B 0664 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
APPI,ICA1'ION/PERMIT BUID -ELECTRICAL ,l PERMIT
CITY
CITY OF CUPERTINO PIMECRANICAL
BUILDING DIVISION BUILDING PRodECT IDFMIIFICAT0N Jppp
i V VJ
SANI'IARV NO. AI'I'LICAI'ION S1111M1'1'I'AI.DAf
BUILDING ADDRESS:
tar,-71 cT-
OWNIiR;S NAME: PHONI!: CONI'RACfOR:S NAME LIC ND: N/C CONTROL
MILM R, Mp-9_, Rtc�T 1a t/ ? 8
I'TI[CI
CH '/P.NOINEER; LIC NO: AUD E.'S: ❑ T -J
p IV C,2t 3'2.6
CONI'AC'I': PHONI'.: BUILDING PERMIT INTO
❑ Consultant Pecs Paid by Applicant(initial) BLDG 121.IiC9PLUMB MECII_
LICENSED-CONTRA CfOR'S DECLARATION O i'O QTY. GLECTRIC PERMIT PEE CJ JOB DDEESCRivrION rCJ�
1 herby affirm that 1 am Tice o,d under provisions of Chapter 9(commencing
cwz IhSmJnn 9lMXp nfDivision3 of0rc Rosiness and l'nsfcseinne Cale,and my lhmuc is IJ 1
FOO with Sfranc and effect. PERMIT ISSUANCE 'FUWL ❑KUcUFN REMODEL
YLLF m
aZW Datc Chis Lica APPLIANCES-RCSIUENTIAI. ADDITION PLUMBING L PIPE
h Zyl Da¢ CSDECr ❑MULTI-UNIT ❑ST0.UCTURAI.
m Z a
ARCHITECTS DECLARATION I'nNELS
~m,NZ Iandernamn,pfm,,W1I he used as publlcmcords CHIMNEY REPAIR TION
ZOy,. UI'T021XIAMI'S ❑IKfHHl012 (-I CHIMNEY RI!PAIR
LUJ Licensed Prefe"Wit-I 201-10N)AMPS IMPROVIiMENT ❑SWI
f-r/_sMMING POOLS
,Y7OWNER-BUHAYER DECLARATION OVER IIXI(1 AM1tl'S ❑BATH RENIODELIREPA1R [I DEMOLITION
'1
Q 1 berth,union Lha 1 am exempt from the Crmmanr's License Law for rhe (](IIHIiR
iyyi55 O y U ❑dlowing mown.(Section]0315,Business and Pral'escions Calc:Any city or county SIGNS ELECTRICAL
t++3 LL y which requires a pcmtit to cnnstmct,ahcr,improve,demolish,nr repair ria,tmctarc
F'1='Og primo its issuance,also reclaims the applicant for such Permit to Em asigned statement SPECIAL CIRCUI'I'MISC.
f, y that he is licensed punoth
uanue provisions of the Conforms License law(Chapter9 COMMERCIAL'
�a0�0 (commencing with Section]0)(001 Division 3 ofthe Busincssand Profccsions Cotl0or TEMP.METER OR POLE INST.
m m ea chat he is cscmpt lamci'rom and the hats..for the alleged exemption.Any viuf h mor NEW BLDG/ADDITION ❑DEMOLITION
NSeen,,.703 1.5 by any npplicam lin u permit smnocns the applicant to a civil Perot(,or I'OwER DEVICES ❑TENANT ❑FODU SERVICE
not more than five hun lmd dollars($510). IMPROVEMENT
=O ❑has owner ofthe property,or my employees with wages as theirsnle compensation. SWIMMING POOL ELECTRIC ❑OTBER
Wtw willdo the work,andthB
emcthre is not intended nr offered fnrsale(Sm.J044,Bminms pUTLI'I;S-SWITCHES-hl%TURES
3 a, and Pntlexsinnx Gsde:'Uw Con raclnh License Low does net apply ,,oro owner of
d property who builds in improves mcrenn,and who docs such work himself or through
his own employees,provided that such impmvemrnu are not intendd or ofliad for NEW RESIDENT IAL ELECTIt Sp IT.
sale.If.however,the building or improvement is sold within one year ofcompletion.the SQ FT.FLOOR AREA SISQI°f.
.
owner-Wilder will have the burden of proving that he did not build or improve for PuF
pose t�:dc.)� '1 OTAL:
[A.r� r rat the property,nm cnduaivdy cnnirucling with IiecnnN mnlrnalory w
answer the project(Sec.900.1.liminess and Prnfiev inns Cone:.The Comm lla' Li-
moo,Law does not apply to an owner of property who builds or improves mereon,and QTY,, PLUMBING PERMIT FEE 2j-"6 427
who contracts for such proie s with a e mmetor(s)licensed pursuant to the Conoocmrs
License Law. PERMIT ISSUANCE Z3�7( 4 r d G 2
❑ re , tande'S m.,, .Ii&PCR thisrc vn
Da,
ALTER-DRAT & W'ATER IIiAI VALUATI(IN 1
D HKE 'S COMPENSATION DECLARATION��� BACK FLOW PR .DIiVICE 2-1 O O c)
I clic Yallirm under penalty of perjury one of the following declarations:
❑ Ih"candvillnnunenn a Ceti licamuf Contemn set f-insure for Worker's Conniver- DRNNS-Iq,UO ,H A ,CD' S'I OR I I!S 'I'YPH CONS'I'RUC'I'IG
sation,rte provided fr oby See hon 3700 of the Labor Code,for th .omn
e p,. race
wofthc , 1
ork fn,which this pcmait is issued. FIXTURES-PER TRAP aZ N
❑ 1 have and will maintain Worker's Compensation Insurance.as required by Section
3710 of me Labor Code,for the Performance colic GAS-FA.SYSTEM-1 INC.J OUTLETSe work for which this Permit in issued. rrO1�CCGROUp APN
My wak,,C..... nanial lnsunn,ccarler and policy number are: GAS-BA.SYS"rEh1-OVEI24(EA)
Canicr: Policy No.'.
CEKI'll'ICATE OF EXEMPTION IzROM wORKERS' GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUIhIIING DIVISIDN PELS
('This section need not be completed ifthe Permit is format hundaddoldars(SIW) GREASETRAP 1'hANC11 FEE S 'Cl
or Ices.)
Loy anythalm he any manner
its tohe prk flu subjectch to thepermitworkers
Co.,.Ishall SEWER-SANITARY-S'IR)RM EA.2fN)1T CNL'R.Y > Z
nmo employ any ix'rsom in any manner m as m become subject w the Worked C
Z sation laws of Culi4rmia.Data WATER HEATER W/VF.NT/GLECfR C A ';FEEz O Applicant i
litho
Not ICI:"TO APPLICANT:if,after making this Ccnificnte of Esemption,you should WATER SVS'I EM/I'REA'I'ING
a , hecmne ah,W In the Workers Coniverrodan prov shme of 0m 1a1,or Cale,You nwt
forthwith comply with such provisions or this permit shall be Jecmed revoked, WATER SERVICE
7.Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM1IIt, r Sp.FT. P pant Receipts
U O thereby affirm that here is a consrmelion lending agency for the Performance of
W F the work far which his Permit Ix issued(See.Tin].Civ.C.)
Q La'ndcrs Name TOTAL:
IcndcfSAdulm, BUILDIN 'EE
6. I cenify that 1 have read this application and tate that the above information is
h coned,l agree it)comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE SEISMA17-i -Z t7
U noldingamstrnnlon,andhcrebY nuthnri'rercpmeuntativas ofthi,,iymvamrapoathe
al.womcntioned pmpery for inspcctinn Purposes. PERM11'ISSUANCE ;Li -FEIi
(We)agree a save,indemnify and keep harmless the City of Cupertino against
liabilities judgments,costs and expenses which may in any way accme against said City ALTERORADDTOMECI. ,U ING FEE
nmeyuence of the gmnring hlapermir.
AI' ANI'I1NUI!ItST'A ) AND WILL COMPLY WI fit ALL NON-POINT AIR HANDLING UNIT(IO Jd,dpp CFM) "CHANICAI,FEE
SOURCa ILLATION'
�r. AIR HANDLING UNIT(OVER IO.gOCFM) 'ONSTRUCfION TAX o�
Si' t cunUComracnn m EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEF. Z ( 3
HAZARDOUS MATERIALS DISCLOSUR
Will the applicant nr ftamuc huilding amupant sore a handle haeun.ous mu trial I IIIATING UNI'1(1'0 I(XLIh o BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely HEATING UNIT(OVER ab.000 B'I'D)
Cale.Section 25532m)T
E3 yes ❑No VENTILATION FAN(SINGLE RESID) PAID
nate Rccdpt x
Will the nPplicam nr(mare building occupant use equipment nr devices which BOILER-COMP(3HP OR 110.0(X)]I I Of
emit hazardous air contaminants as defined by the tiny Area Air Quality Management
Diona? BOILER-COMP(OVER 100.000 BTU)
❑Yes ❑No
AIR CONDITIONER ISSUANCE DNtF
bout mad the hman.t x mamdnls car,33 under d Z5534 1 and R to of the Call h-
,fianat, I snalcan I fon Ct's'camnvaffaidu5myte"hilitYmds ify the arund that fNun NEW RIi51DLM'IALMIiCH. SQ.FI'.
ofth qu c nut le met prior m issuance oft Cenifica of 0.c
Ownr am ci'n agent )nc TOTAL: ISSUE])BY:
OFFICE