99100082APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BUILDIT
CITY OF CUPERTINO LUNIRING. MECHELECANICALICAL SPERM
BUILDINODIVISION APPLICATION/PERMIT 1'LUMBINcf:. MECHANICAL
noir nlJn PHOIRrT IDENTIFICATION 11 `OM—.
BUILDINGADDRLS5:
• I D Ilo� o/sH
O i 'S i? I'IIONE: CON"ICAC' OR'S NAME::
ARCIIITECI'EN TIN[EK: LIC NO: A D0S, 6g3l/1 ,/fn
INTACT:4_1 PHONE: Sol /� YV'll� 'll f�
i- ❑ Consultant Fees Paid by Applicant (Initial)
LICENSED (CONIRAC'IYIR:S(DECLARATION J� l QTY ELECTRICPERMIT
I hereby affirm mm into lra nxw ander provistops of Chapter 9lmmmencing
to
�Z auto Section 7000) of Division 3of Ne Business once l'ndesahhns'ode.ynJ mylicense ismylittnee is PERMIT ISSUANCE
in full force and effu:t--�z/j YY
�F
UU Liavn,c Class Lith APPLIANCES- RESIDIiN'I'(AT,
G a ARCHITECT'S DECLARATION
F y Z 1 understand my plans shall W used as public records
O Z'm--
17,14 Fly Licensed Pmfes,ional
OWNER -BUILDER DECLARATION
IY row G I hereby affirm that 1 am exempt from the Contravtor, License Law (.,.he �L gi, U following reason. (Section 7131.5. Business and Professions Code: Any city or county
W LL WO y whielh torture, a pennit m umm
um, altar, inlpmvC. domolleh
, or "'id, any xWclum
prion, as is ..... C. also m circ, the vppliart for such pcook 1. ]!to t,igncd smRmmu
f } that he is licensed personal maepmvrsionsofthe Comracal License law(Caap¢r9
W14C�O (rommcncingwith Section70000of Division 3 ofthe Business and Professions Code) or
Cl. p, o cy art, he is tempt lhcreGum and the hall, far the alleged emmplion. Any violation of
W N
Sort inn 70315 by nny appllemr for a penton subjects the mpli'ma or a civil penally of
not mom than five hundred dollars ($50).
SSG ❑I.as owner of the Purior my employees with wages as their. sole cona,mation,
F., will do the work. and the summit, is not intended or offered for, sale(Scc. 70sJ, Busims,
1�i1 �' L. and 11 test ionx Code: The Contractor', I:mennc I.nw does ot apply to an owner of
2
property alto builds of improves Inerenn, and who dors such work hinlcelf nr through
his own employees, provided haat such improvements art not intended or nffemd liter
sale. If. however, the building or improvancm is sold within one year ufcompletion, the
m.boulder will have the burden of proving that he did nm build or improve for pur-
puneof ,dot.
D I, as owner of the prow.,, tat exclusively ormraching win licensed contactor to
instruct the Fmjem (Sec. 70W. Business and Professions CsdeO INC Contactors U -
e "wastes not apply to an taperer property who builds or improves fl emm, and QTY.
wlm ontacts for%,tell pit era with a contractors licensed pursuant to the Corral
License Law.
1 um encal under Sec. . B .k 1' C for this ..,an
PANELS
UP TO 2W AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEl METER OR POLI: INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - VENTURES
Owner Dote
W'ORKER'S COMPENSATION DECLARATION
1 hand will
mai under penalty o1' perjury one of tire fularvinsim, nhg declaWork,''tons:
se 1 have and will tnainmin a tion 37M of [teat Lite Code. fore for Worker', Compcm
cation, as provided for by Section J]W of the labor Gdc, for the performance of the
ark for which this permit is issued.
D I have and will tnainmin Worker's (.onhpcn� alis n Inwmnce a, accrued by Section '
370O.Olel Mu yCtsndc forth, perydoomtuarokhe work forwhich this Teapot is o, J.
MyWCehrieorkcSA 1,�i W A1lJ PolcyNmY�I—
�^S-S an
CEETIFICAT17 OF EXI:MPI'ION FROM WORKERS
COMPENSA[ 'ION INSURANCE
(The, section need not be completed if me permit is far cal hundred dollar IS I W)
or lm<H
1 cenify that in the Performance of the work for which this permit is issued. Col shall
not employ nny pchxon in tory mm�ncr un x m beenmu nuhjmt w the Workers' Cnmpem
O Z cation Iaws of California Dam f�l_
Z Applicant N
rN-r NOTICE TO APPLICANT: IL afmr h akin, mus Compoom of Focal you,hauld
Mcome subject It the Workers Cnmpcnxatimn provisions of the LaM,r Crle, you must
halt, !Ill comply wpb xuch,e vision, or this permit ,hall be decreed revoked,
aQ
Z CONSTRUCTION LENDING AGENCY
U
V O Iherchy affirm thin there isaconstruction lending agency for Performance of
F the work lin which this pmnhil is i. rte Sm. 3097, Civ. C.)
0 U Lenders Name
}Isndcrs Address
ty 1 certify that I have read thisapplicanan and vale that the move i.hmnafirm is
f-' V) correct l agree it) comply with all city and county (,romances and slam laws refuting to QTY.
U IZ bnildingcunsmiction,vndharcbyanthnriiemprescnlativCaofthist'nymcntcruponhhc
u voo-mentioned property for impcdinn Imposes.
(We) agree to save. indemnify and keep hurl Ne City of Cupertino against
limairms.judgmcers, costs and expenses which may in any way accrue against said City
in omcrucnee of the grunting of this permit.
APPLICANT UNDERS'I'A' S ANU WILL COMPLY WI'1'II ALL NON -POI N
SOUXJiotGULATI(INS.
jl3-18�R`t
Signet 1 A pli nVcm,tmCwr\ Umc
AZARDOU. AI'IiR1Al,$IIISCLOSUItI:
ill"heap Cunt or future building receptor atom or handle hvadous aerial
m defin d by the Cupertino Municipal Code. Chuper 9.12. and the Health at Safety
Cade, Section 25532(n)'I
❑Yes ElNo
Will the applicant or future Wilding met Wm use ryuipment or devices which
emit hav adjurs air conmminunts a, debneJ by the Bay Area Air Quality Management
Doln,l'r
E3 Y" ONo
1 have raid rhe Imzvduus material, mrufremcnu under Chapter 695 mare Cali-
fornia H� ar Safety Csdc, S trio., 25505. 25537 Lind 25534. 1 understand that if the
,,,r,n ,.•.,sol ...... cba hmnenv tlsn it ix nry m.nnnsihillrymnotify the «ctrpvm
of me
FEE
d' 1,
IHALDINU PliKMI I Witt
ill I LET Ill MEECCH
JOB DESCRIPTION
RESIDENTIAL
PERMIT ISSUANCH
O SFDWI,
vvtt
Xy KITCHEiN REMODEL.
DADDITION
El PLUMBING RI PHIE
❑MULTI -UNIT
DS'fRUCI'URAI,
GAS -1:A. SYSTEM -1 NC.40U'H.EFS
MODIFICATION
❑INTPRIOR
Ll CHIMNEY REPAIR
IMPROVEMENT
C] SWIMMING POOLS
D HATH REMODEURTH'AIR D DEMOLITION
❑OTHER
BLDG/ADDITION DDEMOLITION
NT D FOOD SERVICE
NEW RI:S IDHNTIALIII.ECTR SQ FI'.-
SQ. PL( AREA
PLUMBING PERMIT FEE:
FBI
f
PERMIT ISSUANCH
ALTER- DRAIN & VENT -WATER (EA)
VALUATION
O D 0 D
BACK FLOW PROTECT. DEVICE:
DRAINS - FLUOR. ROUP. AREA, CDND.
S'TORIE: I YVE
FIXTURES-PERTRAP
GAS -1:A. SYSTEM -1 NC.40U'H.EFS
fCCGROUP
GAS - EA. SYSTEM -0 VERJ IPA)
S T I CE
R 'E
BUILDING DIVISION FV
PLANCHECK FEE
SEER-SANS M
V Ii
ENERGY FEE.
GRAVING FEE
PAID
Uatc Rcccipta
TOTAL:
MECHANICAL PERMIT
FBI
f
SIi ISMICFLI:) U
IT.IiCTRIC I�IiI: ^^
PLUMBING FEE 10 Lj
NacHANICV, IEE
(1(
PERMIT ISSUANCE II i1
ALTER OR ADD TO MCCH. ,.
AIR HANDLING UNI I(10 I ILINIB CFM)
AIR HANDLING UNIT(OVER I0.000CFM)
CONSIRUCION TAX
EXHAUST HOOD I W/DUCF)
`h
HOUSING MI"1'IGATION PEL
HEATING UNIT (10 110.001 IFIU)
HEATING UNIT (OVER 1 W000 BTU)
PAID
VENTILADON FAN (SINGLE RESID)
Uutc Rec•
BOILER - COMP (3HP OR I00.00B BTU)
BOILER -COMP (OVER I W JXXI BTU)
AIR CONDIi'IONER
ISSUANCE DAT13
/ O 9-
ISSUED BY:
I /
NEW RESIDENTIAL MECH. SQ. FT.
TOTAL:j
OFFICE