S 1876 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES--USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD NG-ELECTRICAL, PF.ISIT N(F
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL \V C8
76
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANUARYNG. APPI.ICATIONSUBMITI'ALDATE
IZmb;�el 7- zo • 9�
OW Fai'S PflONII� CON ^/P'SN G [` LIC NO: N/C CONTROL#-
�tIII'rFCT NEER: 1 nZOM 3LIC�o x(26 A RL / /r •`l r ❑ i
CONTACT: Y Y PHONE: - J BUILDING PERMIT INFO
eve' 7 77-Ol Oil El Consultant Fees Paid by Applicant(Initial) BLDGELECT PLUMB ME 11
fA.w J LLd I�r LJ
LICCNSEICONI AL,An QTY ELECTRIC PERMIT FEE
I hereby affirm a i l r nsed under p x of Chapter 9(commencing JOB DESCRIPTION
naOZO with Section 9000)afl) 3ftleBus1 IY gs,i is Code,aid my license is pgRMl'I'ISSUANCE RESIDENTIAL'
Fy� Full roan and effect. ❑SFDWLCITCHEN REMODEL
dUU Licen.c Class Lic# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPF.
�zj ul Date Contrucmr -
¢¢C ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
F h PANELS
I andersean.I In,I lma durll he used.,p.hire reutNs MODIFICATION
UP10200AMPS
O Z 2 ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Pmfwsiowl 201-IUOUAMPS IMPROVEMENT SWIMMING POOLS
OWNERBUILDERDECLARATION OVER list()AMPS ❑BATH REMODEUREPAIR El DEMOLITION
I thou vine teat I am exempt from It,Comracmdx e:Any c Law far the
p�,C>)WU followingDOTTER
pj y F s reaxnn.(Section 911JL5,Business and improve,
de in demolish,
h, ,,Any city o rmwuY SIGNS ELECTRICAL (J S�
yy
four
I ' . p o construct,pp p d -.h , Y dramatic V
trio t t L y 'he pth tf hp t E argued statement SPECIAL CHIC UIIIMISC, C
yteeth I Ip a tb p ". tlh C L (Ch(Chapter
d (can g lh Su.l 911fq) IU i rth B .' dP f.'' .Cde)ar TEMP.METER OR PO Il COMMERCIAL,
m
that lie
)1131¢9 6 thereinto and the ' subjects the applicant m o civil penalty ur
c g p viola inn ol - ❑NEW BLDG/ADDITION ❑DEMOLITION
basis fo the alleged marcharms,u t.Any
mW y hundredicxmrnrnpo -' gena ) POWER DEVICES
not' , than Baa hundred Jnllars($500). ❑TENANT' ❑FOODSERVICE
Y IMPROVEMENT
Lav own,rof the pmpedy,nr my entpinyces with wages ux their sole annpansmiun, SWIMMING POOL 51, -
O will do the wrnkvndth,amanre is not intendedornfferod for sole(Sec.'l044.Basi, [-]OTHER
y3 m and Prom,jorx Code:Tee Cmnenater,lica,h,Law does not apply In an nwne I' OUTLETS-SWTPCues-
CC propcny who hands or improves thereon,and who docs suet work himsclF or Fico gh
his r eon employees,provided that such improvements are not merriest on in ercd far NEW RFSIDFN GAL BLL+C'fli
sale.If,however,the handing or improvement is sold within one year ofeompletice,the SQ.FI'.FLOOR AREA $/SQ.14.
owen-bradder will have the harden in having Feet he did not build or improve for pan,
iteof sale).
I,ns owner'If the property,an exclusively contracting with licensed imameters to AL' O
ms.
.vun thepmjmet(Sec.90,I4,Business and Professions Code)The Cmnincmr's 1.1-
craw,Law does matipply to an owner or primary vho builds or improves thereon,and
i-seLawdoesnaapplytoanownerorprnpatywhohuildsorimprovesthereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projmu with aeomronagn)Ilwmedpurtinat mthe Ccmheder's
License Law. PERMIT ISSUANCESQ
E] Iamex uWia,Im, .B&PCfor t
ALTER-DRAIN&V ENT-WATER(EA) VALUATION
O Date
WORKER Si7brWYNSAl'I NUF,CLARATION BACK PLOW PROI CCT.DF.VICF.
1 herebyalfnn under,penalty ol'perinry one of the fallowing Jciuroti ns: 0 D
❑ Ihaveand will maintain aCertifcateof CLrnenuo self-insure for Worker's Cnmpen- DRAINS-FLOOR,ROOF,AREA,GOND. C
STORIES
TYPE CONSTRUTION
cation,us provident I by Section 3]W of the lobar Code,Undue perfmnnadee of the
stuck for wh'mI thin permitis I....L FIXTURES-PER TRAP
I Lave and will maintain Workers Compensation Irxrnmce ax veined by Section //�l
34ft0oftne Labor Code,for the terfarmnnceot da,work fair this permit is issued, CAS-EA.SYSTEM-I INC.4 OUTLETS p O GROUP APN
My Workers Compensation Insurance carrier and Policy handier arc:
Carrier Policy Ne.: GAS-EA.SYSTEM OVER (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSAFION INSURANCE GREASE INDUS'I'RL WAS']E INTERCEPTOR -
('Ihis section need not be completed ifthepenuml is forma,hundred dollars($W) n ,H]IE,DINp DIVISION FEES
orless.) OREASE TRAP ANCHECK FEE S—Q
Iccnifythnt ionic per(nrmanwaDao work finwhichthlspemtil isissued,Labatt SEWER-SANITARY-S'IORM EA.2LOFT. r
not employ any person in any manner so as to become subject m the Workers'Comped- ENERGY FEE � 3 to
Zi saner Laws of California.Date WATER HEATER WNFILDI CyR
Applicant RIDI
NOTICE TO APPLICANT:If,after making tui.Ceri mato or Exanptioq you should W11 FR SYSTEM/FREATING
(~ heconm,rnrrd m the Workers Coh,Cx.Ibat pros sides of the Labor Code,you must .OIL, t
Wforthwith comply with such provisions or this permit shall be retained revoked. WATER SERVICE
tD Q
CONSTRUCTION LENDING AGENCY ' NEW RESIDENTIAL PLMB. SQ.FI'.
z ThumbY aGnn thaveere iaawnstmdion lending agencfor the performance Rmceipt#
Ll� the work for which thio factor is (See.9097,Cie CJ r VI
L4 H Lender's Nunn, TAL,
C.1 Lender's Address TOT
nY a . 1/0 PI-
iO
certify that 1 have read mix anpeaend and come that me above information is
.H. Ln correct.l agree(I)comply with all city and county omirnalex and xtam laws renting m QTY. MECHANICAL PERMIT FEE
'Z ��
C,7budding consnaction,and hereby authorirc representatives alibis city upon the CFEE
uhnve-meouoned progeny for inspection purpoxev' PHRMI'I'ISSUANCE
(Wc),grcem cove,indemnify and keep aamJessthc Clty of Cupeninn agaimt ELE TRIC FEB 00
IiublEues,judgmentx,costs and expenses which may in anyway acme aguIra'ard Cay AI.TFRORADDTOMECH. Z� !til
in mseyuance ofthe bona gof this permit PL MBINO FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MCHANICALFEE
SOURCE REGULATIONS. If I
AIRHANDLINGUNI'F(OVER IU,ON)CFM) C STRUC'HONTAX
Slgnaunreof ApplicanUCnntmemr Date EXHAUST'HOOD(W/DUCT) HOUIIII
ITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will tire appliwnlorfuture buildtngrcanponeme ur bundle hmandommmedal HBA'1'INC.ONI'If OO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health unit Safety
Code,Section 25532(x)7 HLOA'ING UNIT(OVER I00,000BTU)
❑Yes ❑No VENTILATION PAN(SINGLE R ESI D) PAID Uule Receipt#
Will the applicumcr name,
n,a,building by
Bay A.Air cntor lity Meesweiah BOILER-COMP CMP OR 100,000 BTIB
emit hazardous air comvminann as defined by the Bay Arev Air Quality Manugonem
District' BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑No
AIR CONDITIONER
leave Safad eyhode,Ss....asmaterials505,15533 an under Chapteemand that
ifde, _ ,�y� ISSUANCE DATE
Emla Health& ,nom Code,have.recur 25505.25593 add 25534.1 undersmnJ taut ileac NEW RESIDEN'T'IAL MPRH. SQ.Up.
ofthed6drearem,whih st mnvnt,thatllis my responsibilitytonotify Feeuccupom CF{ GJ/O`
of the reynirunente which must he mrxpdnrmissuance nfv Cenillcatc of Oecnpvncy.
Owner or aaeeoroed agent Date ISSUED BY _L)
OFFICE