B 0666APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING D'D'ION APPI,ICATION/PF,RMIT PLUMBING-:IIECHANICAI,
BUILDING PROJECT IDENTIFICATION
PIiRMIT NO.
L.00(yl �O♦ ,u
DtYtNfF (O (O L!i
dU1LDING ADDRESS: tM✓\ ��nn ]
pCil 11—•V
tiANI'I'ARY NO.
AI'I'aIC—AfIUY SUliM111'1'1'AL IIAf
OW :SNAME: ('HON'
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QI'Y.'� ELECTRIC PERMIT FEE
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COYIROLa
ARCIHTECT/ENGINEER: LIC NO:
CONTACT PHONE:�t`(L�:�
1
BUILDING PERMIT INFO
BLDG ELECT PLUMB / M11 E❑CH
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LICENSED CON] 'sed ordrp OIiCLARA'DON
Inereny arumlhmlam nccmcd ender pmrismns er cnapmrv(ratntecnd„g
sithsenion?alu)al'Dwisian 3enhe Bminew.rd Pmfc,sions Cede calm, license i,
in all force and died.
License Class Lic.a
JOB DESCRIPTION
RESIDENTIAL:
CSFDWI. CKI"ICHF.N NCMOUIiL
❑ADDITION CPLUMBING RE-111PE
❑MULTI -UNIT C STRUCTURAL
REPUPT0200AMPS C] INTERIOR ❑CHIMNEY RF,PAIR
CHIMNEY
���� IMPROVEMENT' SWIMMING POOLS
PIxtHREMODEUREPA1R ODEMOLITION
❑ OT11ER
PERMIT ISSUANCE1
APPLIANCIN- RP-SIDF.NTIAL
PANIi1.5
201-10%,
Dora Creamier
ARCH1TIiCTS UfC1.AkA'1lON
1 undersand my pt.m,hall be used as public record.
Uveae] professional
OWNER-RUILD17R DECLARATION
I hereto, attire then I am oxen,, Gant the Goan^nor', License law for eche
following rwhon. (Section 9031.5, B.,ine,x and Proless,om' Code: Any e+l, or eomny
whi,b 4 pc nit t t t I¢r, p J m lisp p anY swnurt
pro u,a, i ... nor. alkomquim, the 111ic to h "nonatt file '. faced aamear t
that It is Ir od!pursuant tthe p ons l' the C a en's License Law (Chapter v
with Section 1100)of Division of the Business and Pndessions Code)or
Ihm ns is exmnpn therefrom and the hn,iy rnr tha nllcgeJ excntpainn. Any vinlntio^ of
SmdoOWI.S by any applicant for a Permit subject., the applicant a civil penalty of
nut orae ,hon Eve hundred dollars ($500).
❑1.mrw^rref,heprspery. army cntplayccs wish wages., thei,cle nnnpc^sarrn,
will dobe work, and the structure is not inrtndedor offered forsale(Sec. 9Ofi, Business
and Proc..i s., Cale: The Contractor's License Law does not apply to an owner of
pmMnywho build, or improves lhacon, and who docs such work hici or nhmmg
his own employee,, provided Thal such improvemrms am ^a intended or attend for
,ace, if, hawanthe brilda,er Improvnncm „eld withinone youroreompleter, the
OVER If%X 'S
SIGNS EL R :AI.
SPI!CIALC C I'I'/
TEMP.MID ORPOLEINST
AM i /
COMMERCIAL %N 0(_(f�
❑NEW BLDG/AUDITION ❑ DIiMOLITION
0TENANT CFOOD SERVICE
IMPROVEMENT
CO'1'IBilt
POWER BE (CFS
SWIMMIN( Pfl1
OUTLETS-SWITCHES-FI%TURES O
NEW RFSIDENrIAL ELECfR SQ IT.
SQ. FT. FLOOR AREA
ESQ. IT.
owner byid�der will have the burden of proving that he did not build or improve far pur-
nms to
iu^, with li omosd camct
r the pn+pcmy, um moloorely conm
+ nuc,theoprojeO(Sec.TW. Boniness and Pmdcssions Codc:)noContractor sLi-
an,c Law does not apply to an owner of po,amy who builds or improve, thereon, and
Q'I'Y. PLUMBING PERMIT FEE
who umnkan for such project, will, a contra ears) licen,ed pursm,nI ro the Conincelei s
License Law.
❑la eon,under Sea .B& I+ C forthis rcmen
`
PERMIT ISSUANCE L
AI:1'LK-GRAIN &VENT'-WAI'lili (IIA)
/ VALUATION
Cl O
Ow Dae
W'ORKIi :S COM PENSATION DECLARATION
BACK ROW PR(YTECT. DEVICET
1 hereby affirm under penalty of perjury one of the following declaration,
Qlhavaarxl will mainaina Cenifica¢n(Co^xnuoulGinmrefor Worker's Compo^-
DRAINS - ROOT. ROOF, ONO.
gT( PES
TYPE CONSTRUE"110:
anion, as provided for by Section 3700 of the Labor Coda for the performance of the
work farwhich This permit ix issued
14 FIXTURES -PRN TRAP
1 have and will maintain Worker's Compensation Insurance, or, re,mood by Section
PIII)of eche P.alar Code, fur eche perfnrmnncc nfthe work ter which thin lwnnit i, cd.
My Warier's Compcnwtion Insurance carrier and Policy number am:
Cocoa Policy No.:
CpRTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GAS-EA.SYSTEM-11 .i- TL
OCC,GROUP
V`
�� �aoa6
GAS-EA.SYST[M-OVIi
GREASIVINDUSIRLWAS'TEIN'IF CE 0
BUILDING DIVISION FIiES
GREASE TRAP
I'LANCIIECK PEE
In, section need not he complaeddthe Permit is arcane hundred dollan(SIM)
zZ
0
?became.mbjecf
s.+.l
I<miny that indic matey manner of stobekhsr whichlhin torah;, is'C.l shall
ern employ any pernnn in :ury manner so as m Mcon,e subjem m the Wnrkcri Cnmpen-
ohim lawaof Califeed.. Doc
Applicant I
SEWER -SANITARY-STORM EA. 200 F.
ENERGY FLIT
WATER HEATER W/VEN VELECTR
GRADING FTi
NOTICE TO APPLICANT. [Tither making this Ccnifiente of Exemption, you should
In the Worker's Compen,mion pmvincro oa the Taber Code, you nasi
forthwith comply with such provisions .,,his perp ildnedl be created revoked.
WATER SYSTEMITR EATING
SOILS F
WATER SERVICE
i.a
y O
7 Z
U 0
W F
CONSTRUCTION LENDING AGENCY
(hereby affirm that is a construction loading agency lot the performance of
the work for which chis peratit1, red (Ser. 3047. Civ, C.)
Lerace, Name
PAI
)ate Receim #
NEW REST[ PIAL PP.MB. SQ.IrI''
TOTAL:
\te
Q U
W
Q,
IA
U Z
<nddn Address
1 certify shut 1 here mad this application and slate,hal the above Infornntin o 1.,
snorer, P agree to comply with all city and county ordinances and state laws relating to
IF ldi^goo^s0umioo,and herebynuthnrir.eer,resemenivesofdo, city to onmruM+^one
shoot mentioned p.,.y for inspection purpo,cs.
(We) agreem save, indemnify and keep hoots,, the City of Cupertino against
kadildes.judgmems,coots and expenses which may In any way acme against said City
BUILD. GIT
QTY, MECHANICAL. PERMIT FE{'
SETS 1 FELT D
PERMIT ISSUANCE
LLECI'RIL TF 2 -
ALTER OR ADD' 1'0 MECIL
PLUMBINGF'E D
in conicquence or the gaming of this permit.
APPLICANT UNDERSTANDS AND WILT- COMPLY WITH ALL NON -POINT
AIR HANDLING UNI 'I'('TO El.WCPM)
MECHANICAL FEE
S I{$LRCI?RpIIGULA'kIONg��
\C R
ING UNI'1'IOVER 10.gXI CPM]
CONSfHUCTIUN TAX
•nI Appliount/Qommnm DmcOOD(W/DUC)
HOUSINGMI'DGATIONFEE
HAYARDOUS MATERIA S DISCLOSURE
Will thcupplicumocfumre Wildi^g¢aupanl sntremh.ndle W.rame, materialIT(TO
ns defined by the Cupertino Municipal Civic. Chapter 4.12, and the Health and SafetyNIT'
Gila Section 25532(x)?
❑Yes ❑No
100.0!10 RTU)
MD
(OVER II).(NN) BTI])
N FAN( SINGLii REST]))Will
rhe applicant or future building occupant use equipment or devices whichOME(3HP
htvurdoun airconuon am, as defined by eche Bal Aro. Air Quality Mawgemantl
OR 100.000 BTU)mit
BOILER -COMP(OVER 11.0)0 BTU)
Dimrict?
Yes ❑ NnAIR
CONDITIONER1
"BY:
1 have mad lva Cade, S st ... 255 5,2553 a under 1.1 and hq5 of the CWi b+mia Health &t curre Cale. Secton, 25505, May and n,dei, l undenrand tool if Ne
doesnil o, hkh huvcameant,ohm it Is,ny rcvpnnsCcitiycanatiytheency,/+ft�mntenu wnkh nw,l hepty.prim1oj�aotce n(a CertiE<meoflkcup.nry.]� r% t,eJ rot -
g Der
NEW' RESIDPiNT1AL MIiCH. SQ. FT.budding
TOTAL:
//
OFFICE —
_