S 1840•
z
zz�
V
a�
UC
OF
4
a
U2
0
APPI ICeNTTn'Fit 1 IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENT'IF'iCNERlN
PI?1g`pttI NO.
SJ 1840
BU I LDING ADDRESS,
SANITARY NO,
APPLICATION SUBMITTAL DATE
/02Ct4&WD
OWNERSNAMI?:IPI ONE'.
`! N Ar --..v P_
CONT ACTOR'S NAS�Il,,: LIC NO:
L 7 V C E 2 2
"IG
❑
CON] ROI.
A RCHITECfIF.NGINHEIt; LIC NO:
S Z 6 -L7_
ADDRESS:
ell V
CONTACT. PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (initial)
BLDG ELECT, PLUMB MITCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby aHlmm Wnt I ren lironsed ruder pnwinin is or Chapter 9 F, aneaaing
QTY ELECTRIC PERMIT FEE
_
.JOB DESCRIPTION
PERA11'f ISSIIANCIi
Milt Section 700) of Division 3 of the Brotwo, tan Pori .. on, Cude, and my Ileamw is
In full force and el7ect.
RESIDENTIAL:
❑SIUWL El KITCHEN REMODEL
APPLIANCILS— RESHNINITIAL
Liccnse Class Li,#
Date C.ntmmor
[]ADDITION ❑ PLUMBING RE-PIPH
❑STRUCTURAL.
MODIFICATION
❑ PIT 'ERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING POOLS
ARCHITECTS DECLARATION❑MULTI-UNIT
used I uncle ,mad my plans shall he ed as public records
PANELS
UP DO 200 AMPS
Lia mW PtafinNion.l
201-1000AMPS
OWNHR-BUILDER DECLAR61'ION
I hereby chit than I i i exempt from Tho Canmmlor, License Law lin he
followin6 reign. (SLO...m 70]1.5, I3a...... and Pndcssin is Cade Any it, or sooty
which requires a mrmil to construct,alter, imicas , dmmdlel+, or repair any rurnia,
C BATH REMODEIAREPAIR 1:1 DEMOLITION
❑ OTHER
0
OVER HIDOAMPS
SIGNS ELECT RICA.
SPECIAL CIRCl11TIMISC.
`.
GOOK
,mab,i,, ismance.aho requires lire applicant Enmrh p_mmiun fmleaeignedsmtenmnt
in., he is licensed pars ctu aOhe Provisions cal Contractors Licence Law (chapter ()
(commencing with Section 7000)of Division 3 at the Business and Professions Cule)or
that he is exempt therefrom and Ilene basis for the alleged exemption. Any violation of
TEMP. METER OR POLI? INST.
GDMMERGIAI:
❑ NEW BLDG/ADDI'T'ION ❑ DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars ($500).
:Dl,asownermfthoprnpmy,onnycmployecswilhwugesusthcirsolecompensation,
fiat fur o
will Jothcwons
POWER DEVICES
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTIIhat
SWIMMINGPOOI #.' RIC
OUTLETS—SWI'(" STORES
do ;in owner ul
Liceme Law Anus not apply to tat ownerol'
Cis, Ili Contra a Liter -of apply
I' and Professions Cada: The
ave,damm
pmpcny who builds ur improves mHerean, and who Jmwv tech work himself... Ihnmgh
his own employees, provided tial such impmvanems are not intended or offered lin
IL however, the building or improvement is sold within one year ofemadelion,Ihc
NCW kF,SIDI?N'1'IAh (HSC SQ PCsale.
SQ. F'!� L Ali
LSV. Irl'.
er-builder will have me harden of parents Jr., he did nm build or improve for par -
now of sale.).
❑ LosawneTofthelanperty, am exclusively contracting with licensed connector, to
JUL 14 ANSID
'
construct the project (Sec 703Q Business and I'rnfessinns Code) The Cnmmetnr's Li-
neLawdoesmatm,ly mmmawttr,ofpropeny Mar badda ar no....es thereon,and
QTY. PLUMBING PERMIT PEE
who nmme¢t'ormch pr Jectn with eumt.ctor(0lianvtd Pn"arma or the Camnmter'e
Liccnse Law.
[2I am exempt under Sec. , It A P C for ffio,wvsnn
b
011 Ur l/UI'CnIINQ
P
I?RMIT ISSUANCE
Daiwa Date
ALTER — DRAIN A VENT—WATER (ILA)
VALUATION
WORKER'S COM PENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
1 hereby affirm under pcwlty of perjury ane of the ralhwing decDrdtionn
Vane andwillmaintain. CmificaeofConsemmslf-insure farWarkersCompem
,flan, as provided for by Salim. 3710 of the Labor Code, for the performance of the
DRAINS—FLOOR. ROOF, AREA,COND.
STORIES
' TYPE CONS'fRUCI'ION
work Ibr which this permit Is i—ard,
FIXTUR17S-1117R l RAI'
❑ I havn and will nminwin Workers Compcnsa li nourune , as reyuimd by Section
r ch this penning lesaed,
3900ai the Labor Care, Innta,doonancenflhe work fowhi
�/
' GAS— HA. SYSTEM, INC 40U'IY.T?TS H/
OCC GROUT'
APN
My Worker's Compenunian Hrsurance carrier and Policy number ore'
Cartier: Policy No.:
GAS— EA, SYSH'I?M{WE 4 (EA)
GREASMISDUSTRL WASTE INTERCEPTOR
CF.RTIFICA'1'B OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(This section neednm be completed tithe Permit it fnrnne handrcddalLanP($100)
ar Ieas.)
GREASETRA'
PLANCHECK FEE
I certify that in the lwrfammnce ofthe work for which this permit is issued. l shall
n (employ any pe: a many armarrso axmhvcYYYYYY111((0 h,,�11'��4e�js a+the ders'Cn into
e
SEWER—SANITARY—STORM EA. 210 FF.
I?NERGY PEE
WATER HRA 'I'17R W/VI?NT/ELEC'FR
GRADING PEE
salion I-aws of Cafi til, IYm
Alp] icum W-5� Lm
NOTICE TO APPLICANT: It, after making lhls Carliferric of Exemption. you should
becoe subjcm m the Wnrkcr's Compensation prevoino, of the Later Code, you nmxt
WATER SY Sl 17MC R EATING
SOILS FEE
fnthwitn comply wish such pnrvman, or this peram shall be deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I herebyaffinrthat here i ....... aion lending agency far the wromnantaof
NEW RESIDENTIAL PL.MR. Sp. FF.
PAID
Dam Receipt#
the work for which this permit is nand (Sec. 3007, Civ. C.)
Lender's Namo
T(TI'AL:
'I'0 IAL.0
xader's Address
is
BUILDING FEE
I certify that 1 have road this application and sIac Jan the.twve infornalin i
t -
restl agree It comply wuhall city and countynMaunas unit nine lvwsu,1adr,m
building eunslmt9 ion. and hereby mdhano,. rewmmlves of do, city or erten''() t be
Q'IY. MECHANICALPERMFF FEE
S131SMIC FEE
PERMIT ISSUANCE
BLIiCI'RIC FEE
ana, mentioned pmpeny for inspection purposes.
save, indnify and keep h.mJess he City of Cupertino.,.i.,,
(We) agree m em
ALTER OR ADD To MECH.9
1'LUM1IBING FEE V #
liabilities.judgments,costs and expenses which may in any way creme againsmsaid City
in comegaence ofthe graminmit.
gof this per
AIR HANDLING ONI'I'(1'010.(00 CFM)
MECHANICAL FEF.
APPLICANT ON D17RS'[AN DS AND WILL COMPLY WITH ALL NON -POI N
la TRICE REGULATIONS
AIR HANDLING UNIT (OVER 1111011 CFM)
CONS' I'RUC'1'[ON TAX
e \ �AA cg* • 7 _IY_W
~ //ll id
Signature r' pplicr aTICominauer` Dale
HAZARDOUS MATERIALS DISCLOSURE
P,XHAUS'f IIDOD(WIDUCT)
I DOUSING MITIGATION FEE
HEATING UNIT (TO 100,0011 BTU)
Will mneapplicart or furore building ocraparn smrcor handle hamncomnal,did
as definN by the Cupcnino Municipal Code, Chapter 9.12, and the Health and Safely
Coda SnJlon 25532(a)1
HEATING UNIT' (OVER 101,000 BTU)
El Yes / No
PAID Date Receipt#
VENTILATION FAN (SINGLE RESID)
BOILER — COM(' OHP OR 100,(00 RTU)
Will the ,,airs or fuwrc building cecupum use equipment or devices which
mutt haOrdo,s air mnaunin�Nt+defined h Tho Buy Area A,, Quality Management
Difn,l
/'� Y
TYPAL: D �
#
BOILER—COMP(OVER 100,00(1 It IID
AIR CONDI'I IONER
1 have read the haeardnus materials requirements ander Chapter 6.95of the Cali-
f.mia Health d Safety Code, Sections 8505, 25533 and 25.5.34. I understand Thal if the
baildialul {i t u responsibility tly have a Road, at it is my ressibility to notify the cu
ISSUANCE DATF,
i
NEW RESIDENTIAL MECH. SQ. 14.
of the we s w `wh muss m Pri o issu.me af. Cenifcae of [kcup^ncy.
e
'fOTA L:
Disinter agent Dore
ISSUED BY,
OFFICE