99120065uennaaalTION WITHIN RFD LINES USP BALL POINT PEN ONLY _-Hr 19 W1 I 2001
CITY OF CUPERTINO
BUILDING DIVISION APPIACATION/PERMIT
RUILDING - ELECTRICAL
PUBMIRING- MECHANICAL
BUILDING PROJECT IDENT'IF'ICATION
PERMIT O.
BUILDING ADDRESS:
/�)• (%/^y�/J
�1/Y/1
it
SANITARY N0.
APPLICATIIIN $ JIIMITI'AL DAT
F ^�
-R'S NAME. PHONE":
CONI' CfOR'S NA ¢,Z CLIC NO
ILM j��n
N/C
❑
CONTR(JLN
IIyTF,Cflllli5'N-GINE R: d//��a�LI
"/Al lJ r\,Tf54lJ{/ &_Q�
CON /'� �I,I�
/I CSJ�N'je�%'rj�
ADD I'S. (��r
jCq J (-,4
/J
❑ Consultant EceS Paid by Applicant (initial)
BUILDING PIiR INFO
PLUMB SUCH
BLDG ELT( LU
`{af^
r1LICCEENNNSSED
s
COMI'RACTOR'I DECLARATION
1 herchy uflim, that I am licensed under pnwi,cinns of Chapror 9 (cnmmeneing
wird scc,inn7UlXB nI'Division Jot tic Eeriness on oil I' wsionsCde.ypdn, prevcia
indn Se,rccandellcd // (r (Jr
Littms Lica l0W
LECTRIC PERMIT FEE
ANCE r
QTY.MAN
-RI...... NTIAI.
JOB DESCRIPTION
RESIDENTIAL:
❑SFUWL ❑ KITCIIEN REMODEL
[]ADDITION El PLUMBING RE -PITC
Dam Contract
❑h1UhT1-UNIT [I STRUCTURAL
tCHRECI'S DECLARATI
C TION
1 undcrs,and my plans stall he umd as public records
PS
❑INTIiRIOR ❑CHIh1NIiY RF;PAIR
IMPROVEMEN'T (] SWIMMING POOLS
❑ RA'I'I I REMODF;L/REPAIR ❑DEMOLI'T'ION
❑ OTHER
hhcnscd l'rnlossinnnl g
OWNER -BUILDER DECLARATION PS
1 herchy affirm Nm 1 am exanpl from ,he Contract. Licence haw for the
following rcamn. (Section 7071.5. Rosiness and Pmfeaxiuns Codc: Any city nr coun,Y
SIGNS ELECTRICAL
which respites a permit in cnmrmcl. almr, improve, demolish, or repair any etrumare
prior to alaissuance. also requires the applicantfor such pprou to file a signed slamment
that he is licensed pursuant the previsions of the Collector's L' me Law(Chapmr9
(rommm�cingwlth Scmion 7fXll0 of OivisiunJ ofthe lLtcin nd Pn,fcrdunx Codc)or
that he le exanpt therefrom and tire basis for Ibe aIle savel i..n. Any violation of
Sedion70315 by any applicant for a femur subje the applicant a civil rynullYof
not more than live hundred dollars($510). -
L as mvneraflhepmpen,ormycmplo- swithwvgeca'darrmlauomser-lion,
Business
will d..,hewons C,,h,: he Copus nm' ended" Law dofs notall
and I'ndexsinnx C,de: The Cnnmac s Licence Law Jocv not apply ownergh
SPECIAL CIRCUFFIMISC.
'I EM P. METER OR POLE INS' 1',
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLEI:S-SWITCHES-FIXTURES
COMMERCIAL: r'
❑ NIiW BLDG/ADUI'1'IUN ❑ DIiM01,1'I'ION
Ipd'f:GANT ❑FOODSERVICE
IMPROVEMENT'
❑OTHER I
, ll
property who huI nr impnrve rerun, and who dace such work hlmnclfor through
his own employers, provided `n1 such impnrvonanls arc not amended nr oProol for
ealclLhow'eveq,hchu Ili i.,tmvcmcn,is sold within enc year ofannpleion. me
e.ustar-builder will have a lumen of proving,hat he did nm build or improve for pur-
NEW RESIDENTIAL TECTR SQ 1--r
SQ. ET. FLOOR AREA
$/SQ. I
pouol'one.).
1, as owner of I Porten, ren exclusively contracting with licensed connector, to
m.nmd the poi n Isec. 71111, 0uainess and Profnainm CoJeJ The Contramor'.c Li-
ecit-Lawdo- not apply to un owner,dpropeny who builds or impmvcx theram,and
whocannnt for such p,ajmts with acentroanr(s) licensed pursuantLo,he Contractors
License 1
❑la emplu"der Sec. .BSPCfor,hisrcamn
TOT
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANC17
ALTER -DRAIN & VENT- WATER (IiA)
VALUA'11ON
weer Date
WORKERS COMPENSATION DECLARATION HACK FLOW PROTECT. DEVICE
I herchy affirm under pros ty of perjury one of the following dcelaru0a,r.
I havered willmaimain a Ccuifmwenl' Consent tnxell r1befor Wnrkerx Conmcn-
smion, as provided for by Section AW of the I-sar Calc. for the perfnnnnnicotine
for which his pe,mi, is issued.
w I have and will maintain Workers Compensation Insurance. as required by Section
0 afthe Labor Code. for the performance ofthe work for wh IM's m,nrs,,tard
DRAINS-I'I,DQIt, R(IOP,AREA, L'UND.
PIX TURES - I'HR TRAP
GAS-FA.SYS'TCM IINC.a0U1'LIifS
Sy ORIES
'I'YPI?CONS'fRUC'I10
�+ OCC.GROUI'
�I't
Carri 5I Policy N, 17 1
CaW a'm ' unInst tamerandy N,
C nR'I'IFICAO IIP SAI [ON INS FROM WORKERS
CUMI'IiNSN'ION INSURANCE
GAS -EA. SYSTEM.OVERJ(CN
GRIiASFJINUIJti'I'RI. WASTE IN'I'IiRClil'IT)R
/
ItUILUINO DIV ISION I�IiES
ITANCHECK ITE
(TTls,Ojer need..., be nnntleted if he peurn, is Bache hundred dollars(S IW) GREASETRAP
arlhus.)
Ne becont which this the W,)kcm'esomKnl
net employ any person in any manner so as to become subject the Worker: Cumpen-
Ioy any shat int in taretail retailer
$ sou"n Le—ol' California DareWATER
J ALIN,.." 1
NOTICE 10 APPLICANT: 11;.Hernmking thin CanilieMoul Exemption, you should
become cobject In he Worker's Compensution pmvisions of 'be Labor Gde, you mus,
funhwermit ith comply with such previsions or this pshallM dmined revoked.
SEWER-SANITARY-STORM1I P.A. 210 FT.
HEATIiR WN13NTLECIR
WATER SYS']17MOREATING
WATER SERVICE
N
I U�
ENERGY FEE
_
CNAI)ING PIi13
SOIhSITL' I^
n1, 9'999
CONSTRUCTION LENDING AGENCY
NEW RESIDENT ]At, PLMH. SQ. 14.
�{If- IIIF�
Dam Rccci e
I hereby affimuharthere is a con,dmdion lending agency for the perfommnce of
the work for w16d, IIIIs permit'I, issued (Sec..10k7, Civ. C.)f�
101 1,1
Naree
lender's
Lenders Address _
TOTAL.B
_,�----
6UII:IHNOPE
Q I ee tify,hat 1 have mad this application and state that the .have information is
n conca.Iagrau, comply with all city and county ordinances and nam laws relating to
buildingcnne,mc.Leal and hereby authorise mpresentmlvesofthis oily toenmrril he
QTY. MECHANICAL PERM IT FEE
SEISMIC PEE
above uncolored property for inspection pmposcx,
m
(We) ohne le ,ave lydmnnily and keep harmless the City of Cupertino aguincl
Iiahikies,judgmen,s, costs and cnpcmes which may in any way accrue against said City
I'ERMI'f ISSUANCE
ALTER OR ADD1'0 MECH.
171-ITCI'RIC FEE
III.EMBING FEE
in consequence of the granting of this permit.
APVLICAN'IONDERSTANDS ANI) AT LL COM PLY W 1111 ALL NON -POINT
AIR HANDLING UNFECfO 10,000 CFM)
MSCIIANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT (OVER 10,100 CPM)
CONSTRUCTION *FAX
I IOBSING MITIGATION PEE
Signmurcnf Applelo/Cnmmmor Ilam
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicanl or future building oecupxn, tan's or handle haeurdouc mamrial
ac defined by the Cupertino Municipal Code. Chapter 9.12. and,le Health and Safny
pe
Cade, Section 25532(n?
❑Yes ❑NnVENILATION
EXHAUST HOOD I W/DUCT}
BEATING ON] T(f)100.000 BTU)
BEATING UNIT (OVER 100.000 RN)
PAN (SINGLE, RESID)
H\IU
Dam Bit p
Will Ile applicant or Tamm hid,ng ocn,po, esu nryipmenl or devices which
,
,.it luenolo I, oar conmminares as defined by the IJay Area Air Quality Management
PDistne,'!
HOILER-COMP UHP OR 100.IXNl BILL)
TOTAL:
BOILER - COMP (OVER 1B)., , BIG)
❑Ycx 0 N
ISSUANCE ATI:
�n
/ C
/
AIR CON D!
1hath reaafet h ore. pll 1,255,2553mmx under4.1 undporpter 6.95 ofthe ifup,
4,mia Ne;" h Safety Calc, Sections 25505.25573 and 255Jq. I undcotunJ that if Nc NEW RESIDIiN'TIAh MECH. SQ. Ff.
ing Asrcsnal enrrcoly ha ,ret.Ihmr,,ulyr sl meihility,I oar yth"center"'
o ,''nfnlxw cnct prior a c Ccniti.
Ownern, a nhented ag Dam
TOTAL:
ISSUED BY:
ut-I'ICt