN) AMPS
Licensed Prna,vord
OWNER -BUILDER DECLARATION
I hereby amrm that 1 am exempt from the Contractor's License Law fur tM1c
following reason. (Section 71771.5. Business and Professions Code: Any city or county
which minims a omni( to construct. alcor, improve. demolish. or repair any suucmre
print to its issuance, also requireslheapplieunl for such permiun life asii,rd,amnsm
201-1000AMPS
OVER HXX)AMPS
SIGNS 13LECTRICAI.
SPECIAL CIRCUIT/MISC.
i�aI
u1�p0
m a (�
x �'s•
W^w
SD
F+
W, m
that he is licensed pursuant to the provisionsa meComructax%Liceme,Law(Chaptef9
(utmmencing with$eelinn]IXXq of Division Juf NcBminess and Professions CWe)or
Ilia he is exempt Therefrom and the hasis Lor the d1cgal escnnnion. Any vwh tion u(
Section 70311 by any applicant for a permit sFbjm, the applicant nt a civil Penalty of
oat more than five hundred dollars($500).
I, as owner of the properly. OF Illy employees with wages as thei,od. sssmpcnsation,
will An the work, and the svucwrc is not innmdcJ ar nllircJ for sole lScc. ]Is1J, Business
and Professions CW.: The Conaaaofs License Law does not apply to an Owner of
pmpeny who builds or improves thereon, and who J«s such walk himself nr through
his awn cntpleye, provided that such improvements ore not iamuded or offered Ira
colo. I L howewclhe building or ingmmement is sold within areYmrof aompletor. theSQ.
TEMP. METER OH POLE INST.
COMMERCIAL:
[I NEW IILDGIAUDITION ❑ DEMOLITION
TENANT Cl FOOD SERVICE
(MPR VEMENT
'(
POWER DIiVICEi
SWIMMINGPOOLELECTRIC
OUTLCI:S - SWITCHES - PONT 'URES
NEW RESIDENT (A], ELECT'R SQ FT.
PT. FLOOR AREA
$/SQ. PI!
,nover-buildar soill have the bards. of proving that he did nut Wild ser improve for pur-
TOTAL:
pose of sede.l.
I, os owner of Ila fintoeny, um exclmivdy smashing with litcnsed contractors ht
con,ama the project (Sec. 7044, Business uad Profensloms Cede)'Me Con mater's I.i-
se Use does not apply to an owner of pmpeny %no builds tar improthereon. and
QT . MBING PERMIT FF:E
Y Is,
wen commets for such projects with a contmemHs) licensed pursuant to the Carman s
Liccnsh Law.
1 am exempt under Sec. . If k P C for this reason
is 5, QOO.O
Job RMI'I' SS N(' i
ALTER - BRAD -WA R (EA)VALUATION
Data
owner
WORKER'S COMPENSATION DECLARRI'ION
❑ [haveand y.ffirmuain a pcnaltyof ofConeneofthefoRuwimi-WokOrkas:
sure for Wif
IM1meand will maintain aCcnifcaeof11ss
BACK ILOWMARE CE
I7RAIN5-FLOOR.N .A A. D.
STORIIiS
TYI'IiCONS'I'NUCI'101
aComp(he
f r by S, ilien 971X1 nr 0e labor Cndc, for the perfnnnm¢c of IM
LalmK..to,
work for which this pcmnt is i
workfas hick his
FIXTURES - PER '1'RAP `
GAS -EA.SYSTEM-I INCA (]U ?TS
O 1 have and will ode. fon W loados ComBmarc al he, Insurance, h required by Section
Worker
J]IX]of the LuMtt Code. for the perlbnnanm ol'the work for which this permit is issued.
UCC.GROUP
GAS-HA.SYSTEh1.OV[R4(EA).
My Wor nn losers er uad Policy.. JufJ1
'aricr •s cnrrl Policy �`y lig-��
GREASFIINDUSTRI, W'ASTI! INTERCEPTOR
CMTIP]CAT OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BONDING DIVISION FLAKS
GREASCTRAP'
PVsNC11ECK ITC
Thi—eamn need nalEve .ompleted if the pcmtit is fusion hundred hot lars ($ I(a))
or l asJ
Iraritythat i..the O(the r whichthis permit
urnempll),ny peroan in a", mamallntm hisFumobjectm the Wrker,'Compen.
SGWCR- SANITARY - STORM FA. 21)IT
ENERGY 'FE
WATER HEATER WNENT/Ii.O=
GRADING FEE
Z
Z O
EX?
WEX
U O
F-'
0 U
U
scion Lawsof C.ifamm Dale
1
Applicant .
NOl"ICI: IPI APPLICANT. If, after making this Cenilicale of Exvmpuon, you should
bacilli, subject to the Worker's Cmnpunsmion farl"Wuns or the Lahnr Orals, You must
IIlnhwitb comply with such proviniom nr this permon,hell be, decmcdrevnkcd.
CONSTRUCTION a'ION LENDING AGENCY
alinn Lending agency the perlirtmanf
mt in a cnn.dmfor ch o
1 hereby ulEthat
the work Iia which this permit is issued (Sac..1090. cit. C.)
I<nJcr's Name
Leola', Address
WATER SYSTEMORHATING
SOILS hili -
WATER SERVICE,
PAID
Irate R...In k
NEW RIiSIDEMIAI. PLM17. SQ. FT.
A„�IDIA
'NUILDINOfB ^
E_ I I 1.+1
TOTAL:
QTY. MECHANICAL PERMIT 193E
ate the infurmaion is
I cantly that l he read this application sed sma shove
have
curl tagree m comply with .Deity and eountyoNi... ces and nam laws mining to
fondling construction,and herchyaumnio, representatives ofihis city no moon the
dave-mentioned property fur inspccdon puruss—
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments. cons and expenses which may in any way accrue againxtsad City
SEISMIC�ER V
PI?RMI"T ISSUANCE
-
s.E .F. 200
PLUMBING FEE
ALTERORADDTOMECII.
it msequenceaf the nomting of this permit.
A PPUCAN"I' UN OF RSTA N DS AND WILL COMPLY WI'1'll ALL NON -POI N '
AIR HANDLING UNIT (10 10.10011 CFM)
M ECI I A NICAL I'1! Ii
SOURCE REGULATIONS.
/-�J0
u El /{" / ��I /9
/
AIR HANDLING U10,000T (OVER IO,CPM)
UGTION=IA
Signrome IicamiCmarannr Deaf
HAZARDOUS MATERIALS DISCLOSURE
Will lheapplisnm,um, building occupnnl uare nr handle ha(.ardous material
sea defined by the Contanin, Mnniclpal Code. Chapter 9.12, an I the Heaah and Safety
Code, Savona 255321:0"
EXHAUST HOOD OVIDUCT)
HOUSING MITIGN'ION FEE
HEATING UNIT (TO I W.000 BTU)
HEATING UNIT (OVER 100.000 BTU)
VI:NTILADON PAN (SINGLE RESID)
E3 Ycs C] No,
PAID
Bum Receipt p
Will the applicant or future building (occupant use equipment or devices which
emit humdous air ennmminant.. as define) by the Hay Are. Air Quality Management
IIOILEH-COMP (3111' OR HRLIX)0 BTU)
TO
BOILER -COMP (OVER IgLIXXI BTU)
District? -
❑Yee ❑Nn
AIR CONDITIONER
ISSUANCE DAH3
•Z .� ', ZV cl
I have teal the haevdemanumrials mquimmcros abler CluPter 6.95 of dte Cali-
fnmiu Health X Safety CWc, Section 25505, 25533 and 25534. 1 understand that if live
NEW RESIDENTIAL MECIL SQ. IT.
handling Aces not currently have u tenant, that it Is my rexponsibidity m notify the occupant
lAcu cy.
prix O�(�'
1 l live rrcyy ' menu which must M metr ¢e of a Cer ilicae &47 of Q;04,
/
TOTAL :
ISSUED 111':
—/ I��i j
Owner nr unlb sA (gem
OFFICE