S 1243APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull 'u1Nr.-ELECTRICAL'
BUILDING DIVISION APPLICATIONIPBRMIT PLUNIIIING-MECHANICAL
HUII,DIN(:I'ROJEC IDI!N'I'IF'ICA'1'ION
PB�J IT NO
1243
IJILDING ADDRESS:
C0 -_6'1_9'k �w(�
SANITARY NI
APPLICATION SUBMITTAL DATE:
8
NEE'S NASYF PIIONE:
ARCHITECT/IiNGINf:Ek: IC
CON'I'RACI'OR'S NAME: LIC NO:
))) SS. (' 1 J r S /{� ��
L/
NIC
❑
4 CON 1ROI
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CONTACT: PHONE:
BUILDING PERMITINFO
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[
❑ Consultant Fees Paid by Applicant (Initial)
NLU' Iil,li[.T PLUMB MECH
I}��` lyel_�(
71
LICFi SED CONTRACI'O 'S DECLARATION
1 nerenr afrnn mm 1 anh Banaea miner Pmvixions or chapnr 9 (connlenaing
wnn Sectmn](X01 or lbmaion3onne Ha>ina:and m,rexaiom nate. aha my team i.
in full force and effect.
License Class Cour
Dore Conmucex
QTY. ELECTRIC PERMIT' FEE
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'T'ION
JOB DESCRIPRPSIDENTIAI:
CSFDWL CKI'fCIIIiN RIiMODEL
[]ADDITION ❑PLUMBING RE -PIPE
Ch1ULTI-0X11' ❑MORUM 1lTCJVAI.
MODI19CAf10N
0INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT C] SWIMMING POOLS
O BATH RHMODHJREPAIR 0DFAOLMON
❑OTHER
PERMIT ISSUANCEy�41^
APPLIANCES - RESIDENTIAL
AHCHITGC'1'S DLCLARAI'ION
1malerdo my plans shall be used mPublicrecords
I'ANIR.S
UPT0200AMPS
Licemerl Professional
OWNER -BUILDER DECLARATION
I hereby affirm Ila, I am events from Be Contractor's Lifetime Law for the
following reason. (Section ]031.5, Business and Professions Cade: Any city or county
which y re. permit to construct, aft, p demolish, repairany structure
pd: I is nl. th Tl t it IPemu tl y dstommeat
201-I000AMPS
OVER INN) AMPS
SIGNS ELECTRICAL
SPECIAL CIRCmTrh .
oj
C OQ
a E m c
x 4.
41^In
,SD
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that he 1 : Elms II to p sa III < I'9o: I I (Clumon9
(m.nmcamip web Samna 7dHXqofId,iaen3offm Hoomes,mul'rntenmonx Code)er
that he N emend Iheml o n and the basis for the alleged extandiun. Any violation of
Section ]031.5 by any applicant for a tennis subjects the applicant is a civil penally of
our more than five hundred do][. (3500).
01.as owner ofrhe property, or my employees with wages as their sole conttensmion,
will do the wortnnd the structure is not intended oro@red forselc(Sm. 91W4, Eusinesx
and Po fic.iom Cock: The Contractors Licmue Low does not apply n an owner of
propmy who build, m Improves thereon, and who does such work himself e, though
'FEMPMETEROR .1; INST.
COMMERCIAL:
EW BLDG/AUDITION ❑ UESBoLITION
ANT ❑ FOOD SERVICE
IMPROVEMENT
COTI IER
POWER DEVICES
SWIMMING POOL FIT I
OU'fL6I'g-SW ITCIII?$ - FI CS 3. 3
his own employees, provided shot such impmvcnmms arc not immnled incurred for
sale. 11. however. the building or improvenmm iv sold within one year (if "completion, the
NEW RESIDENT Al, HLEC"R SQ IT.
SQ. FT. FLOOR ARE
F/SQ. FE
w er-builder will have the burden of proving that he did not had it of improve forpur-
tose of sale.).
O I, as owner of the pm,n,, am exclusively mmracfing with licenced comma., In
�-
r�L'
construct the pngact (Sea. 7004. Business and Professions Code:)'Ibe Comrne or'a In-
cenm Law does nm apply to an owner of pmpeny who builds or Improves me cer, and
QTY. ENO P. T FEE
who cemmms mr such Pnjectx with a e a nam(s) Iirmord Proaran in tem Cmnmelora
PFRMII' ISSUANCh
License Law,
0 lamcxcacarualer. Sec .BNI'Cfonhis reason
Owner Doc
ALTER - BRAINN VENT' -WA EA)
VALUATION
'2,1
WORn r'rT1 ATION
BACK FLOW I'ROIT:CT. DEVICE 3 O
`�
el Ity of per,(�r� one of a o in Jcclarmions:
Ihereh 111+++rrrAAA
0Ihavea willumimat a n aaofC suites - re lie Workers Camper-
anon, a p me tin by ' inion. t0 it Tic Lahore a the ryrlurmanec of the
workterwh t' ,or lis meed,' (fie
T`
STORIES 'I YPH CONSTRUCTION
DRAINS- FLOOR. BOOK. AREA, CCNQ (%
FIXTURES -Plilt'I'RAP D
0 1 have an 11 ,:,at, in Wgrk C�iPt ®Dl as un to "in"! by Section
3]1X1 of mel: h Jc�(�i�f c Ithe work! 1 hthis pv'nnil is issued
1Y
GAS - EA. SYS'I'1?M.1 INC. 4 OUTLETS
OCC GROUT' APN
My Worker's if,. .0 7rnrNY� nammace turner and Policy numb, arc
Carrier: Policy No.:
GAS - EA. SYSTI;M-OVI;R 4 (EA)
_ RTWICATE OF EXEMPTION FRO ME'
COMPENSA'1'
(This reef"BY no cPermit is for one hurnlrcJ dollars ($11X11
nrlas.)
B G DIVISION IBES
GREASFIINDUSTRI.WASTF.l TERCEVIOR
GREASETRAI'
_
-- - ---� --
PLANCtIECK T3; 04
(certify tbul in the Perf trance of thework l"orwnich rh lx Pcr.nitiskoutd.10mll
am employ any pawon in any manner son to became subject to the Workers' Cooper-
oo per-
SHWER-SANU'ARY-STORM EA. 21X1111',
ENERG F, h
WATER HEATER WNI;NT/ELECTR
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soden laws of Cilifomia. Data
Applicant
GRADING FEE
NOTICE TO APPLICANT: If, afar making this Certificate of Exemption, you should
become subject to Inc Workers Compensation previsions of the Later Code, you mat
int comply with weh previsions or this Permit shall be deemed revoked.
CONhemiseU(INaction NG AGENCY
Ihereby u(fnnlM1m lhoroisvennvmdinnlenJing agency for@e perf nnanoenl'
the work for which this Permit is issued (Sea 3097, Civ. C.)
WATER SYSTEND7RHATING
SOU -S FEE
WATER SERVICE?
PAID
Date eveim#
NEW I2F.SIDEN'I'IALI'LMR. SQ, I'll
0 F"
LJ
} 1
Ftn
U z
Lenders Name
TOTAL:
Lenders Address
1 ced y that 1 have mad this application and ante that the above information is
correct. l agree to comply with all city and county ordinances and store laws relining to
building contraction. and hereby authorize enmtives of this city mercer upon me
TD
-FEE
BuikaqrcE
QTY. MECHANICAL PERMIT
SEI. IC Eli
PERMIT ISSUANCE?
IA : "f C FI31? r 2
roperty for ne pretinn pre .us
uhuvo-mentit nal Pro
(Wt.) "gone to ease, indemnify unp hannlea5 me City nl"Cupertino against
liabilities, judgments, cols and experts iahmay in any way accrue against said City
naequence n(Ibe granting of this roil.
ALIHR OR ADD' IU MECIL
P 1 LNG FIi1i
AIR HANDLING UNIT CFO I0," CFM)
MEC ANICAL FEE O
APPLICANT UNDERSTANDS WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IB.000 CFMJ
CO STRUCfION TAX
. tgnamreaf APPIie:lnUConl Int Date
I I'C SMA'I'IiIt1Al.8 UISCLOSIIIiIi
EXHAUST HOOD(WIUUCf)
IIOUS 'C MI'T'IGATION PEE
Willtber"'Ito umrcbuilJ ngnccupanl stere or handl, nmardnos materiel
IH3ATING ONI'I'CIO IBf1,1111B BTU) VD
as defined by the Cu no Municipal Codr. Chance 9.12, and the Health and Safety
Cede. Section 23532 ?
HEATING UNI f(OVIER 110,1100 B'ITJI
0 Yes ON.
Will the applicant or future building occupant use equipment or devices which
mit hazardous air commainnms as delimn) by the Bay Area Air Qualify Management
District'
Yes El No
PAID
Data Receipt If
VENTIIA'1'[ON PAN (SINGLE kESllll
BOILER - COMP (311P OR 100.0110 RTIO
T
HOILER-CGMPIOVI IR IU0,000131U)
AIR CONDITIONER
I have andthe haavdons inderiuls nquiremems under Chapter 6.95 of the Cali-
ISSUANCE DATE?
NEW RES(DENTLAI. MECH. SQ. IT.
fomla Health .FSafety Code. Sections 25505,' 25533 and M534. I undcoland that if the
. building does not currently have a tenant, that it is my responsibility to notify the acceptor
of the unpor nems which must be met poor to ismance of a Certificam of Occupancy.
'D)" t
ISSUEDBY:
Game, oramthorieedagcat Dam
OFFICE