S 1800APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CI•I•Y OF CUPER77NO BUILDING - ELECTRICAL
BUILDING DIVISION APPLIQYTION/PERMIT PLUMBING. MECHANICAL
RUILDING PROJECT LDEN I IFICA'TION
Pi rT No
1800
HUI LDING ADDRESS:
SANHARYNII.
INSUBMIl9AI,DA'I'li
S O a crtlk RL_
'/L'
Le
OWNER'S NAME: PHONE:
w cal`N
l
CONTRACTORS NAMIi: LIC NO:
t a L O y/
W�rJ1V�a %�
YIC
❑
CONI'ROI.p
D
I ARCIITECfIENGINEER: LIC NO.
4Us
ADDRESS:
t n k"Fbtl
Co ACT: PIIONe,
IRA
BUILDING PERMIT INFO
t�
I u Rea �Ib -°133'0578
❑ Consultant Fees Paid by Applicant (Initial)
_
BLDG ELECT PLUMB MECII
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afrmh thus 1 a, licemc l under provisions of Chapter 9 (nnnmeneimg
Q'IY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
wish Sulinn]fXNI)nf Division3of the l4rsiness and Professions Cnde,andntylicemeis
in full force and effect.
crenaeel:ya s Iowa Lir.w 7oZYILk
Dmc—L '`—Convenor
RESIDENTIAL:
❑SFDWI. ❑KI'fCHHN REMODIiL
❑MUCTIION ❑ PLUMBING
0MUhTI-UNIT ❑STRUCTURAL.
MODIFICATION
0INTIiR10R ❑CHIMNIiY REPAIR
IMPROVEMENT ElSWIMMING POOLS
AI'I'LIANCIiS-IthSIDIiNT1Al.
_ 1 RIC111TECTS DECLARATION
I understand my plum shill reason] us public records
PANELS
UI'TO ZIXIAMI'S
Licensed ProfeWaral
201-ISMAMPS
OWNER -BUILDER DECLARATION
I hereby infirm that I an. exempt from the Conlin uns, License Law for the
following reason. (Section 70315, Boonce,, and Profession, Code. Any city or cnunly
❑HATH RGMODEURF,PAIR ❑DIiMO1,IT10N
❑ OTHIiR
OVER IIXNInMCS
SIGNS III.1'mRICAL
which requires a penal to common, alter, improve, dcrolish, or repair any strucmrc
SPECIAL CIRCUIT/M ISC.
prior to its issuance,alaorequim, the appliennt basalt .it is, file a sigmedlummert
(hal he i, licrnred pmsuanl In lhn maloam nn lire Contractor's License Law (Churl, 9
(commencing with Section 71XX11 of Division 3 of the Husinesand Professions Code)or
(hal he is exempt there) an I the too,for the alc,il exampfion, Any violation of
TEMPN17R OR POLE INSII
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Scene. 7031.5 byaoyapplicmr for a pe .it cubcaluhe applicannou civil penalty if
nm mom it,,. Coo, hundred dollars ($500)
IDl,mnwnernl'Iheprthperty, nr mycuhployeuwith wagesunlhcirsnleeongmnsin i,
1 will do the work, and lheamaum is nolimendeJ oro06ntlfor sale lSec.7(D4, Rusineas
POWER DEV1CIiS
El TENANT ❑FOODSERVICH
IMPROVEMENT
OOIDER
SWIMMINGPOOLRI.E. 1
.mA Profusion, Code 'Fire Counts, r'a I.iccnsc Law does not apply to nn nwnef of
OUTl.li'TS-SWITCHES-FIXTURL.
property who builds or improve, Iherenn, and who does such work hint a throught
his own employees, provided that such impmvemems ore not intended or offered for
sale. IL however the huilding or Improvement is sold within one year afcmnpletime. the
NEW RISIDFNI'IAL ELECI'R S 1O'.
110
SQ. FT. FLOOR AREA
5/SQ. PE
caner -h older will have the hanlen of proving that he did not build or improve for pur-
ryhso of sccJ.
Fl 1, n owner en the prnpeny, am exclusively contracting with licensed continuous to
'r(ITAL:
rmtmet the project (Sec. 7044, Business oad Professions Code:l the Commemry hi-
seLaw doe an apply nth unnwncrorprnperty who bald—,an rnvis, mmro a,and
QTY. PLUMBING PERMIT FEE
who mitrals for such pmj., with a canwnngs) licensed pnrsmam uh the Contractors
PERMIT ISSUANCE
License Lew,
I ash exempt under Sea. , B Ab I' C for this reason
Ownm Dale
ALTER -DRAIN & VIiNT- WN'F.k (EA)
VALUATION
(ON DECLA
WORKER'S Caltyof
HACK FLOW I'ROI'F.CI'. DEVICE
dugonXI
efollo following ion:
under pcnehy of perjury one of the inure lot d
ul
1 hand
orlon'
❑Ihave and will mainhhina CcnlGcum nl'Cnnxennu self -insure for Workers Camprn-
w mo
nation. as provided for by Section 3](e, of the IrMn Gde, for the perfomunce of the
DRAINS -FIDOR, HOOF, AREA, COND'
STORIES
TYPE CONS'1'ItUCI'ION
work far which thispenult Is issued..ker
FIXTURES -I'lik TRAP
a, required by Section
L]1 have are will maintain Workers Compofffic w rkfar which
of me Luton Cale,fnnhe performance ofidPolwk fur wbetter: ry:mhit is iuucd.
OCC, GROUP
AI'N
GAS- HA. SYSTEM-) INCA OUTLISfS
My Wnrker'e Co, Lp' is Inn lox ... and Polity`n�u�mber ten:
My
Carrier: bTuTGc F1IA JD' Policy No.-y..�!13 11A0•k
GAS- IIA. SYS'r1iM OVF.It4 (EA)
GItEASI%INDI15'IRI. WAS'I'Ii INTERCEPTOR
CERTiizicxrii OFIiXIiMPTIONI'ROMWORKERS'Ild4a (J
COMPENSATION INSURANCE VV
BUIIAING DMS ION FERS
('Nis.metim,ncednol M completed if me perhit is fortune hundred car. IS I (XB
or less.)
GREASETRAP
PLANCI II7CK FEE
I certirylbm in the performance entire work for which this permit is is, ed.lshall
aer so as to hCompact-ecome subject hire Workers' Compact-
not mark, any pemnn is any mnn
SEWER -SANITARY- SIHORM IIA, 200 FI'.
ENERGY FEE
WATER IIEA'I ITR W/VENT/P.I.F.C'I'R
.,,lion Lams of California. Date
Applicant
GRADING FBI?
NOTICE TO APPLICANT: Ir after making 114, Condicme of Exmnplion, you should
baoome subject In the Workers Compensalinn provisions el lbe Labor Cale, you mnsl
WATER SYST'HM/TREATINO
SOILS FEE
WATER SERVICE
forthwith comply withwch provisions onhis perranshallM deemed revoked.
CONSTRUCT ION LENDING AGENCY
I hereby uRlrn that there is aamswction lending agency for the performance of
NEW BESIDE N'f1AL PLMB, SQ. FC
PAID
Date Recei e
the work for which an, permit I, issued (Sec. 3097, Civ, C.)
Lenders Name
TO PAL:
Lender h Address
rip"
1 certify that l have rood Ibis applirminn and some Lha the nhove forma inion isBUILDING
correct. l agree to comply with all city and entry ordinances and state laws relating In
m
huilding constmmion, and hcrchy nuthnrize rcpresc mase, of m,,i,, In enter upon the
QTY. MECHANICAL PERMIT
SEISMIC FEE
ISSl1ANCG 0�
IiLECrRIC FEB.
Incase-mcminned progeny far inspection purlsrsesI'ERMII'
(We) agree to snvg Indenmily a d keep hannlm, arc City tun Cupertino ngains,
PLUMBING FER
Iiabilitics. judgments, costs and expenses which may in any way creme against and CityALT(?Ii
in gnemce or the graining of this pemtit
APPLICANT IINDERS'I'ANDS AND WILT. COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
OR ADD TO MECII. J•v
AIR HANDLING UNI'T(TO PON) CFM) Jk
MECHANICAL PEE
``11
AIR HANDLING UNIT (OVER 10,000CPM)
CONSTRUCTION TAX
Signature of AppliemulComeactor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUSP HOOD(W/DUCD
HOUSING MITIGATION FE,
HEALING ON 1'T(TO 100.040 BTU)
Will the applicantorfuture buildingoccupant slam arheodle contribute, malcricl
as detinet by the Cupcnim, Municipal Code, Chapter 9.12, sad the Health and Sn4ty
Code, Section 25532(x)"
I I IFA'I'ING UNI'(' (OVER IIXI,(IDI ETU)
❑Yea 0 N
VENTILATION PAN (SINGLE RF.SID)
PAID
One Rican M
HOILIiRCOMP(JIJP OR IfA1,IM1f1 ETU)
-
Will the applicant or future building occupant use equipment or devices which
mos it Inieco air contaminants as de fined by the I1ay Area Air Quality Management
Dindrt]
❑Yes ON.
TOTAL:
HOILI?H-CUMP(UVER 100.000111U)
AIR CONCH FIONER
equire p
I have mad the haznNous materials Is under Chapter 6,95 of tin Cull-
ISSUANCE DATE
NEW RESIDENTIAL. M11[Cll. SQ. FII
fnmlu I doe a Safety Coda Section t. n 09. 25533 and 25534.1 o.mirynd that if the
huihengdnesnmcvrcnlly buvcamnnnt, noun is my mop mnaifOv`
�)
(' /Z
iup.
of the alp 1yJymlhx, Ih. 'ch must lgnrct oizsuanm nfe Cenifromof [k. icy.
face"
7
-a/L�sjjLlirJL/(// .� �•r.2 XXrt`
Ownelznauth Iized ager b Uale`
ISSUED BY:
TUPAL:
OFFICE