S 0119APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING. ELECTRICAL ---
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL,
BUILDING PROJECT IDENTIFICATION
PHRMIFNO.
S 0119
BUILDINGADDRESS:SANITARY
.3-0 WOW S o r d k'
NO.
APPLICATION SUBMITTALDATE
G79M
OWN�'S BASIL f f PI1)NE:
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CONTRACTOR 'S NA,V}It� I 1 wl , �j LK
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CONTROLp
%RCHITECT/ENGINEER: LIC NO:
ADDRESV_1r AC✓�a(l S7-
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CONTACTPHONI?:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG HLECT PI.0 MECII
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LICENSED CONTRACfOR:S DECLARATION
affirm that I am licensed under provisions of Chapter 9 (commencing
of Division 3 offleBn.uneesand l'ndesdac Code, and my license i.s
F7(XX))
( I_A� �/PERMITISSUANCE
Liap %p- ~❑SFDWL
si or
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QTY ELECTRIC PERMIT FI7F:
JOB DESCRIPTION
RESIDENTIAL:000 ❑KITCHEN kCMOD1iL
[]ADDITION ❑PLUMBING RE -PIPE
❑MULT6UNIT ❑STRUCI'URAI.
MODIFICATION
❑INTEk[OR ❑CHIMNEY REPAIR
IMPROVEMENT (] SWIMMING POOIS
❑BATH kIiMOUli1JRIiPAIR (]DEMOLITION
❑ OTHER
(I -Iry _
APPLIANCES—RESIDENTIAL
_jRCHITECTS DECLA ATION
1 understand my plans shall the used m public records
PANELS
(if, 10200 AMPS
LicenaJ Pmfexsinml
OWNER -BUILDER DECLARATION
1 mushy oIfum turn 1 am exempt from the Contractor's License Law for the
fallowing parson. (Sermon 7031 5, Business and Pmicvxinns Code. Any cityar county
which requires a permit m construct, alter, impnwa, demolish, or repair any structure
print In hs isxu:mee. m of requires the applicant dirt sneL lsencita, Me igned smmmem
201-1000AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
gSPECIAL CIRCUIT/MISCO.LA-1
JJJ
ay
Ihal be is llcemnd pursuant In the provisions or the Contractor's License Law (Chapter 9
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favocing with Section 7") of Division 3.1 the Hnancvs and Professions Coal
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit suhjecls the applicant to a civil penalty of
net more than five hundred dollars(S50f).
❑Las owner of the propeny, or myemployar with wages es their sole rnml+ensatinn,
for sale (Sec. Business
will do the wnrk, ad the ne scture is niended arnlfcrtd 4
nt
Profeesians Code: The Commars License Law dues nm apply to an mune, of
who builds or improves thereon, and who docs such work himself or through
TIWP.MIU17R OR POLE INST.
CI
COMMERAL:
❑ NEW BLDG/ADUrrION ❑ DEMOLITION
[I TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES —FIXTURI'
property
his own employees, provided that well improvements am no, intended or named far
sale. it, however, the M1uilding or improvement iv solJ within one yearaf complelinnJhc
NI?W RESIDENTIAL ELECfR SOFT
SQ. IgtJ)01ALVA
VSQ. IT.
ealtudder will have the burden of proving that he did not build or improve for per,
gIw
pose nitric.).
❑ I, .,owner of the propeny, am exoluxively contrac(ing with licensed contractors in
mvtmd the p,,,jet, (Sec. 7044, Brumes, and Pntfm.ianv Carle:) no Contra . ..... L'.
AUG 25RE
RE'CI
CI
TOTAL:
cease Lawdoes a,,, upplym mowner nfpomvhy who hdle ar hnprovesthent sad
QTY. PLUMBINGPERMIT FEF
contracts for such pmjeets with a contnmmr(s) licensed Imsuunt m the Cransror's
Limp, Law.
Iain exempt under Sec .H& P C for dinacannn
CITY Ur Wf-EhIINU
1'IBtMI'I' ISSUANCE
ALTER — DRAIN As VENT— WATER (EA)
Owner Date
VALIDATION
WORKER'S COMPENSATION DI[CLARA'1'ION
HACK FLOW PROTECT. DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Comenuo ulf-inmm for Workers Compen-
moon, m Provided for by Section 3700of the Labor Code, for the performance of the
DRAINS— ITOOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
k for which this permit is issued.
I have and will maintain Woder's Cempenmtion Insurance, m required by Section
PI%'TURES — PER TRAP
.700of the Labor Code. for the performance of the work for which this permit is issued
GAS — BA. SYSTEM -1 INC, 4OUTLETS
OCC. GHOUL'
APN
y Wor 'iCa envsaonmance caniern*&m nd Policyue:/QN7
Carrier: a u l Policy No, 6 TY
GAS—EA.SYSTEM-OVER4(F,A)
CERTIFICATE EX MPTION FROM WORKERS'
COMPENSATION INSURANCE_
Gkl?ASI%INDUS'1'HL WASTEINTF.RCIiI'I)H
BUILDING DIVISION FEES
(phis section need not be completed flue Iminmit is bureau hundred dallam($ Its))
or Ie..x.)
CREASETRAP
PLANCHISCK Plili
I comity that in the perfommanceofthe%ork Rawhichthlspermit isissm,l shall
not employ any person in any manner sn as m becnmm. suhjed m the Workers' Cnmpen-
SEWER—SANITARY —STORM EA. 200 IsT
ENERGY FEE
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satinn Laws .(California Date
Applicant `
WATT?R IIF.A'rER W/VENT/ELECTR
GRADING FEE
SOILS FIJI
NOTICE TO APPLICANT: If, after making this Certificate of Esta, ion. you should
herome subject to the Workers Compensmman provisions of the Labor Code, you must
forthwith romply with such provisions or this pennitaholl be deemed revoked
CONSTRUCT[ON LENDING AGENCY
hereby oftirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ, C.)
Lenders Name
WATER SYSTEM?REATING
WATER SERVICE
PAID
Date K Rreip
NEW RESIDENTIAL PLMB. SQ � IT.
TOTAL.
Lenders AJJrcxs
'(OTA L:
BUILDING PI?
I certify that I have read this g,licadan nn l Anne thud the shove information is
w. LI)
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comply with all city and cute 1, oainuncexd statm e law, mWing
correct. ingme compan
m
huddingennstruction. and hereby authorim rel)re,emadvwnfthiscity menmerupinthe
QTY. - MBCHANICALPERMIT FEE
-
SEISMIC FE
PERMIT ' ISSUANCE
ELECTRIC PIJi
above-memlonul propeny far inspection purl osea
(We) agree m save, indemnify and keep Iutalce, the City of Cupertino against
ALTER OR ADD TO MECH.
PLUMBING FE
iabilities,judgments, costs and expenses which may many wry.cc.e against said City
in consequence of the granting of this permit.
AIR HANDLING GISH (TO 10.000 CFM)
ECHANIC IH3B
APPLICANT UNDERSMItIlDS AND WILL COMPLY WITH ALL NON -POINT
SOW E EGULATIO'l
F- � /
AIR HANDLING UNIT (OVER IB,IXgI CPM)
NSTRU HONTAX
Signature o ppiica ntrrctor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(WMUCT)
USING ITIGAI'[ON FEE
ABATING UNIT (TO 10(1.000 BTU)
[VIA
Will the applicant or future building eccupamstnrom handle hmadous material
as derated by the Cupertino Municipal Calc, Chapter 9.12, and the Health and Safety
Crile. Section 25532(a)'I
HEAr1NG UNIT (OVER on,fl(111 it ru)
E] yes t E] No
VI?N' I'I LATION PAN (SINGLE RES I D)
ID Wale Rcceipl
BOILHR—COM P (3HP OR I00,01N) BTU)
WIII mho applicant or future imildi ng occupant use c,a lancnt ar devices which
emit Intimidate, air contaminants as defined by the Hay Amu Air Quality Management
TOTAL:
1301 RR — COMP (OVER 100,000 BTU)
DistrirP Vev [_] No
AIR CONDITIONER
I have read the haadous materials"maemonN under Chapter 695 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL A1ECE. SQ. IT.
forma Health & Safry Cede' S inns 25505, 25533 and 25534. 1 understand that if the
building dye% not currcnHYh atrnant, But int is mY rt'Prout...ly to ramify rue occupant
v
of mite rt to wit' t 4 me m iemence of 5"1#itiWP Occupgpcy.
V — ! �YDa/
TOTAI<
ISSUED BY:
Owner at eallonoed agent
OFFICE