29881 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUHABINC.-ELECTRICAL PERM]'INO.
BUII,DINO DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n O O 1
BUILDING PROJECT'IDItATIFICATION J o O 1
BUILDING ADDRESS: .C- SANITARY NO. APPLICATION SUBMI'PFAL ONE
C--AVX Lot
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO.
PErs,IiAV 2 coZ NIC CONI'R^OL a
�OCTET ECTIENOWEER: LIC O: DDRESS•. IZZ.$O $rwwo- OCo SSI V14LE Q.L ❑ /
44-En CAI qqj�jp
CONTACT: PHONE: BUILDING PERMIT INFO
2
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEcx
LICENSEDCONTRACD)R'SDECLA2�;,
QTY ELECTRIC PERMIT FEE
1 hereby athran tem I em live sed.neer Prov!:inm rt mang JOB DESCRIPTION
C�ZO withSection AMNI)o(Divi%ion 3..fthe Bmitmssand Pr cylimnse is PERMIT ISSUANCIi
..}�._ ESIDENTIAL
Mull force and of t. FDWL O KITCHEN R17MODIiI.
QIJ V�ypenu Class—J> __ APPLIANCES-Rf51DENTIAL ADDITION ❑PLUMBING RGPIPE
y.t! Dam-Q'^7-z� Cnntracm1
Fly ARCHIT'ECT'S UEC' PANELS [IMULTI.UNIT [I STRUCTURAL
Z O y? I understand my plims shall be used as bli oNs MODIFICATION
UPTO20BAMPS ❑INTERIOR Fl CHIMNEY REPAIR
W Licensed Pmfevsinnel 201-100OAMPS IMPROVEMENT
ELDR C Q 1 hereby affirm OWNER-BU1 am emoteddEfrom the ontm&Eel�ors License Law for the OVER IUOO Ah1P5 ❑BATH REMODEVREPAB 0 DBEdOLITION
iqy,a5�O Y U following reason.(Section 7031.5.Bataan,and 11..In-...Calc Any chy or county SIGNS ELECTRICAL OTHER
R13 t ya which nyuims a permit In construct.alter,improve, rrm
delLM1re
,or pair any snucmre
F'yJ prion..its issuance,also requires the applicant for such Permit o rile a signed statement SPECIALCIRCUTUMISC.
C} that he is licensed personal n the provision%of the Contractor's License Law(Chapter 9 nQ
Q0 (commencing with geetion]IKK)of Divisi.n Sol the Business find Pmfcai...CoJOm TEMBMETERORPOLBINST. ,yJ
a e that he is exempt flu rcfmm and the basis for am fillet e l nateraion.Any violation of 0 NEW BLTX3 _ IONU 0 DEMOLITION
Section 7031.5 by anyapplicam lin n permit subjects the applicant it)a civil penalty of MOWER DEVICES 0IHNANT ❑FOOD'SERVICE
oat marc than rive hundred dollen(5500). 2 I�
F=Q 01,mownerofthe P-1.1or my employees with wages as their role compensation. SWIMMING POOL ELECTRIC OTHER EMENTii , VU
will do the work.and thc%trurc isnot
cmimmoJcdorofferen (S
for.alecc.7(1,Bsaire ❑ THER
6 3 m
ad Professions Code:'Ihc Coarectors License Inw does not apply m an owner of OUTLEIB-SWITCHF'_S-PIXTUNES
Fropmy who builds or improve,mamma,and who Jars such work himself or through
his awa employees,provided that such improvements am not intended or uttered for NEW R17SIDEM'[AL ELECTR SQ FT.
sale.IL however the building or intprovemm�us sold within one yearof completion.the O SQ.fT FLOOR AREA ASQ.FI'.
owner-ImAder willhavethe buNenofpeavingtbat hedidnot boilderimprove forpur- O&S t�-1,
pose of's1c.). `
0 1,m owner of the property.am exclusively contracting with licensed contrmmn.t T` OL ��a�
construct the F..j¢t(Sec]BW.Beef...and Pmfeasimw Cud.:)The Con.ncon,Li- • L
cense Law dews not apply to an owner of pituitary who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who sontramn tia,taeh projects with a emarucmr(s)licensed pmomin,a the Comractol l
License Law. PERMIT ISSUANCE
0 I mn caempt ander Site .B&P C for this reason
Owner
ALTER-DRAIN&VENT'-WATER(RA) V/AII.UAHON
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE. 2M 0w
I hereby Romancer penalty of ,a,oneof the followmit dceiamdane .J / ffC.•JJJCCJJJ 6
G lhvve and will maimnina Ceniricate ofConum molt-insure for Worker's Cumpcm DRAINS-FLOOR.ROOF.AREA,CONO STORIES TYPE CONSTRUCT ION
%tion,as provided for by Section 3700 of the Labor Code,for the performance of the
rk for which Ibis Perot!,is island. .FIXTURES-PER TRAP
Z I have and will maintain Weaker,Compensation Insurance,as required by Section
37M of the Ltior Code for the performance of the work for which this permit is issued. GAS-RA.SYSTEM-I INC.J OUTLETS OCC.GROUP APN
My Workcr�TmP tat IJlftnfu_n15ancrand nu
Policy ,nhcr are:
Carrier, ^IL Policy No.: GAS-IiA.SYSTEM-OVER 4(CA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASf%INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
1 (This section need not becomphand ifthe permit is forms,hundtddollar,(5100) GREASETRAP
or less.) PfANCHF.CK FEE U
I vaulty that inthe parfnmtnw,chat work for which this permit is i,mad],hall SEWER-SANITARY-STORM I?A.2001T.
nlbos
ot employ any Person in any ntmmer so as to become abjecno the Worker.Gtmpcn- ENERGY FEE 2
Z .mind Uwsof Cediferm.,Data WATER HEATER WNFNT/ELECTR
GRADING FEE
z� Applicant
h
NOTICETO APPLICANT,If,ober making this Certificate of EnemMi.e.you should WATER SYS"I EM?REAI'ING SOUS FEE
F' become subject y the Workers Cutup;or thin provisions of the devoted
Cale,you must
� H
forthwith comply with such provisions;or Oil permit shall he deem<J revoke]. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.pp_ PAID
y
U0 l hereby affirm that there in a Canaraction lending agency for the performance of Data
Receiptp
the work for whlctylhiv 1i is .v� I ISca 3 )].Civ.C)
w0 F' L.eadera name IJ�FfOD1�I S I.1"tJT1[irlfG �r.l le-- ly'ya� rAL:
r W Lcndcr's Address "OSh BUILDING FEE
Q. I cant,that 1 lutve read Nis apphcatiou and seam that the fibnvc........... se1
Nh Carmel.l agree mcomply withal)city and county ordinances and state laws relating to QTY. MECHANICALPERMIT FEE
V building construction,and hem uNnriecrcpmumative%of this city m emerupon he SEISMIC FEE
abovo-mentionedt,... y in emioa purposes. PERMIT ISSUANCE
(We), .inner in and keep hanalev%the City of Cupertino against ELIi.C'I'RI I
liabilities,' �ostson xpemes which may in any way accrue against said City ALTER OR ADD TO MECH. I l
to c I c,Tari of this permit. PL 'EE tel.
APPLIC sT DERST US AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MEC biFE. l�
SOURC LATIs S. 8/26/116 OO P� AIR HANDLING UNIT(OVER((1.0(0 CFM) CONSTRUCTED TAX
F& O.Finme,
r2onnaatoDam E%HAUNT HOOD(W/DUCT) HOUSING MITI ATION FEE
HAIARD(ID5 MATERIALS DISCLOSURE
licamor funum building occupant store or handle hva bmo material HEM INC,UNIT Municipal Cade.Chapter 9.12,vnd thea Health and Safety32(u)7HEATING UNIT 0/Na VENTILATION FAN SINGLE REMO) PAID -k
,.I,
Will the applicant or future building occupant use cq.ipmcnt or devices which
mit hazard....air nen rmninams as dcfinad by the Bay Arca Air Quality Management BOILIiH-COMP(3HP OR 100.LYyJ RTU) TOTAL:
Ditri t o BOILER-COMP(OVER 100.000 BTU)
�Yc.
I a the h mamrims rcquimmenrs under Chapter 6,95 o(the Cali-
n]R CONDITIONER ISSUANCE DATE
fornia calf a @ty C .Sections 255(15,25533 and 25531.1 undersmml that Hthe NEW RESIDENTIAL MECH. SQ.ET.
build; g currc h.vcv mount.that i,is my respoiwlhiliry to notify the occupant
of th hich must M met prim m issmna of fi Cenificme of Occupancy
S4 Na PQC3
rida m �_r sM Dmc - ] A ISSUED BY: —
OFFICE