99110188is
u FORMATION WITHIN RED LINES - USE PALL POINT PEN ONLY _4 4 I ' l 0 I 6 O
.PPMAN. rsi rr�� ra. rr.:..: s..�... .............. ..__ _...__ ___ __ ___ _
CITY OF CUPERTINO BUu.DINr. - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PING PROJEB NG CT [DIIANIFutu
INIhDINf. PROJECT 1DIiN'I'llr1CA'1'lUN
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PERMIT NO
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BUILDING AlA)NESS: �
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SANITARY NO,
API'IJCAI'ION SUIfMI TIAL PAI'
% Z 9 -4
AMI i: PHONE:
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LIC NO. /
CONE H SfIA :. ' Sac
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❑
CON 'IROL4
,
RCIIITECTHiNGINEER: LICNO:
ADD ES.'
/ 11 �, i, / 5 �cc yIi/
WNNNN�}}T{��ACI: PHONE:
C�t N r (
_ V
❑ Consultant Fees fait by Applicant (Iniliap
BUILDING PBRhtI'1' INFO
BLDG ELECT PLUMB ME❑CH
❑ ❑
QTy ELECTRIC PERMIT PEE
LICENSED CONTRACUON:S DECLARATION
1 hereby affirm that 1 ren licensed under provisions of Chapter 9 h ummencing
,,ill Section mxgn of DIvlsloo 3 at ac If t,iness and Profession. C«r and any license is
/
in Bill lance :mdv 't. /. b � 7/
License Claw V Lice
JOB DESCRIPTION
RESIDENTIAL:
❑SI'DWI. C:1 KITCHEN REMODEI.
❑ADDITION El PLUMBING RE -1'11'1:
PERMIT ISSUANCI!
APPLIANCES - NLSIDENTIAL
Dam Contracmr
❑MULTI -UNIT �
RCHITECPS DECL AT
PANELS
MODIFICATION
I mderannd my plan.. shall be toed a, public records
UP ID 2110 AMPS
❑IN'fIi1210R [D CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING POOLS
El RT;MOUIiI/RT;PAIR [I DEMOLITION'
❑ OTHER
d`
/ v
Licensed Pn+fetionrml
OWNER -BUILDER DECLARATION
1 hereby affirm tom I am exempt from the Contractor's License I.uw for the
following rcmnn. (Stan. 7031.5. B.Oncss and l'rofcnsinns Colic: Any city nn county
which req re. Permit l comfort, It p J 1: h p y suucarc
prion t..: 1 4 theWilt tf ch pc 'n fl -g Jstat....
that haccused p 11 thep (If the C t t L La (Chapter9
(tmarmas.itg with Seat i llIDlBol Pavilion 3 oftha aminal, dl 1 :.' :Cada)Of
That he is exempt therefrom and the basis fm the alleged cacmption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
201-10WAMPS
OVER IINO AMPS
SIGNS I?I.pC1'RICAL
SPECIAL CIRCUIT/MISC.
IFMP. MISTER OR POLE INST.
R I ,
❑ .UG/ADDITION ❑ OpM01.1'1'ION
TENANT ❑ FOOD SERVICE
POWER DEVICES
n more than five hundred dollars(Strp).
..... I he propcnyormy canpleyece with wlalla a thcirsole mmpenvatio^.
will do the work. and fia,meare is ma ialededorolEreE far .wle(Set. 9044. Puoinea
mal Prom"imn Cade: *Hm Conlmnor's Licence Law does not apply m an owner of
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
OUTIJ:I:S-SWI I'CUES-121X I'GRES
NEW RESIDENTIAI. ELECIR SQ FT.
property who builds or improves thereon, and who does such work himulf or through
his own employees, provided ohm such improvements arc not intended or nRercJ for
sale IL huwccp the building or impmvcmmlt is sold within nnc your of mmpl tion, the
owner -builder will have the burden of proving that he did not build or improve Iia pur-
SQ. Pf. FL(H)R AREA
$ISQ.14.
TOTAL:
P"c of wile.).
❑ U i s owner of the praperty, am exclusively contracting with licensed contractors to
mstrnct the project (See. 7(94, Business and Profession, Code:) TI¢Contmewr's Li-
sclatedoe.s not apply ea an owner of pr'Tcny who build.,,, improves thereon,and
who contract for such projects with v commmonO licensed purstentto the Contractors
License law.
❑lam cecmpt under Sec ,B& P C for thisreaoon
QTY. PLUMBING 1117RMIT FEE
PERMIT ISSUANCE
ACI '17R -GRAIN & VENT'- WATER (EA)
BACK FLOW PROTECT DEVICE
VALUATION
2 -O v
Owner Dine
WORKER'S COMPI!NSATION DECLARATION
1 hereby offrunder penalty of perjury one of the following declarations
an
❑ Ihavc vnJ will muinhainuCcnifcntc cel Conscm msdf-msurc for Workers; Cnmpen-
,union, as provided for by Section 3918) of Ne Lida Code, for the pema nu all of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as required by Section
�70(I ofthe Labor Code in, the path nnnmamof the work for which Hit permit is issued,
DRAINS - FLO(IN, ROOF, AREA. COND.
STOMP
OCC. GROUP
'TYPE CONSTNIICfIC.
--a APO !!
S7 -041
(
PIX'1'UNES - PER TRAP
GAS-1iA. SYS'I'IiM-I INC. J OUTLETS
GAS- HA. SYS'I 'MOVER 4( lin)
My Worker, Com, loauan In ur:nmt carrier and Pulley number nnc:
Camcc W �/-a �1—Policy No.:
C UIFIC QE OF (EMITION PROM WORKERS'
COMPIiNSANON INSURANCE
7
GREASF/INDUSTRL WASTE INTERCEITOR
BUILDING DIVISION PIKS
GRHASE'IRAP
PhnNCI ICCK PI?E
(This smion neral not hoeample,,ifthc pnno is fmm�a hundrae dollars($1Pat
less.)
maymnne of the work for which this Permit is issued, Ishall
not employ any person in any mannenn us to become subject m the Workers' Compen-
Toy any KI
FUllnn Lnwo of CalJimain. Pule
SEWER - SANITARY - STORM 13A. 2(011'.
ENERGY PG[
WAI IiN HEA'T'ER WNBNT/ItLECI'R
GRADING FEE
Applicant
Nurici; TO APPLICANP H. after staking this Ccrtificme of Exemption, you should
become subject In the Workers Compemaim provisions of the labor Code, you must
forthwith comply with such provisions or this permit shall M teemed revoked.
WATER SYSTIiMfIREAT INC
SOII \ PU
WATER SERVICE
N1iW BE OR SQFli
CONSTRUCT ION LENDING AGENCY
p Thereby affirm thatthere isettmsmchon lending agency for the performance of
the work forwhich this permit is lsmed(See, 3097, Civ. C.1
PAID
—Dal Rcccipl#
1"A's, 1 r 1 1;O1A
F'
UL ,noR, Name
Latdcrs Addos,
a 1 eenrcy mm 1 nava mar applmmntn ata come mat the ab^ve mntmtannn is
correct. l agree m comply with all city and county adirences andstate laws relining to
Z milamgcansmtotlnn, lad hereby an, fa reprmemmives onMscity to enter upon the
ahovo-muntin ice pmlx.ny In, lmlwtlon pnt a,.
(We) agree Insave, indem^ily vat keep bnamde s the City Of Cupertino against
liabilities.judgments, costs and expenses which may in any way accme against said City
'TOTAL:
BUILI, FIiF.1 U
'ISI I
QTY. MSCI IANICAI. PERMIT' FEE
pElir ISSUANCE
E.EC'I'RIC ..
PLUMBING PER
ALTER OR ADD' TO MSCI L
in onue4^once If 'he limiting of this permit,
A'PIJ CA N'T UNDERSTANDS AND WILL COMPLY WITH ALI, NON -POINT'
p
AIR IIANDLING ON IT (TO 10.0X0 CFM) B
h1 BGH A NIGAIL-1 -
SOURCH REGULAI IONS.
AIR I IANDLING ONII'(OVER 10.000 CPM)
CONS 'IRUM ION TAX
0OD(W/DUCT)
HOUSING MITIGATION FEE
Signature of ApplicanUCantrachn Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicandurfumm build{ngoccupuntstore nr handlchuzallousmamdd
as defined by the Cupertino Municipal Cade. Chapter 9.12, and the Health vat Safety
Code, Section 255321u)'
❑Yes ICANo
`!'
A I'( TO 100.000 BTU)
IT (OVER 1(X1.100 BTU)
PAID
Dam Ncra'Ipt#
=��M
N I"AN(S I NG1.13REM On
Will the applicant or future building Occupant use ta, ipmrnt or devices which
hansoms air conwminards usdi fnesl by the Bay Area Air Quality ManagementTODistrict
MP (3HP OR 100.00011'TU)mit
OMP (OVER 100,000 BTU)
I
❑ Ycs Lt�Nn .
AIR CONDITIONER
ISSUANCE LATE
2 /� 4,
L r
ISSUIiD BY:
1 have read the M1mard S nli and 55 m, 25533 ausan under . I and fi to of the Cuh
filmic IIcnIIh Safely Gde, Ss'ti n" 505, 25533 and 25534. I understand than if the
banding Aa ncurrmjt huv a mu .(nal it lsntyot"nall 111 to miry me ryryryaaallln
.,,he aqui mu. n prior In i.....menfu Cenifica If He
NIiW RESIDENTIAL M111iCH. SQ. FT.
TOTAL:
Os>uth ze Uate
wner
of=rlc;t