10113APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY U V 0 I
TPY OF CUPF,RTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG -MECHANICAL.
BUILDING PROJECT IDE„YI'IFICATION
PER�O.
UILDINGADORESS.
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SANITARY NO.
At (ON SUBMITTAL DATE
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CONTROLEI
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.,CHITEC'TITINGINFER: LIC No
ADDRESS:
CON'T'ACT //lfff PHONE;
Gii A1(� 111iD. G74 �{]�
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❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
RE ELECT S PLUhfli MECIi
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LICENSED CONTRACTOR 'S DECLARATION
I hereby affirm that 1 nn Bcen%ed ander provision of Chapter 9 (commencing
th Section74)(Bul Division Sof the Huxines.+and Yndessions Ctde, and mylicense is
nalull lane and disc ,^ pti//_�.2
Lice, 'lass Lir. p �.�—JTI(�—
Dae Gin
ARCHITECTS DF,CIARATION
I umdenlandmyplansshall be used asmbl'm«eords
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL,
0SFIDWL ITCHEN REMODEL
❑ADDITION El PLUMBING RE -PIPE
❑STRUCTURAL.
MODIFICATIONOZ-� :RIOR 11 CIE REPAIR
IMPROVEMENT 0SWIMMING POOLS
❑ HAITI REMODEIJREPAIR ❑DEMOLITION
[]OTHER
PERM IT ISSUANCE
APPLIANCHS- RESIDENT( Al.
PANELS
UP TO 200 AMPS
1=.4FIy
�Is:
IY C Q
Oy
�aadU
t+I 3 h
Eby 1
License)Prufcsionnl
OWNER -BUILDER DECLARATION
pl form the Cner's License Law fnr the
1 hereby affirm that 1 ao eacmoro
following reason, Business mal Profession% Code: Any city or county
which require.% a period to cmnn'un, dace i,npmve, demolish, or repair any structure
prior to its issuance, also Inco es the applicant forsuch permitIn file a signed stntemenl
that he is licensed formunuo In, provinionsofthe Commences Liam, Law(Chapter9
201-IIXp AMPS
OVER HpOAMPS
SIGNS ELECTRICAL
SPECIAL CIRCU IT/M ISC.
d ty cC
�MN
=O
F.
Lam
(con.tormangwith Section74)(M1nflJonian 3 ofthe Bri,meaand Porte,%tam'Code)or
that he is esempa therefrom and the basis fnr the alleged exemption. Any striation of
Section]031.5 by any applicant for a Permit "object, the apdiram his civil penalty of
see than Use hundred dollars Will)),
01,as aware ofthe prapeny, or my anployses wilt%ages as their wle compcnsaion.
will An aM1e work, and the structure is not intended or uttered for sale (Sec.96M.Business
and I'rofcssian, Coda: The Contractor's Liccmc Law does nal apply man own
pmperty wbe builds or improve% thereon, and who dues such, himself ar th ugh
his own cmpinyces, provided that such improvements me not interm, or oflnrc for
sale. IL hrnicier. the building arimpmveoenlis sold within enc yearn! cumplcau robe
'TEMP. MEI'1iR OR POI,E INST.
'mow'
ryyv BLDG/ADDITION [I DEMOLITION
❑T17NANT ❑FOODSERVICE
IMPROVEMENT
❑OTHER
i'OK'EH DEVICES
Sw'Ih/MLNG POOL ELECTRIC
OIHn.ET 'WI' -P
t
NEW ftLSIDF.N :
- �,
SQ. 1'L FLOOR AREA
USQ. IR.
cormer-hatildcr will have the burden of proving that he did not build or impress, for put-
F
I
mlaJ.
❑ I. as owner the property, am exclusively contracting with:teemed contractors m
ej sine
tiseua the pronto (iply tonin Business and my wht) hui drd)r i pb Crneaclors nil I
scLawdo,csnntupprele;m whored
-
QTY, t ,f •hll TEF.
a cdpmpany
Pitorimprovice Commerce
Licensee.., for such pmjecu withunmeannr(,)licensed panuanunlhe Camracmrs
with
License Law.
I um swoops under Sec. . N k P C far chi '
i } PERMITISSUA F.
VALUATION
ALT'-PRAT''V 7
er Dam
WORKBR'SCOM(if ,ju, maof,he (RATION
I hand eRrai under pcnallY re pe Jury ane nl the R,Brwior de rker's
BACK FLOW I'ROI'ECT.De
C/D- S DO C�
STORIES
TYPE CONSTRUCTION
ou
❑Ibavenndwill e]In, by Section ofCcansent the 1,1, Cadcmum far Workers Geopen-
,tion, a provided for ,I Section 37S)of the Lubar Cnde, for Ibc lwrfisrmancc of the
work for which chis perosit is toasts.
DRAINS - FLOOR, ROOF, AREA, GOND.
IBXTURES-PER TRAP
C] I base and will ommain Workers Compensation Insurance, as required by Section
3ltxhdthc labor Codc. far he perh.nnamec el he -ark for which this pc.if is issued.
CAS -IiA. SYSTEM -I INC.4011T1.liTS
UCC. GROUP
APN/�
GAS-EA.SYSTEM�OVER4(EA)
My Work ;rs= o road pyyursner�e;uner and PnlieY nJ{^�beeff are. p y
Carrico! I�f ] Policy Na: t�(p�-{-I
CC
,
GREASEJINDUSTRL WASTIi1NTERCEPTOR
CIiR'fIIICAII[OP CXEMPIIONFROM ORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION PEGS
GREASE, TRA('
PLANCHECK PBB
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(This,rgionncednnihecmeplewdlfthe Amnia is fnrnnclumateddollar.+(SIM)
nr leo')
Lcenifyahaa in lheperinmwneeoflhe work fmwhich thispenat isissuaL l shall
cI o
not,mpiny any Arms re le to he Workers'Cn pen-
sal ion Laws of C. m Avec �' 14N
Applicant o {� ,n.mn
NOI'ICL''IO APP. CANT', Ill after i aka, s CuatGeate nt P..umpoon, you should
became the worAero Campeor hermit ilial of thelabor Code,you mull
forthwith comply withsuch provisions or this permit shall is, deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihereby ailing that here is a construction lending agency for the perfmmaace of
the work fnr which this permit ,% issued (Sea. 3097. Civ. C.)
Lenders Name
SEWER -SANITARY-S'IY)Rh1 FA.3W F1'.
ENEHGY FEC
WAIER HEATER W/VEETTATLECTR
WATER gVST1iM?REATING
GRADING FIiE
SOILS TBP,
WATER SERVICE
PAID Date Receipt If
NEW RESIUIiNT1ALl'LMH. SQ. FT.
TOTAL:
TOTAL:
Lender's Address
BUILDING PEE
I ormy that 1 have nod chi%implication and cute Nat the abuse inform nirn is
correct. I agree to comply with all city and county owhonces and nm, laws rdcting n'
building construction, and hereby nnthrnze representatives ofthis city In enter upon the
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
FJ.ECTRICFEE
ahorvo-mnnionW puv,rI, lin ina,,linn por,,c,
( Wel agree u, save, indemnify and keep harmless the City of Cupertino against
I lahil iaics, judgmcnL+,cnaa and expenses which may in any way acoec against said City
ALT ER OR ADD TO MECH.
r
PLUMBING IEB,
r
in car"mence of the gfaming of this'cola.
UNDERST IL WITH ALL %SON-PQ%%INT
AIR HANDLING UNIT (T010,UW CPM)
M•[CHANICAL FET:
I
so
SO 1+'E .OULA'fIONYS, / /dO
//? /
AIR I IANDLINGUNI'1'(OVLtk IgIXXI CPM)
ONS' ONT
�� 2000
Slgnumrcol Apploam1Cammc (r —Dns
EXHAUST HOLD(W/DUCT)
�fiOUSING MITIGATION FF.E
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,IXX) BTU)
rlt
Will the applicant or future building arcupant store or handle hoeaedous material
peno Municipal Coale, Chnptcr 9.12, arta the I3calt. and $arety
a for ed by the Cais
Cade. Section 25532(m?
HEA'T'ING UNIT (OVER IIXs,O(N)B'TU)
.r1.=�...,,�.-„-,�..�...,,�,r..-
VENTILATION FAN (SINGLE RESID)
❑YI%
J,�`
PAID
1)lu, ReceiptM
'Kill the applicant or future huilding occupant us equipment nr devices which
vuouss r contaminants as defined by the Bay Arca Air Quality Management
,o haNw
BOILER - COMP CHP OR 100.000 BTU)
TOTAL:
Distnn�),�
BOILER-COMP((IVF,R W.000HTC)
e
AIR CONDITIONIiN
read the hnmN�m c,im, o,, ircinon Is under Chain+fi95 It he Cali-
h a IIea1 rR Safety Gde. Secm� 5 S. 25533 hind 2SB4. 1 understand that if the
uildingd-,ame,ecntly have aitisoyre"'reithday ami Iheox<a nt
ISSUANCE DATE
NEW RESIDENTIAL. MECIL SQ. FT.
ua
ul tbcre scan which n,u oyfjs+g ncc nfu CcniY c�ttco�Y.
- -
OFFICE