S 0403APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. - ELEL`FRICAL
PERMIT No.
BUILDING DIVISION APPLICATION/PLRNUT PLUMBING -MECHANICAL
S 0403
BUILDING PROJECT IDENTIFICATION '
BUILDING DDRESS.
-
SANITARY N(l.
AI"IJCAI'ION SUIIhf ll'fA I. DATE
O yER'S ONy:
Ct TRACTOR'SNAME: IJ' O�
�
NIC
E:1A
CON '1'ROIL p
EHITECT/ENGINEER: WC NO:
DRF_
1C ov- r3
CONTACT. PHONE:
BUILDING PERMIT INFO
❑ Consultant FCort Paid by Applicant (Initial)
ELECT PLUMB MUCH
❑ ❑ ❑
LICENSEDCONTRACTORS under S DECons of ION
Iherchy))of Nat1am (the Blunder Provisionsof Chapter9(commencing
Z wird Section](NXq ofUivisinn3 ofthe Rosiness and Professions Gale, and my license is
in full farce and clleeb
J Licence Class Lia#
S Date Contractor
QTY - ELECTRIC PERMIT FEE
JOE DFSCRIPTION
RESIDENTIAI:
❑SEUWL ❑KUCHEN REMOUE.
C1 ADDITION ❑ PLUMBING REmPIPE
❑MULTI -UNIT ❑STRUCTURAI,
MODIFICATION
PI7RMIT ISSUANCE
APPLIANCES -RESIDENTIAL
AHCHITECI'S DECLARATION
1 understand my pla nx eholl be used m public remrda
PANELS
UP 102(X) AMPS
❑IN'IPRIOR ❑CHIMNEY REPAIR
IMPROVEMENT �SWIMAfING IY)OIS
❑ BATH RF.M1fODEVREPAIR ❑ UEUE 10
Licensed Professional
OWNER -BUILDER DECLARATION
Q I hereby a(R,m that I am exempt from the License law for the
201-100AMPS
Oyuµ l(NOAMPS
le,metorx
following reason. (Section ]orsor Business rad Pa, denons Code: Any city nr cony
which requires a Permit re omswn,
improve, demolish, or repair uny shootsPtic
SIGNS BLP.CTRICAL
. [� (YI'IIER
applicant
that he sliensed a..D..tit, sNe applicant far CmitustMh tminoiccre. usilumementaw(Chapter9
that he is licensed pursuanne the pmvisinm of the Cnmrsctors license lawlChaper9
� pommonchng wilh Section](XHI)^f Division Sof Ne Business and PloM11ionv Cw1o)mr
y lost he is exempt therefrom it the basis for the alleged exemption. Any violation of
Section 7031.3b an applicant subjects the applicant to acivii penalty of
y hundred
not more than five hundreA donors (85(0),
SPECIAL CIRCUR/MISC.
TBMR METER OR POLE INS'(.
COMMERCIAL:
❑ NEW BLDG/AUDITION El DEMOLITION
❑TIiNANT El FOOD SERVICE
POWER DEVICES
SWIMMING POOL ELECTRIC
1, as owner of the property, army employees with wages as their sale compensation,
will do the work, and thesl ructure is not intended .r offered for sale(See. 9(W ,llusiness
u and Professions Code: The Contactors License Low does not apply to an owner of
IMPROVEMENT
El Or[ ER
OUTLETS -SWITCHES - FIXTURES
praPeny who builds or improves memo, end who dsws such work himself nr through
his own employees, provided that such improvements ore not intended or offered for
NEW RESIDENTIAL ELECIR SQ Cr.
side. 11, however. the building or improvement is said.1're.nn"a,ofe^ntpletion, the
m
pt scm(sale
owncolmilder will have the burden of proving that he did nbold or improve for pur-EJ
SQ. Fr. 14AOR AREA
A
p
$/SUI -i
1, u ownene r the Property, am exclusively crooning with licensed convectors m
construct the project (Sea. ](Ds, Business and Pn+l'asxinna Cak:)'The C.nlraanfe Li-
cense Law does not apply In an owner (it property who builds or improves thereon, anJ
who contracts for such projects with a commuctons) licensed pursuant to the Contractor's
License Law.
❑ l am esempt under, Sea. , li do P C for this reason
TOTAL-: �s
y
F //
y1VIN
`y
QTY. PLUMBING PERMIT F
PERMIT ISSUANCE
AM HR - DRAIN M VENT'- WATER (IEA)
Owner DateVALIIAI""ION
WORKERS COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations:
BACK FLOW PROTECT. DEVICE
DRAINS-FLOOR,µ00P,ARIiA, GOND
❑louse undwillmolmoiuuCenificumnl Consery(.-self-insuru for Worker's Compen-
super, as provided for by Section 1700 of the Labor Code, for the performance of the
'TORIBS
'1'YI'h CONSTI<UC'I'ION
FIXTURES -PER TRAP
work for which this permit is issued,
❑ 1 have and will maintain Wolace, ComNtesm nn Incur required by Section
3]WoftIs a Code, Itsrth perOurmu Meof the work twit I, do, coon is issued.
My W it 1 +m of a sn6nce Iman r and l'ohey nam r u
GAS -1?A. SYSTEM -I INC. i OUTLET
OCC. GROUP
APN
GAS - EA. SYSTEM -OVER J(HA)
.mricr /7� Policy No.:
CERTIFICATE OF EXEMPTION FROM WO KERS'
GREASFIINDUS'I'HL WAS PE INTERCEPTORCOMPENSATION
INSURANCE,
IThis section need not he completed if the actual is future hundred dnllms ($10(aBUILDING
ur less.)
1 certify, that in the Perm
forance of the work far which this inis issued. I shall
no t employ any person in any manner so as mIncome subjectu+N. Workerx'Cnnn Pc^
Laws of Cul'Comio. ])at,
A
Applcant
Applicant
DIVISION FEES
GREASE TRA?'
PLANCHECK hill
SL'WER- SANITARY -S'DORM F.A. 21X1 FT
ENERGY FF.F.
WA'f1EN IIEA'TI?R W/VP,NT/ER
LECT
GRADING FIJI
NOTICE TO APPLICANT: If,free making Of, Certificate of Exempti.n, you shouldWATIiR
subject the WorkerCompensation provisions of the Cole, you must
SYSTEMOREApING
SOILS PEE
ibecome
forthwith complyy with such h poxpnrvieinnx nr this permit shall he donnned revnkeA,
cedr
WAI'IiH SERVICE
CONSTRUCTION LENDINGAGENCY
j ten thatthemis lending agency for the performance of
PAID
D:nc Raeip'#
NEW RESIDIENTIAL PLM.. SQ. Er.
i workeby far his oral( (See 30
the work for which this Permits issual ?Sec. 309], On. C.)
Lender's Name
O AL:
t Lefull Addow,
'TOTAL:
I certify that I have toad this application and xtate that the.hove information is
BUILDING LLE
QTY. MECHANICAL PERMIT FEE
meet. I agree to comply with all city and county ordinances and state laws relating'.
building comwc'iov, and herchy.u0uniec represenwdves of Nk eity to error Pon,tie
above mentioned property for inspection purposes.
(We) egrte to save, indemnify and keep hannlax Ne City of Cupertino again.
1'P.RAf l'T ISSUANCI4
liabilities.judgments, costs and expenses which may in any way accrue against said City
in asequence of the gn min, of this permit, W�P APPLICANT' UNDERSTANDS . ND WILL COMPLY -II ALL NON^ -POINT
. EGULATIONS.
ACI ER OR ADD TO MECH.
EIC
AIR HANDLING UNIT (TO 10.00 CPM)
ERSOURG
HANDLING UNR(OVER IB,IXNI CFM)
wn1llll��..AIN
V
TAX
Si oat I Applicunt/Comorem, Dale
HAZARDOUS MATERIALS DISCLOSURE
"i HAUST HOOD(W/DUCT')
HOUSING MITiGA'1'ION PEI?
I]EXTEND UNIT(1'0 100.000 BTU)
Will the applicant or future building a ecupant xmrt or handle huandoes material
,
an defined by the Cupertino Municipal Code, Chapter 912, and the Health and Safety
Calc, Section 25572(.)?
I IEAPINC, INTI' (OVER I IXI,110H BTU)
Cl Vex -1 No
VENTILATION PAN(STNGIA RISID)
Will 'he applicant nr future building occupant use equipment or devices which
-mit hazardous air conmminumx as definod by the Buy Area Air Quality Management
PAID
Date Receipt Of
BOILER- COMP(3HP OR 100,000 BT U)
-District?
TOTAL
BOILER- COMP (OVER 100,000 BTU)
❑Yes Fl No
AIR CONDITIONER
I have real the huzallouu mmeri.ls to D rude, Chu to 695 of the Cali-
Health825533 a
Lmir gdoes n Safety Code, have terra 25hat i 25533 and 2591, I understand that if the
buildingdoesantc which have a(enema that it ismyre oraCilitytoe wr the occupant
of the rryuimmentx which mus he met prim'. issuance ora Certificate of Qcupancy.
ISSUANCE DATE:
ISSU1iD BY:
IS EW RESIDIEN'I'IAL MECH. SQ, EL
Owner or amh.rised agem pate
TOTAL:
OFFICE