B 0158APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -M1JI:CHANICAI.
BUII.IIING PROJECT' II)FhTiFICATION
PERMIT G,�015 8
BUILDING ADDRUSS:
SANT"1'ARY NO.
APPLICKI'IION SUBMITTAL DATI
r
-9
UWNIi NAME: PHUNIi
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ONIRACT)R'SNAM� .IC NO:
NIC
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it 117NGINEER: LICK :
ADDRESS:
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;•�CON'TROI-k
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CONTACT: I 'r�IfONE:
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❑ Conaullant EceS Pala by AP icaol(initial)
BUILDING PERMIT INE
BLDG ' ELECP FI,UM MECH
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I.ICENSED CONTRACTOR'S DECLARATION
1 brachy voirm Lha 1 am licensed under provisions of Chapter 9 (ennunencing
'thsestianl")of Divi'on Sof the Business and Pmfc as mylicenoeis
x
mull farce and effect. /! no /./ 4 7
Licence Class NN Lick /
Date CnnOaclor
QTY ELECTRIC PERMIT FEE
T
�T
.LOB DESCRIPTION
RESIDENTIAL :
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMHINGRE-PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
El IN] ❑CHIMNEYREPAIR
IMPROVEMENT [3SWIMMINGPOOLS
❑ BATH REMODEUREPA1R❑DEMOLITION
OTHER
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PERMI'p ISSUANCE
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APPLIANCES -RESIDENTIAL
ARCHITE SDECI.ARA'I'IOIS
IomrlenhmJ pions sl het d rspuhlic recmds
may'
Jrl _ I!�
PANELS
UPTt)200AMPS
LicensedhicenseJfiexianalfessicard
OWNS- ILDER DECLARATION
I hereby uftlrm Ihul I a ex npl Tann the Cinderella's License Iaw for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit m c ... h um alcor, improve, demolish, nr «pair any stmemre
dcsigimdstmemanl
ant mrsaehmlmo fa
o it, eouar, olsoreqas the applicpm
prianuir
that be is licensed pursuant othe prnvisioanofthe Convectors License Law(Chapmr9
(commencing with SectinnID(ID)nf Divinm3ofthe Businessand Prefeii mr,Codelar
(hot he is exempt Iherefmi and the basis far the alleged axemptina Any violation of
Section 7031.5 by dnyapp car l(a,. arnd subjects fleapplicuntm a civil penallyof
not mom than five hundr dollars(b500).
compensauan,
owner orfthe propthimis toy ampinyewwithwred in, I'll,
will Pathework, Crate: c Cmd isnot imm�Jedor offered Tor.enlo(Sec.9M4,Buxlnes
and Hnfessinns GJe: c Commcmr's License Law fres not apply m an swvner hf
property who builds or not rovcs themed, and who does such work himself or ,hrnu
his own card'ecs, p wide) Ilial such intpnwcnents are at intended m osmcd for
sale. IL however. the Ailing or improvement is sold within one yearof completion, he
201-10MAMPS
OVER IM)AMPS
SIGNS ELECTRICALn 0
L
SPECIAL CIRCUIT/MISC.
TEMP. METERO LE INS] I
COMMERCIAL
❑ EW BLDG/ADDITION ❑ DEMOLITION
TENANr C1 FOOD SERVICE
IMPROVEMCNT
[:1 OTHER
POWER DEVR`
SWIMMING POOL F:LIi
OU'[LETS -SW C 1X'I'U
y%"
NEW VESIDENTIAL IC SQ ET.
SQ, FE FLOOR AREA.
S/SQ.I
a the burden of proving that he did not build or improveforpur-
p wmer-builderwillh
of'ale.),
❑ 1, as onvner of Il prel eny, am exclusively contracting with licensed contractors to
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i
TGTAL.
ro s Nc proj (sec. 704-1. Nosiness and Professions Conical The Cnmractoes Li-
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L-
erase law dne'aI pplyman owner ofproperty who builds or Improves thereon,and
QTY. HING PF,I(MIT FEE
-
-
I con tracts for su h projects with v comraetm(s) Ferri pursuant m the Contractor's
PERMITISS
Licenxc",
❑ I am exempt under 'cc. . B & P C for this reason
O Dme
WORKER'S DECLARATION
ALTER -DRAIN & VENT -WATER (FA
VALUATION
^/
?s �1QOO
BACK PLOW PROTECT. DEVICE;.
ookyofCOMPENSATION
herebyllCtral under cookyof rycrp'D minor he following declnnninne:
WmkcraCampers-
❑(have andwill far bySetion 37M of]at LimroCoxte. home
smirk, os provided far mi Section 3104 of Ne Lahr CMe, for the performovice M the
this penult is issued.
work rave
DRAINS - FLOOR, ROOP.ARIiA, GOND.
STORIliS 'pYl'L'CONSTItUCr10N
1
flX'1'ORES -i'IiR TRAP O
❑ 1 of he Li will maintain Wmkrfin Compensation Insurance, h his lac, by Seel on
and
3100of the laMrCMe.linthe performance of the work for which this pcomit is issue].
My Wmker' pp2� W/� Ii7rue camerand Poliev rc SQ
CartiueV/�I/ n Policy Nn.l
OCC GROUT' APN
GAS - EA. SYSTEM -I 1NC. 40UTLF.T:S
Q GAS- EA.SYSTF.M-(IVP.RA(FA)
GREASF/INDUS'rRI. WASTE INIERCEITOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
arleos)Thi"ce, a need not lar completed if the armit is forsme hundred dollars S 100)
GREASEIRAI'
PIAN H IiP45-f 66
Ie, maylhmin in an,performanceall
,r.,t hatione,lork ire this Perthe it Wisisxued. I ' Camara -
not enhpluy may person in uny munncr m as m become subject m the Workers' Comlen.
SEWER -SANITARY -STORM EA. 21X1 .
ENERGY FEF. 0
WATER HEATER W/VENT/EI.IiCTR
WATI7R SYS'IT:MlfREATINGSOILS
WATERSERVICE _
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rFr N
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satinn Laws of California. Date
Applicant l(P—La
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, yon should
become atibact m the Workers Comrynvatii proem is of the taloa Code, you rear,
forthwith comply wi,hsuch provisions or this perno shall he deemed meeker.
CONS3'RUCI'[ON LI?NDING AGENCY
Iherehy effnnthn,�brre iov conswc,ian lending agency forlhe performance of
the work for which this pen itis issued (Sec. Jf199. Civ. C.)
Lenders Name
GRAVING FF.0
FEE Q
PAID
Ihne ceclplp
NEW REMDENT'IAL 1'. B: SQ. 1.
fOTA
QTY. MECHANICAL PERMIT FEE
IOTA
9 )I-�lN DI:I: r Q C
Lenders Address
rtify that 1 h, a mad this application and come Nal Ilhe abort infommtion is
correct. l agree to co y with all city and county ordinances and state laws mlvting a
building wnstraml and hereby nothoieu representatives or his city memter opon the
SEISMICfEE �Q
PERMIT ISSUANCE
above"meatinned mpenyforimpectionpurpmes.
(We) ag a to save, indemnify and keep hemi... Na City of Cupertino against
PLUMBING FEWO
•-..•.CE a"$D
MECHANICAL I• E
imoblies,jud rens, costs and expvnsco which may in uny wuyaccruenyainstmid Chy
nreyuen cof the graining of this pemtil'
APPLICAN UNDERSTANDS ND WILL COMPLY WITH ALL NON -POINT
ALTER ORADD TO MECH.
q�
AIR HANDLING UNIT CFO 111,000 CFM, i•LJ
CG ;'111.ATION
Alit HANDIANGIINIT(OVER 10,000CI'M)
CONSTRUC'H 'TAX
7^
Si vw of A", v�l Cemencma Date
HAZARDOUS MATIiRIALS DISCLOSURE
EXHAUST HOOD (W/DUCT)
HOUSING MITI TION FEE
IDEATING UNIT (TO 100,00(il BTL)
Will the applicmt or forum building occupam store m handle hmmdous anh rial
as defined by the Cupertino Municipal Code, Chaprm 212, nail the Health and Safety
Carlo, Second 25532(x)1
❑Yes ;Pell
f EXI'ING UNIT (OVER IOgOq) BTU)
PAID -
Date Receipt p
VENTILATION FAN (SINGLE RESID)
BOILER- COMP (31 IF OR 100,000 BTU)
Will (he applicant or From huddin' accts ml use equipment or devices which
pp b N
ami, haysNnus air nmmminants ar JetineJ by the 13ay Area Air Quality Management(IT
Dis,riclt
❑Yes-/
Nan
I
BOILER-COMP(OVER Ig1,IXXl BTU)
Alit CONDITIONER
irea under Onger h95 of the Cali-
aoue maerials «qumem
1 have tend ,he hmN
fomin Health & Safety Code, Sections 25505, 25533 and 25571 I understand that if the
buildingdocs not currently have v tenant, that i, is my responsibility m notify the occupant
ISSUANCIi DATE
/9
11 .Q ^ /l f�
•L,6 7 0
NEW RESIDENTIAL MECH, SQ. ET
of,he mgniremems i h m M met pdnno issuance ora Certificate of Occupn cy.
Ga• 14 9
ISSIICDBY: 015A f 0
T rAI.:
Owgcm Date
OFFICE