S 1759 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - +
CITY OF CUPERTINO I - RUD.DING-ELECTRICAL PHSI I No
APPLICATION/PERMIT PLUMBING-MECHANICAL. �-- 1759
BUILDING DIVISION +,1 t,•I:BUILDING PROJECT IDENTIFICATION .
IIUILIIINGADIIRE S: « - /� SANITARY NO. APPLICATION SIIBMI"PIAL DATE
22A
ORPHONE WRAC
1111'S NADE NOwI7KII aocw� _
1971
•I 'T/E GINEERLIC N[ A9
lZi )q
CON'T'ACT: .PHONE: t ;'BUILDING PERM UU INFO
^ n ❑ COnStAtant Fees Paid by Applicant(initial) BLDG " ELECT PLUME 3b 51 . ❑ ❑ ❑
LICENSED CON IRAC IOkS DECLARATION QTY ' •ELECTRIC PCRMIT' ati • FE
I hen ,htI l d d -P r IChapter 9 teonh s _ - JOB DESCRIPTION
�p� wills i ]01Hq iDvse.aenhe Briial.ndl r.:,,senor,ane,tyl censer, ov
PERMrnSsunNa. RESIDENTIAL,
FWv2 in fell romm id'EElSFDWI. ❑KITCHEN REMODEL
QVU Licence Class Lictt APPLIANCES-RESIDENTIAL EADDI'NON ❑PLUMBING RE-PIPE
mzw Onle Conwuns -
F�,a ARCA I'I'BC'I"S DECLARATION PANh19 ❑MULTI-UNIT ]STRUCTURAL
z O-Z 1 undullund my plans,hall hcn.al as pehllc nand, _ MODIFICATION
p Z4^� _ UPT0200AMPS [3 INTERIOR ❑CHIMNEY REPAIR'
WLicensed Protit,an nal -
- 2111-10,111AMP5 IMPROVEMENT EjSWIMMING POOLS
OWNBR-RUII.UFR IHCLARAHON OVER I000AMPS El BAT] REMO E ❑DEMOLITIIyy /
a d 1 hereby aftnn that I am exempt from the G+Nmdtnh License Law Inr Lha
O C U following remvn.1Scetion 70315.Business and Profession,Cock Any city o,coemY SIGNS ELECTRICAL ❑OTHER -
W'3 W N which reyuircx a'craft to construct,illw,improve demolish,ar repair any'cern..
FEO still to its issuance,also rcgnires the applicant forsnchpermil tofillito,cialldenmm SPECIALCIRCUIT/MISC
mml :'1' Ip a ti p ftl C 1 I,r 1' (Chaptci9 -
WSi
dorm ing,0,Section7000) ID l of tl,Bio dP f :Cadha TLAI P ML IR OR POLE
Gp,oC lhnh It there) and the k.'. f th IIbJ Pt Any luf of - - .0N17WBLDG/ADDITION El DEMOLITION
iitt {L Seel 70315by any applicant Inr.pera t.ubjden the app) tt civil pennlry of POWER DEVICES
W^w ❑TENANT ❑FOOD SERVICE
te)bun five hundteJ dollar.155001. 'IMPROVEMENT
W� QvoInvn rI.the properly,start ..tnyotibeeydralo,hwved R, air(Sole catnpcnsntion, SWIMMING POOL F.LEC'I'RI -
wall Prole work,C a Tire Co eii.not i Livens Law does all
t 1'.o all air ❑OTHER
3 and property
inions code:The Qmwetren License Law dues not apply to un owtici of OUTLETS-SWITCHES-PIXY
properly woo nnu nrttnnm�ex Inerenn,aw wan dues soca work nimxdr nr mmegn
his own employees,pmvlduE that such'nnpecral ¢ere not.i mended or offered for NEW BESIDHNI'EAI.ELEC'1'It S el'
sale lf,however.the building or ianpmvemcm In cold within one year of annpldion,the SQ.EC FLOOR AREA $/SQ.T.
see,talikerwill haeme bnnlenorpnwing Oad,he did not beim mve nrimpfor per- - -
sof,me.). qq pp�� _
1,vs owner of the property,em cxduxively connvming wish licensed conirumocs to TOTALI P M 10
nnlrucl Ore project[Sec.]IWh,Foxiness end Prof'inns Codn'J Tho Cunwdot's Li-
m a
e 1 apply in rpmpeny who nmlds p m . d QTY' •' PLU MDING PERMIT 1 1 FEE i ��Q-((}}
L.-
vase
t t.f hp j lx with.eettraclm licensed p tt Ih Cear I }"' JUIN nlrtik{�
Lee : 1 •,R MII ISSUANCE
❑ 1 ant recnpu nderSc 11&PCis,, reaaon' -
ALTP.R-DRAIN&VENT-WA'I'Ek(HA)
Owner Data
'
. WORKERS COMIINSAI ION.DICARAI'VES BACK FLOW PROTECT DEVICE
lheichy;iffirin1erpityoiperitiryc)neolthciollgdeclaratioiis:
�,I M1.vc mtdxdl ata nl n'C a'f 't nIC It II" s ref W total C otpcn- DRAINS-FLOOR,ROOT,AREA,COND. STORIES TYPE CONS'IRUC'1'ION
ambo,Its provided for by Section 3700 of the Labor Code,far the performance of the
work for which this permit ie isatin. FIX'FUSES-PP.R TRAP
❑ I have,lnd will mainuin Worked,Carocan ion hcaltnnc,as re In ed by Section .
3900,4 the Labor Car,In, ped robaal of the watch for which Ili,permit is)clued. GAS-IIA.SYS I'ENE I INC 4 OU'ILE'rS
DEC QItOLIP- AI'N
My Workerts Centpens d ono Readable cvrricr and Policy nun ecr are:
Carrier: Polley No GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GREASE/INDUSTIiI.WASTE INTERCEPTOR
_ EG_IWIING D7ti1_SION-PP,R.S _
(This saation nucd,mtheanoplatc+lif thepennit lr tonne handled dollars(SlfNll - 'GKHASE 9'KAI'
orlesv.) PLANCHECK FEN, � - -
.Imnifythatlndeperft fthc work fnrwhioh thlapcnnll is issucA.l shall SEWER-SANITARY-STORM P.A.200 FT.
all on Luwsun e n as to become Inject m me Workers'Compen- ENERGY FEE
rs n WATER HHA'ITR W/VF.MI'/IiLI C'I'R
job
GRADING FEE
NOTICP.?n REPLICA after staking mix CertiHcue of Exemption,you should WATER SYSTENVEREATING
become subject I the Worker',Cnms,...tiori pmv sions of the Label Code,yon Ina SOILS FEB
W forthwith comply with such provisions or this permit shall he deemed revoked. WR'I'ER SERVICE -
aQ '
CONS'I'RUC'i'ION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.LE PAID
UO l heresy norm that mere is a eonlmetimt lending agcnen alpcdoccrnce of - -Dale Rmoiptk
w
all vwoH lot whlehIli,peonit ie sal(Sad,3097,Civ.C.)
V Lenders Nana, TOTAL:
W Lender,Address 'I'DE'AL:
teaI certify that I have readth ppl' tion laid sain,tholiffir abovef Ions
' m �,1r LBUILDING FP
E
IA ., I ca t ply '0 11 city d ly � u d aidelaw,elair,to pl- MECHANICAL PERMIT GEC
LZ building, luq m and henby nth r' representatives efthsety toenertpot the SEISMIC I'LE
above"mentioned property for inspection purposes.
-
.. ,"
(We)a to save,indearad d keep harmless the Cit f Cu Lino u most PERMIT ISSUANCE ELECTRIC FEE
habilgree nun p yo pct g
in..i...cant,of0a,anisand expense..which may in any wayname against said City AL'fIiR ORADD'I'O MECH.
in conNequcncc of ate gmmin• lhix pennih PLUMI3INC FEE
APPLICANT UNDERS D AND WILI,COMPLY WITH LI.NON-P N AIR HANDLING UNIT(TO I0,000 CFM)
� SOURCE HEC L
MECHANICAL.iti;E
AIR IIANIILIRQ UNIT(OVER III,OW CPM) CONSTRUCT ION'I'AX
Slgnmur of p Cmnracmr me EXHAUST HOOD ONMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOS RE -
Will meapplicnm orfetete haldingocerpannmreorhandlc hazxNnusmatedal HIA1 ING UNJ 1'TIO Haight BTU) -
r as defined by the Cupertino Municipal GAe,Chapter 9.12,uad'tbe Health and Safmv
Code Swit 125532(x)! HEATING UNI,(OVBR IOl IdTU)
0Yc. No PAID
.
VENTILATION I-AN(SINGLE RBSID) Dam RceciptR
Will all applicant or tomer,hnilding weupmd too equipacll or devices which BOILER'-COME'(3HP OR 1011,(11111 ETU) -
emit hwunlou,air cornball as derned by ata Bay Area Air Quality Management
Dilrinf - '�^'^ TOTAL:
E]Yes F_]No BOILER-COMP(OVERI00,000HTIL -
I have Paid the heorciaus materials rcquiretncnts under Chapter 695orthe Cali- AIR COND I'fIONER ISSUANCE DATE
fomia Hl&Safety Cade,Somions 25505,25533 and 25534.1 understand that it the NEW RESIDENTIAL MECH. SQ.Ef.
building demnotcetrcmly have a rea 1,that it is by rotpmsdably to amity the wcnpnnl
of the requimntonts which mux he all prior to issnal of a Cenifiew,of Carapace, -
Owner or authorized agent - Date - TOTAL: ISSUED EY'.
OFFICE