94080217APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY (-4 w U O "
CITY OF CUPERTINO BUILDING - ELECTRICAL,
PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDENTIF'ICA'PIO,N
HUILUING ADII� 0 � � � � � �
SANITARY NO.
AI'1'(L/:.I/C�A�I'ION SUIH�MI'ITALypDATE
)WN. LNAME: �P3O CV2,3
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GHITECT/P GINEER; LIC NO:
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CONTACT.PHONE:
CONTACT:
BUILDING PERMIT INFO
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Pkv /.Mol l (K' 1, C� Y O� r (� L/ /
V R "C % O U D J 7 6
❑ Consultant Fees Paid by Applicant (Initial)
B[.UG ELECT PLUMB MLCH
❑ ❑ ❑
UCHNSED CON'] RACIOR'S DFCLARA'I'ION
I hereby affirm for I am rimmed under previsions of Chapter 9 (commencing
with Section 70(m) of Uivi,AHCFi TECTS �on 34 he Bu,ine,,unal I'csslnrvs n dmY licenm is
full force and effect. S�%l{ un
In V
Dale°1 Contrec in /Sy i A
DECLARATION
I undasmnd my plme shall he mad as public records
QTY ELECTRIC PERMIT FEE,
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JOB DESCRIPTION
RESIDENTIAL '
❑SFDWL ❑KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE-PIPE
❑MULTI-UNIT []STRUCTURAL
MODIFICATION
El INTERIOR CCHIMNEY REPAIR
IMPROVEMENT []SWIMMING POOLS
El BATH RLMOUF.VRFPAIR ❑DEMOLITION
OTHER
PERM IT ISSUANCE
APPLIANCIiS-RESIDIiNTIAL
PANELS
UP T02WAMPS
face .... I Profaimal
DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License law for the
(rout wipg maven. (Section 71131.5, B. me ,and Profession, Code: Any city or county
which requires a permit to compact. alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant lbrsuch lemritm Blea,igned,ourare l
that he islicensed pursanuulheprovis,nmofineContons License La.PC1baptrr9
(commencing with Section 70IX0 of Division 3 ofthe Bucinessand Pr..fx,ions Code)or
mdamnationy a he is exempt damnation the basis tar the alleged exemption. Any violation of
Section 70315 by any applicant for a permit subjects the applicant it,. civil penalty of
not are Oma live hundred dallars($5(Mp.
nwnernfine pmpcny. or myemploYen with xngcs avheirnok compensation,
will dollen work, mrd timoorcure lmol intended orofrcrW torsulc(See 7044,11asiness
and Professions Cale: The Conami License Law does not apply m an owner of
Property who builds or improves ,hcresm, and who does such work himselfonhrough
his own employees, provided that such improvement, arc not intended or offered for
sale IL however, the building or improvement i, sold within one year ofconipletion.the
201-10OAMPS
OVER IfMMIAMI'S
SIGNS ELECTRICAL
SPHCIALCIRCUIT/MISC.
TEMP. METER OR POLE INST.
R
BLDG/ADDITION C DEMOLITION
❑ NT []FOODSERVICE
IMPROVEMIiNT
OTHER
POWF,R DEVICLS
SWIMMING POOL ELECTRIC
OUT 'LETS -SWITCHLS-FIX 'PURLS
NHW RESIDF,NI'IAL ELECTR SQ IT
SQ. FT FLOOR ARBA
$/SQ. PT.
'
owner-builder will have the lumber beer of proving that he did not build or improve for pur-
pose of mle.).
❑ I, u, awncr of me properly, nm excla ivuly ennrtndfng w,In Ifccmed cunnew ri to
TOTAL:
construct me project (Sec. 70x4, Ifusinns and Professions GMc:) The Counim r", Li-
eLaw cases not apply it) anowner ofProperty whit builds or improve, thereon, and
Q PLUMBING PERMIT FEE
who eontmcls for such projects with a umbadodd luerwa puroont w the Contractor's
p E
q
iR-D AN&VENT-, E
license Law.
[] 1 um uenrpt under Sec. . B & 1' C lin this reason
Date
VALUATION
r
tic WORKERS COMPENSATION DECLARATION
BACK F OT '1'. DfiVIC
I hereby affirm under peachy of Perjury tine of the following Jetta tions:
I have and will maintain a Certificam at Consent to lin Worker's Grmpen-
cation, as provided for by Section 37W of the Labor Code, far the performance of the
AM OF, ARBA O
STORIES
TYPE CONSTRUCTION
work fin which this Ixonit in named.
PIXB'UR17S - PER TRAP
rce, as required by Section
and will maintain Worker's Coation Insuan
%1 have mpens
l,I the labor Gale. for he fork) ... a ecnl th. work fin which do, permit is issued.
GAS- P.A. S YSTEM I INC. 4 OUTLETS
OCC. GROUP
APN
My `orkeryyCCpp pp��� tinyyl1 r;qe J Policy nu
Currier:�`NsMP F✓N/! e�ePolicy No,: , �r 7(L2-3 / d
GAS-EA. SYSTEM OVER
3751 -zoo
L
GRFASFONDUSTRL WASTE INTERCEPTOR
r
CERTIPICATEOIE SATIONIIN FROM WORKIiRS'
COMp1iNSAT10N INSURANCE.
BUILDING DIVISION FYkS
Um,wOamneedno, be uon..lenM iflbu permit i, fon re hundreddollam($ Pill
or les,.)
GREASLIRAP
PLANCIII!CK FEE
SOWER- SANITARY-ST(IRM EA. AIB FT,
ENIFRGY FEE
I cemlythut In me urlimwnceofthe work forwhich(hispennt is issued. I shut)
ploy any 1x^on in y manner m m m hermit, subject .,he Workers Camper-
not eman
WATER HFATER WNENTULCCFR
WATER SYSTEM?REATING
GRADING FEC
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,miter Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, aver making his Cenificam of limen] tion, you should
have noc,.bjec,,, the Worked Camponcatfon pmvi,ions of the Labor Cede, you mus,
fodhwim comply with tech provisions or this permit shall be deemed revoked.
CONSTRUCTION LF.NDINGAGLNCY
I forwhichirmmmthere i.vucu (Sov.3097, Cingagency fmthe performance of
the work for which this portent is ixmNlSa, 3097, Civ. CJ
Lender's Name
SOILS FEE
WATER SERVICE
PAID Dale Receipt#
'TO
BUILDING IT,
NIiW RLSIUENI'IAh I'LMB. SQ. I'1',
TOTAL:
Lender's Address
information is
1 certify that 1 have read this application and slate In., me above
correct. Iag,ce to comply with all aftyand aounly aNinaneex and state law, relating in
buildingdmmructfun, amt herebyiumorim represerannonofutochym enter upon he
QTY. MECHANICAL PERMIT FF,E
SIdSMIC FEE
PERMIT ISSUANCE
ELECTRIC FEE
:move-mentioned property for inspection pugxves.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
PLUM1161NG FEE
liabilities, judga ts,custs and expenses which may in any way accrue against said City
in n,ryton,vof lie grunting at th.. P:nnit
AUTER OR ADD TOMECH.
AIR HANDLING UNIT (TO 00,000 CFM)
MFCHANICAL FEB
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
�OUNC�J�iGU6 ''r�[�NS.
i[/
(' J
AIR HANDLING ON] '1'(OVIiR111,UWCIsM)
CONSTRUCTION TAX
Signature of ApplpbeamiConwclor me
EXHAUST HOOD(W/DUCT)
HOUSINGMI'HGATIONFHF
HAZARDOUS MATERIALS DISCLOSURE
HTATING UNI 'I(TO tW.IHMI BTU)
Will the mquicam urtutw'e buitdingaere,fnumr, or handle hueordnusnnteriul
a, defined by the Cupertino Municipal Cale, Chapter 9.12, and he Health and Safety
Cal.. Sea,nn 25512(x)'!
HEATINfi UNIT (OVIiR I(X),OdU RTU)
VENTILATIONFAN (SINGLE BUSED)
❑Yes ❑No
PAID-
—Dam ReceiptX
Will the applicam of future building mxupanl use equipment or device, which
mit hazardous air contaminants as defined by the Bay Arca Air Queliry Management
BOILER -COMP (3HP OR 100.000 BTU)
.//
TOTAL "ll,
7 O
BOILIFR -COMP (OVER in, MMI BTU)
Didlul^
❑Yes ❑No
A IR CONDI I'IONCR
I have read the musumous mnteriuls requirement, under Chapter 645 of 'be Calf
ISSUANCE, DATH
NEW RESIDEN-RAL MECH. SQ. FT
fornix Health & Safmy Gxle. Sections 1!5505,25533 and 25534.1 understand that if the
building does not errantly lave amount. thin it is my re,rymsibility mnutily murxcupant
of the romn"ema %h most M1e mel poort) issuanceofa CeddI nV-sevoNtcy.
Cy/'.
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1
OFFICE