B 0469APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY 6
CITY OF CUPERTINO BUILDING,. ELECTRICAL
BUILDING DIVISION APPI.ICATIONAPERMIT PLUMBING.NIF.CHANICAL
BUILDING. PROJECT IDENIVFICA'r1ON
PERMIT NO9.0469 O ^^
50001 . by
�/-
BUILDINGADDRESS!
X32 P4, IW Go. bar
SANITARY NO,
APPLICATION SUBMITTAL DAT
3,�,r
11,RCH11
OWNER'SNAME� 1'IIONI!:
CO 'ItACTUR'$NAMI!; LIC/ NO:
N/CCONTROL#
❑
3
EC IE-NGINHER: W LIC NO:
ADDRESS:
CONTACT: PHONE:
i(ohe✓F /3w 0 322 z
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING Pfa2M1'I' INIYJ
Ba ELECT PLUMB MECII
El❑ EDLICF.NSEDCONTRACfOR'S
04'Z
WOO
QUU
H Z W
DEC.ARAr1ON
1 hereby oRrm that I.. iiecmul under provisions of Chapur 9leommencing
with Section 70,Hof Division Sof lire itminess and Profession., Code, and my license is
in full (ince and cffccl. F� 2 2
license Class Lic.#
lam Commcmr
Q'I'Y ELECTRIC PERMIT FI7E
JOB DESCRIPTION
0SFEW NI'IAL:
❑�y S�I'UWI. ❑ KITCHEN RCMODF.1.
? sDDI'I]ON El PLUMBING RE-PIPI!
�(
❑MULTI -UNIT Ia SI'RUCTURAh
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
Ihll'ROVBh1IiN1' ❑SW'IMMING PIX]LS
r��Q IIQI�
IF BA 'FRF:M4ruotAl3 DE
T' I—
PERMI'i'ISSl1ANCli
APPLIANCES - RESIDEN[At,
0 C.
N N Z
ZOZv�p
A CHI'rEC'1"SDECLARN[ON
I undenland toy Place Shdll be aced as public records
PANELS
UPT021HIAMPS 7— .2O
F„H„ltw
Q�ydp
C C N Q
'�4x20 i U
W34y¢
Licensed Professional
OWNER -BUILDER DECLARA''ION
1 Hereby affirm mal 1 ant exempt front the ComaON Licence law for the
hollowing reason. (Section 7031.5. Business and Professions Cale: Any city or county
to cuisine, peer. improve,JemnouI Orreportnayntermrc
2n1400OAMPg
OVEREOAMPS
SIGNS ELECTRICAL
SI'F.CIAI. CIRCUIT/MISC.
!iL'
,
[IN ! LDG/AI T N EJ1 MOI.(' 10
0T ❑ � DSII V
1 L'MI!NT
Co
10'u'O.J
y11,
�aQ�
so sur
.F.=�
5a'P.
W 3 on
.permit
which its
PH., to t .. c< Iso 9 'he ##lion It hp In fl a Let mcnl
Be is licensed 'ua n tire p ns ofth C ' lor's License Law (Chpter9
poo b lhS trio ](XX)) fD -. ion( lith B sxa JP f ' .Cale( or
that h ese pt therefrom d the basic f thealleged xcmpt on Any violation of
Section 90]1.5 by Any applicant Im. pumen objects the applicant to a civil penalty of
of com.flan live hundred dollar, S.500),
01.a, owner of the property, or my employees with wage, as their sole compen.cation.
wilaothe work,andthe sarrmisnot intended orolfered for sale(Sec. 70". Business
ea
and professions C de: The Contractor's License law does not apply to an Owner of
pntp.ny who huiWs or improves thereon, and who docs such wad himself or through
his own ctnpinyms, pHOided mar such impmvementh are not Intended croffered for
sale If. howuve, the building or improvement is sold within one year of completion. the
rrenhllder will have the burden of proving that he did not build or itnprovc lin pun
TIEMI'. ML'1'IER OR POLE INS'f.
POWER DEVICES
SWIMMING 1O 1. ELIICI'RIC
OUTLETS -SWITCHES -FIXTURES (� Q
NEW RISIDENTIAL ELECTR SQ FT.
SQ. 14. FLOOR AREA
By
S/SQ. T.
Procne otkaa).
n i. m corer of the papery, um exclusively contracting with licensed contractors to
instruct the pamper (Sec. 7( , Business and Professions Calc:)'I'he Canlmotary Li-vrann
u lawJoesnotapply loanOvmTw pmpony whobuild-eintpaves mea.n.,nA
who comma for such projects with a o.namcmrof licensed pursuant O the Contractor's
/ �O
QTY. PLUMBINGPERM1IIT FEE
License Low.
Itnn exempt tinder Sec. .B& P C for this reason
PERMIT IS. E
Ahi'ER - D A VEST -WADER (EA)
VALUATION
Q OO�
YE
Owner Duro
HACK FLOW PROTCr. U' ICE
WORKHR'S COM PIENSATION DECLARA'T'ION
I hereby affirm under Penalty of perjury one of the following Jesipretions:
❑Ihave and will maim.'. a Cenihca are Canwri self-insum for Worker's Coml1e^-
DRAINS - FLOOR, ROO A. COND.
STORIES
'I YPP CONS' I' RUC DO
catio, a, provided for by Section 3700 of the labor Gale, for the performnnre of the
work lin which this bucolic is Is,uad.
1 have and will nuimain Worker', Compawasinn lawrinev. as rnluired by Section
37M Of the Lahr Cute,fonhe perfnrrtmace rlthe work for wbivinO,permit is Issued.
My Waders Compensation Insurance carrier and Policy number am:
Camipc Policy No.:
CERTIFICATFOFEXEMlT1oNI92OMWORKliRS'
COMPENSATION INSURANCE
PI%'rURLS -1'L
GAS - EA. SYST OOT'
C. GROUT'•7
�/
(I`
(aIN�L
.i J
GAS-EA,SYSI'1EM-0 R :A
GREASFJINDUSTRI, WAS TE I R
WILDING DIVISION FEES
GREAMTRAP
PLANCIIh:CK ITE Z3
Anis:mnuir barium beentnplcled it impermil ixfurtam Wastoddollus(5100)
'aless.)
I,rmythat in the,doce.wrofthewnrk for which this permit is iswed.I shall
urn employ any person in any crura to Ecco h1 ua Nc-VVVy(((000rryers'Cninpem
SEWER -SANI'T'ARY- ST ORM EA. Nit 17K
O /
ENERGY VEE O
WATER I ENFER W/VENTMLECfR
GRADING IEE
O z
Z o
y
F'
tx i
W 0
7 z
U p
iL P
cation laws 1.1i- m �'a
'2�
Applicam
NOrscv TO APPLICANT: IL after making 'his Certificate of Esnnption, you should
hecome st hi 1. he Wed e., Compensation peamenuns'If tire later Code. You count
fonhwith comply with such provisions or this circuit shall h]caned revoked
CONSTRUCTION LENDING AGENCY
IhereM1y affirm that there is lending Agency for the perfnmuncc of
the work for which this hermit is issued (Sec. 3097. Civ. C.)
WADER SYS' I'EM(I'REAI'ING
SUITS 19'1!
WATER SERVICE
PAID
to Rcccipt#
NEW kGSN1!N'1'IA1, PI -MIH. SU IT.
'TOTAL:
landeT'x Name
Londa'. Address the abrve information i,
I crnify that I have mad this application and state mat
crrem. I agree rocomply with all city and county ordination, andsm'c laws refuting m
hildagconcwctinn. and hereby outhodm repvscwaives oftni, city'aenter esm the
TOTAL
But I G TIi
0U
>. D]
0.
For/)
CJ Z,
QTY. MECHANICAL PERMIT FET'-
SEISMI T.17
phv .ns ll od properly for nymetion proposes.
(We) ague m ... a. indemnify and keep hamrvO, me City of Cupertino against
Hahilor%, judgments, cost% and expertas which may In any way ucemeagainnl said City
PERMIT ISSUANCE
ELECT IC PILE
ALTER OR ADD' 10 MSCI I.
PLUS INGFEIE
in co mp'Nence of the granting of this pari til.
AI'PLICAN"f UNDIERS"1'ANDS AND WI COMPLY WITH AL1, NON -POINT'
AIR HANDLING UNIT TI'D 10.000 CVM)
MIECII, ICAI.IIiIE
SOURCE REGUI, IU .
i
S-4 - r ` r
AIR IIANDLINGUNIT (OVER Io,000CFM)
CONSTRTTION" .
Signaturpof Applicanl/Cnntnminr Dme
HAZARDOUS MA'FERIAIS DISCLOSURIWill the applicant orfumm WildingOccupant aures handle burcous material
m drained by the Cupertinn Municipal Code. Chapter 9.12, aad'bc Icanitn and Safety
Calc, Semon 255320th" /❑Yc ❑No
(EXHAUST HOOD (W/DUCT)
HOUSING MI'1rflATIFEE
HEAPING ON IT(TO 100.00D BTU)
IIEATING IJNI I' (UVIiR ItXh,1XXh ISTD)
PAIDItceaip'IX
VENTILATION PAN(SINGLIE RISID
Am
IWemit
Will the applicant or future building occupant use equipment or devices which
hmmdous air pun ua inws as drained by the Bay Arca Air Quality Management
BOILER-COMP(3HPOR HAf010BTU)
'f0"DM.:
BOILER -COMP (OVER [00.04X)BOH
l.+
or
i
Disric"
❑ Ycc
1 Lave re ad the bwmJom..... "rialsm9"Imtiew, under Chapter 695 ofthe Cali-
Ibmia Health & Safey Code. Sections 25505, 25511 and 25511. 1 undemrxnd mat if the
Alit CONDITIONER
ISSUANCE DAE
/1 CCC��1
p— _.y
NEW RESIDENTIAL MECII. SQ. F.
builslingdous nm currently haven tenant the ,my re."Isibili'y mnntily the Occupant
of the m9uieerst ,' h timet ti, ce of ntiz,p�yI, yPuncy
u ^L _ff
.J I /
BY:
TOTAL/ISSUED
ovbwcsrautbori #gem Dam
OFFICE