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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELI/Cl'RICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PRIIJEC'I' IDENTIFICATION
PERMI'PNO.
S 261'
BUILDING ADDRESS:
SANI'I'ARYN(1.
APPLICNFION SUBMITTAL DATE
WNER7NAME ' IONS
2 n dl 2 t 6 v
CONTRACTOR'S NAMIi: LIC NO:/ /D
O M
N/C
❑
CONTROL k
1 ARCIII'I VCHENGINEER: LIC NO:
I
ADDRESS
a6S�
CONTACT:gal f}FJ ( Rs$6tI$'&0NE:
BUILDING PGRMITINFO
.A3V-199oA d '
❑Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ 2/ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby afrrm that 1 ant fieenttd under pmvisipna pr chapter 9 ammneacmg
Q'TY
ELECTRIC PERMIT
FEE
JOB DESCRIPTION
PERMIT ISSUANCE
won Sation 7001Divi.tan3.Uhe Busincasand hamesstons Cedq and my lieenso is
in full faceandeRecn `. O
License Class. Lick
Date Cnnu'nnor
ARCI11'I'ECFS DI?C.AR ION
lundersand my din --bill beusedas public recant.
RESIDENTIAL:
CSFDWL CKfI'CHENR I!MODEL
CADDIHON El PLUMBING RE -PiPli
CMUMI -UNIT CSTROMORAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
APPLIANCI!S- I<I!SIUENTIAI.
'
PANELS
UPTO200AM1:5
0
Lierri 11 fit' morid
201- 1000AMPS
OWNER - BUILDER DECLARATION
I hcrehy affirm Ilia I nor enenhn from the CommgOHs License Law IIn the
following reason. (Se OOn 90315, Budnese and Pmfcasions Crdc Any airy or county
❑BATH RI!MODEIJRI ?PAIR CDEMOLIIION
C OTHEk
pypR IB00AM1'S
SIGNS FLECfRICAI,
which or moot a Penrod to cnn.armo, alms, improve. demolkh, pr repmr, any am mrc
SPECIAL CIRCUI'UMISC.
/If P /1 17
kLG III
priorto in i .... ree,alap re4uires the applicant for such permit In fileasl,nedslaenmd
that he is licensed o unnlmthe r s of the CentracmL� license Law(Cha Ien9
p es ci "vianr f
of Division, nlhearnd tndon
ingwithheretrna
'I'1 ?MP METER OR I'(JLEINST.
COMMERCIAL
CIAL:
anal Any
that he is cscntpl lhcrctuun anal the basis Ba the aJlcycd cxcntptinn, Any viol aiun of
that he is
C NEW 111.0 1 /AI DITION ❑ DEVOUT [ON
_
POWER DEVICES
POWER DEVICES
by any:pplicaut Par a permitwN'ts the alplhmlm advilfnnulryof
Section 7031.5 by ynyappllcalll for a perlttllsaN'a the upoheutlllt r Cvilfseaaftyof
not more than five hundred dollars ($500).
❑I,sowner of the pmpcny, or myemplOycezwithwagesu .Ibcirsole rompensale..
will do the work, and the saa me is not intended proffered for sale (Sec.9OW, Business
and 11 fesions Code: the Connector's License Low does not apply m an owner of
C'FENIAN'f ❑ FOOD SERVICE
C'FENIAN'P ❑FOOD SERVICE
OTHER IMPROVEMENT
El OTHER
SWIMMING POOL ELECTRIC
OUILETS- SWI'FCHP_S- FI%I'URE,S
NEW RESIDENTIAL ELEC!'R SQ hL
propcny who builds or Intpnrves thmcon, end who does such work Larson,, thumgh
his own cmpfoyces, pnonad that such Intpnmcmenns are not intended or o0'cred for
sale, If. hrnveer, the building Orimfnnvementissold wllhin nneycarufcontpletiu a. the
SQ. P IELOOR AREA
5 /$Q. FT
owner,bivider will bee the herder of proving that he did not build or improve for pur-
posc of mlc.J.
E] I, as ownerof the property, am exclusively contracting with licensed comtmatns m
TAL:
eD
nm.nuet the project (Sec. 9014, Be,, in,annal Professions Code) fin, Conhucfnrs Li-
achawAoesnntuPPlytnannwnernl' property woo hnilAs ur improves lhemtn ,and
Q'PY. PLUMBINGPERMIT
FEE
who contracts for such projects with a conwmorts) licensed pursu tai to the Cmtmaor's
PERMFI' ISSt /ANCE
License Law.
El I am ,coat under Sec. ,B& P C for this reason
Owner Date
ALTER -DRAIN &VENT -W
VALIIA'I'IUN
WORKI !li'SCOMPENSAI'IONDECLARATION
BACKF1_OWPROI'1!C'I'. DEVICE
I M1crehy .ffirm under penalty o[ lerJury one o[ the following tlahmninns:
-C I Isoaand will nanati ia. Cenlficme Of C....cut to salbirm. for Workers Compen-
cation, as prodded for by Section 3900 of the Lather Code, for Ise performance of the
DRAINS - PLOOR, ROOF, AREA. COND
STORIES
TYPE CONS' I UCTION
work far which his permit is issued
FIXTURES - PER'TRAP
❑ 1 have and will m; .... (am Workdu Caupeealb r Insoninee, as tnhwmd by Section
37000 In, LaborCode,far thefxrforml ace nl' the work nor whi'I'mi. parmft'u Issued.
OAS —EA. SYS'I'I ?M -1 INC4OUIIEUS
(JCC.GROUP
MIN
My Work CumpensI Insura e carrier and Policy number are/'f ((.�.[`� -!�
Carrier. l�iG° �NG cote l'nlicy No.: �4J�[g1kJ_t1 A.,i.,p
GAS -1!A. SYSTI!M OVER i1EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPF.NSANON INSURANCE
GREASUINDUSI'RL WASTE. INTERCEPTOR
BUILDING DIVISION FEES
nr less.) ft,kaeaipnnccd nhe ciandatedd the pcarrim x boron, ntmdred dollars l$ 1M)
OREASEIRAP
PhANCI II ?G'K PI!li
I centry that in the performance of the work for whicharklembil is issued, Ishall
not employ any Persian in any manner so as to become subject m the Worker: Conifer-
S12WER- SANITARY -STORM HA. 200 FT.
ENERGY Frill
salion laws of Califomia. Date
Applicant
WATER HEATER W /VENT/F.LECI'R
GRADING IIir.
'( LS PEII
NOTICE'HJ APPLICAN'Il lf, after making this CeniOCae nbpxanpioq you ehnWJ
herniae aubjeat to the Worker, Companmllnm posvidpas of l e I.rbor Cale, you must
WATER SYS'I HM(IREATI
WATER SERVICE
fnrNwiBlenmply winhmch provisiomor this fcaral,hm) be deemealmvoked.
CONSTRUCTION 1.1; DING AGENCY
Iherehyief finthalthoeisncoerml;'a lend,., agency tar she peifmbrnce of
NEWRESIDENI'IALPLIM
Ll
IQ. 14.
D
Dr Recalls#
the work for which this permit is issued Sec. 3097, Cis. C.)
Lender's Name
TOTAL:
Lender's Address
TUI'AI,
B
LDI FEE
1 cenify that 1 have real phis apldwifi on and Blare that the dance infomalipn is
correct. l agree to comply with all city and sonny ordinances and state laws relating to
building construction, and hereby todlorive repmsentutives Ob this city to enter upon the
QTY. MECHANIC
rf��s
LR
MICE !o
PIiRMI'1' ISSl1ANCH
ELI3C'I'Itlf. I'IiE
.bmve- mentioned prnfany fns inspection 11,111, ...11.
(We) agree In save, Indemnify and keep harmless the City nl Cupertino against
ALTER OR ADD TO MECH,
PLUMBING PER
Iiabihue.a,judlmems,cnslsund astatine, which may in any w.ya...cageincladd City
in ennserpmnce of Rte stunning of phis permit.
AIR HANDLING UNIT (TO 10.0a) CrM)
MECHANICAL PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,IX0 CPM)
CONSTRUC'HONTAX
J
Si an, o p temon/Conuaem Dn7m
HAZARDI JS MATERIALS DISCLOSURE
EXHAUST I{OOD I W /DUCT)
HOUSING MITIGATION FI ?L'
HEATING UNIT TO 100.0110 B 11
Will the applicant Or future building recupant store Or handle hazardous material
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safely
Cade, Section 25532(,)'! ��/f'
D Yes r�N°
ATING UNI(OVER 100,000[1 RJ)
IIH T
PAID
-
VEN'I'ILAT1ON PAN (SINGLE R tHMID)
Dare Re"ipt k
BOILER -COMP CUP OR 100,00D BTU)
Will the applicant nr fume building by tiro Bt use co Air Qnl Ii Mess which
emit bamrJnas air conaminame as defneA by the Bay Area Air Quality hluegcmenl
DisentO
❑ Yes ErSo
BOILER -COMP (OVER I00,0q)13.1'U)
AIR CONDITIONER
I Health Safety hode.S rd..255rey 1533 an under
5534.1 understand d that Cali-
build. Health & Safely Gak. Satinet. that , 8531 and 255,11 a notify the that if the
building does no¢onenJy have a tenant, lh:n it is my responsibility to notify the cecuµ m
ISSUANCE D/A�TE.
3- / 7 p
NIIW RESIDIiNT1AL M1f[CII. SQ. FT.
of the regm metes wni tun — 1prienn t.se,1ance Of a Cent f ate of Occup:ma
`Dane
//11
ISSUED BY: -ate
O uutM1Oriu agent
TOTAL:
OFFICE