S0001C0412 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY M/y/'
CITY OF CUPERTINO BUILDING.EI,b1CTRICAL PF/ " N
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �0412
S0001
BUILDING PROJECT IDENT'IF'ICATION'
BUILDING ADDRESS: SANITARY NO. APPLICATIO SUBMI'TEALDALE
U Nli 'S NAME AMPHONE: CONTRACTOR'S NAME: l LIC NO: SIC CONTROL a
ARCHTT[iCUENGINIiE LIC NO: ADDRILSS,/ T 14 N 460 L- A _ ❑
5kib
COM'AM: PHONE: BUILDING PERMIT INT70
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICE SED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT' FEE
I hereby affirm that 1 an licensed under provisions of chapter 9(commencing JOB DESCRIPTION
p0Z wall Section 7omu of Division 3 efthe nosiness and NomssionnCNc.and myliccnu is RESIDENTIAL
W p PERMIT ISSUANC12
FK IyI� in full fo¢c and fin ❑SPDN'1, C1 KITCHEN REMODEL
aVV i,iconm Liss ngg�5W
gpPhIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
hGa Dae Comm., ❑MULTI-UNIT ❑STRUCTURAL.
ARCHITECT'S DECLARATION PANELS AfOD119CATION
OZyZ I understand my plans dull be used as public records UP T021MIAMPS
El INTERIOR ❑CHIMNrY REPAIR
b'y.~.4Q1 Licensed Professional 201-1000AMPS IMPROVF,MENI0SWIMMING POOLS
06yd OWNER-BUILDER DECLARATION
06e'C Q Ft
1 thereby affirm mm at I aexcropr in,m the Contractor's Laren Law for the OVER 1000 AMPS
❑HATHREM�O,D�II:IIyR�EPAIR UEMDCLT'i'ION
X C) follnwinli cuson.(Section 91131 5,Business and Professions Code:Any city a,county SIGNS ELECTRICAL. ❑OTfiP i fA[.tZY
W 3 LL F which requires a permit to construct.alter,improve.Junolish,.r repair any someone
Fpto prior m its i.usaance,rdso memos,the applicantforsuch permit to file a signed statement SPECIAL CIRCUIOMISC. IV
flythat he is licensed pursuant the provisions of Bre Contractor's License Law(Chapter 9 COMMFRCIAI'
wgCgg fcon...vncing with Secdom 70(Xhof Division 3ofine Business and Professions Crde)or TEMR MEi1ER OR POLE INSIP
Q.a e C mat he is exempt therefrom and the basis for me alleged exemption,Any violation of [I NEW BLDG/AUDITION (3 DEMOLITION
X^mSection 7031S by any applicant for a permita.hjecu theapplicamme civil penahy of POWER DEVICES ❑TENANT [I FOOD SERVICIi
not more than five hundred dollars($500L IMPROVEMENT
SD ❑ I,as owner of the propery,or my employers with wages as their into cnn,cousiun. SWIALMING TOOL ELECTRIC OF iR
F. will do the work.and the mmclure is net intended oroffeed for safe(See 91114,Business
L C m and Pretensions Calc:The Courro n',License Law does hat apply m an owner of OVTLM-SWITCHES-PI%'I'URIS
6 pmpeny who builds or improves thereon,and who does such work himself(ir through
— og I
his own employees,provided that,such improvements as not intended or offered far NEW RESIDENTIAL ELECTR SQ PE
sale.IL however.the building or improvement is olid within one year clardetinnAte SQ.FE Fi AREA $/SQ.IT.
owner-builder will hove the burden of proving that he did not build or improve for pur-
're of sale.). 'TOTAL'.
❑ 1,m.wne of the mopeny,am exclusively commeting with licensed contractors to
construct me projat(Sec.90x4.Business and Professions Code:)'I he Contrucmf's Li-
msa Law does not apply to an owner of progeny who builds or improves themed,and QTY. PLUMBING PERMIT FEE
whocontmctn forsuchprojects withacemarearn')licensed Pun rldlethe Cnnvunor's 11
License Low. PERMIT ISSUANCE J.J
❑ Izmesemprander See. ,Ii kt PC I'ar thin reason
' ALTER-1lRA1N&VENT-WATER(EA) VALUATION
Owner Dole A/
WORKERS COMPENSATION DECLARATION BACK FLOW PROfECE DEVICE
I hereby amren under Penalty n -7--D-7--Df,rja ,,rc nfdre following declarations: LJ
I have and will mnimain a Certificate of Consent osOf-imus for Worker's Coupon- DRAINS-FLOOR,RODE AREA.COND. STORIES 'TYPE CONSTRUCTION
cation,as pmrid,d it,,by Section 39W of the labra Code,for the perkeree ace of the
work far which this prnnd is issued. FIXTURES-PER TRAP
1 hove and will maintain Workers Compcnmrion Insurance,as required by Section
371N)of1he labor Code,futthe por iumanccofthe work far which this permit is issued, GAS-EA.SYSTEM-1 INC.a OUT LETS OCC.GROUT' MIN
My Workers Compensation Insurance exac and Policy number are: GAS-EA.SYSTEM-OVER 4 HDO
Ourier: Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEINDUSTRL WAS'T'H INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thi,wo,vnnead or be completedHthe permit is Jerome handled dolls,D IW) GREASETRAP
1'LANCIIECK PI[li
.r lv—)I
1 certify and lathe ery Foa emceol the work lin which This permit is issued,)shall 'SEWER-SANITARY-S'IY)RM❑A.20017.
oI?NERGV Itili
noI nnLaw Y person in any manners an m became subject In the Workers'Comped- --
Z nation aut Cif Dap WATER HEATER W/VIiM'/IiLECfR GRADING V17
y
NOTICE obj APPLICANT: r'Cher making this wide enc of Labia rod you should WATER SYSTEM/TREATING $GTL$Viii
bsumm object to he Workctsckion, n miffs
marit bol of de LCbor Code.You run
� fnMwim comply with such Prnvismnm onhis permit shall MdeemN revoked. WATER SENVICIi
PAID
CUNS'1'RUCTION LENDING AGENCY NE RIiS1ULNl'IAL PhMB. SQ.FT. D:nc Recvis Is
U Q I hereby affirm rant there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.30V9,Civ.CJ T(ypAl:
QU Landes Name TOTA ,.,
WLenders Address IIUILDTNG II?T?
P. I certify mer 1 have rad this application and state that the above information is
I,, correct.I agree mount with all city and county ordinances and stare laws existing to QTY. MECHANICAL PERMIT FIiE SEISMIC PEE
C.J Z building cor,mcaan,i Ibr,eny atnh.,ive remmwemarives omnis city to enter.,a me
aboromentioned pdnpeny for inspection Purposes. PERMIT ISSUANCE IILECIRIC Fell
(We)agfce m save,indemnify and keep harmless the City of Cupertino against
liabilid"'judig
ments, mss and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
Ia comcyuomsoof(1 i(:ranting of this permit.
APPLICANT IH BST . AND WW. OM .Y Wit It ALL NON-POINT' AIR HANDLING UNT'1'(TO I0A00(1 CFM) MSCI IANICAL FEE
SOURCE I ATI j
_(�-(-%�— AIR HANDLING UNIT(OVHR 10,000CPM) CONSTRUCTION TAX
sign: Apphe Mnt
Cofuml - Q Dale EXHAUST'HOOD(W/DUCT) I MUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplies.,.,fmurt hilding exceptuarm,or handle heaudous mmc,lal HEATING UNIT TO H K1,000 BTU)
as drlined by rhe Cupenion Municipal Ede,Chapmf 9.12,and the Health and Safe, IWATING UNIT(OVER 1(Nk(NN)BTU)
Code.Seen..25532mr?
❑Yrs No VENTILATION PAN(SINGLE RESID) 1' )
Dale RcaiPt p
. Will the a,lic:nn of future building owcup:mt use equipment or devices whichINEW
MCONT)TTIONER
OR 1 W,m1(t
emit hi mtdnus it centenarians ns as deined by me Bay Area Air Quality Management YE
Ulxuicrn R 100.0)f1 BTU)
❑Yes UkNo
I have rear a harardaus mamdCb requirements under Chapter 6.95 of me Cog- ISSUANCE DATE
EI I I Health P ufay C h,Secri s 25505,255A and 25511.i it land the if rbcECH, gT�Al.
building « c y rave a nr,mat' stay 1Fs of.cllityc,tea coeeoccupumlhr ap F nfaCcnificewfUccu ncyO n aumorieeJager Dam I. L
OFFICE