S 1582 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PFSIITNO. 1582
BUILDING DIVISION APPLICAT'ION/1'ERMIT PI.UMBmC.-MECHANICAL. `V
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
22156a r2 ae
O ER'Sz4E' e NAM ^W 1 ' �3PHO CONTRACT( 'S NAME: LIC
,f/&ILL / NIC CONTROL#
ARCHITP,CT/ENGINEER: LIC NO: ADDR55S: ❑
CONTACT
-:rN1l/L//1 PHONE: BUILDING PERMIT INFO
-)q6311
1/ 3'/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
�
r✓1 t./ I .. ❑ El ❑ IY
LICENSED CONT'RACTOR'S DF.CLARAI'ION QTY ELECTRIC PERMIT ' FEE.
I hereby affirm her I en licensed ander pmvisiom of Chapter (entmneading - - JOB DESCRIPTION
�Z withSection 9(Aq)nr ,Division 3 ofthe Business and Professions Code,and my licensees RFI I
BIOp i - PERMIT ISSUANCE OWI. ❑KITCHEN REMODEL.
bow.. nfullf roe end elle
�OU I,icdnee loss # APPLIANCES-IiRSIDENTIAL ❑ADDITION ❑PLUMBING BE
mZ M Dmc Gmuocmr f UA
6 AItCHITFCT:S DECLARA TION - ❑MULTI-ON]T El STRUCTURAL
'Doe PANELS
Z0y25 � •-Ip'Identen myplens sNdl be use u.public records MODIFICATION
CZ-a v�Yl ��� ce'// UPT02011AMPS ❑INTERIOR ElCHIMNEY REPAIR
ul Llcwssm Profess and �"-i 6'b 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
•,]
OWNER-BUILDER DECLARATION OVER 1003 AMPS ❑RATA REMODEUREPAIR ❑DEMOLITION
01 Q I by a fC n that I pt f theContractor's L L for the
a,U follow g reason.(Sect 7031.5,Business.,,it poor ,Code An,adyn,amply SIGNS ELECFRICAL ❑OTHER
'Ifice,rectum. I Inn f01,adlet, I dernomish,or repairany atmcros
r' O� pia 1 1. alamantesth ppli t1 hp permit Il .'g d moment SPECIAL CIRCUI PMISC.
ray thcosecslin,u pureuam lathe vision
sat he Business and emeoine,Capmr9 r
� d� (cat he is exempt
Smaon]000)the
Division,nftheegnema Profesy i ludonor TEMP.MED OR POLE INET. COMMERCIAL:
Pt o that h Section 703
31.5 bt therefrom and the boars far the alleged exemption.Any violation of ❑TNEWEN HhDG/ADDITION ❑DEMOLITION
�-„ not moethanfve hundredienntfonapnmit sohjna,the appllcnm na nclvil pennhy of POWER DEVICES ❑IMPROV ❑FOOD SERVICE
not more ounc flue hundred y,or y crop] OTHER IMPROVEMENT
1,as owner nfthc norm Io nes'.illi wh•h,as Choir sale cum snsatlnn, SWIMMING POOL ELECTRIC proles y yemp Y 6' 1
La^ will eo tnewrnk.Code
The mureisnmineneceomff does
notlepply to
1an Business ❑OTHER
u�13 m and property
whe ho Code:The les teens Licemc Law docs not apply le on owner of OUTLETS-SWITCHL'S-PIXTUItP.S
property who builds or.Filed es Chardon,and who ares such work deedhimselfef dtrou6h
his own employers,e building the such nand is menu ore nm dummied or offered En NEW RESIUENTIAI.ELECTS SQ t0.
sole.IL boweled the building arimprovemem is told within one year ofeompldtiun.the SQ.PC FLOOR AREA $/SQ.FT,
mor-builder will have the burden of proving that he die not build or Improve far pur-
auto of orad').
1,as owner of the property,am exclusively contracting with licensed eonnecu rs to IDIAL'
ensfrua the p feel(Ser.7044,Busineee mW Pont,...an,Code:)The Connector,Id-
,e Low does not apply In no Owner of Property Who builds or narcoses thnamn,and QTY. MHUNG PERMIT - FEE
mvanm
who ae for such prcPaG with a nneemrsua
4,)licensed punt In the Carl m.too,
License Law. PERMIT IS UAN'
I vm exempt undo,Sed. .B&P C for this reeeat
Owner Dam AMER-DRAIN&VE - ER(EA VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DF.VI
1 hereby affirm order penalty o[penury ono of the following Awlarutlons: -
❑rl have and will maintain a Cenmeark of Comenua sell-lmure for Worker's Compen- DRAINS-IUOOIGROOF.AREA,COND-
STORIES TVPF CONSTRUCTION
` rzkfoas pmvi off for by Suction 3900 of the L. Cod, the padurmance of the
rwelch this pannus orke. FIXTURES-PER TRAP
have Le will mainmia Worker rands Compensation Insurance,as required by Section
3]11(1 of the laWrGadn,Garthe perf nuance the work fotwhich this permit ie iaauGl. GAS-EA.SYSTEM-I INC.4OUTLE'f$ OCC.CROUP ANN
My Wor 's C m '.lion ltnu no' y.y
Grrridr q{1Y GAS-EA.SYS'IEM-OVER4(EA) IP A
CI R HTCATF.OF EXEMPTION FROM WO ERS'
COMPENSATION INSURANCE GREASE/INDUSS FRI.WASTE IN I'NRCEPI'OR
t BUILDI 6D LEIaS,
(Tbhscrnlon need not Fzwmpletul ifthe pumil is fomuehundme dollnrx($100) GREASETRAP
nr levoo
) PLANCH -
Iconrythatlnthe podmmnnceufthe work forwhicM1this permit isissued,l shall SKIVER-SANITARY-STORM EA.200 FT.
not employ any person in a nynmrann,.ustohecomesubjen In the Wnderv'Compen- ENERGYFEE .. tl1141/
ZZ cation Lawsof Callfernio.Date WATER HEATER W/VENT/ELECTR
C Applicant GRAIIINrOFFB
lA NOTICE TO APPLICANT:If,after making this Certificate of exemption,yen should WATER SYSTEMO RENT ING
becnmcsubject.the Wor kers Compensation provision,of the Labor Code.you must SOILS FEE
forthwith comply with such provi,ions or permit shall be deemed rcvoRod. WATER SERVICE
aQ
� Z CONSTRUCTION LENDING AGENCY N13W It ESIDF.NTIALPLMB. SQ.FT. PAID Data � eceipt#
rfi
I hereby ana hot hore is a nhnsfronion lending agency forthepm
erforanecdf
U 0 ate work f..which his"Fiat is issued(Sce.3097,civ.C)
L4 F Lender,Franc TOTAL'
U Lenders Address TOTAL:
I eaB,fy than I have read oris applfemicn and sate that the above dal a,,,ma Is BUILDING PEE
.E". V) conmtl agree to comply with all city and coanty ordinances and scorn laws relating to QTY' MECHANICAL PERMIT FEE
U Z handingeon.hnction,and hereby auto orim rcprasenmf,r,.fthis city mante,ugm the SEISMIC FEE
anuvo-memionad property for inspection purposes. PERMIT ISSUANCE
(Wc)agree to save indemnify and ke to hmmless[he City of Cupertino against ELECTRIC FF
liehilitiexjudgmenm,masond expenses which may in any way acerae against said City ALI Elt OR ADD TO SUCH.
in
innow,umccefdo gmnfing of this permit. PLUMBING FE
IN
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) 2— /®
SOURCE REGULATIONS. MECIIANICALP a
Arlt HANDLING UNI'I'(OVER 10. CPM) CONSTRUCTION&
Signulure(it ApplcanUGetracmr Ilam EXHAGS'I'I IOOD(W/DUCT) HOUSING MI'FIGATI(IN FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant at future building occupant slorc or handle hieanlou,material HEATING ONI'I'TO Booths)BTU) �0
as defined by the Cupertino Municipal Code,Chaplin 9.12,and the Health and Safety
Code,Section 25532(a1P HEATING UNIT(OVER 100J)(x1 RTU)
❑Yes ❑Na PAID
VEN'DLA'I'ION FAN(SINGLE RESID) Date Rcmlpt#
Will the applicant or future building occupant use equipment ordovice,which gO11,ER-COMP(3HP OR IW,OfNI B'PU)
chair hamreous air conn minors as defined by the Boy Area Air Quality Management TOTAL:
District" Yns El BOILER-COMP(OVER 100,030BTU)
�
AIR CONDITIONER
1 Hath mama the M1 a tions 55 5,255mmm mtdei 5534 1 and 6.95 0l the CnIF ISSUANCE DOTE
Fnmia Health&Safety tryCode.Satins 25505,25533 dna ns534.I to ratify
the if the NEW RESIDENTIAL MF.CH. SQ,FI'. V]/[J
nndemg ecce hot currently have ntnnam,root pia lav,aspen,inihtrmnmiry memwnatn
at marn, or q tons, a of v can f
Owner authorized agent Dae `-i L IssueD BY: k O`—� 1 L 0
OFFICE