S 1217APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
wDUILDING DIVISION APPLICATIONFPERMIT PLUMBING -MECHANICAL
BUILDING PROJECT' IDENT'IF'ICATION
PE IT NO
1217
ii
BUILDING ADDRESS:
SANITARY NO,
AP^PLICATION SURMI'I'I'N. DATE
y��'� �.aa.. p� �F �L
20 'Jl �.a.`Ju� aLV Y L T
`/r
WNER:S NAME: PHONE
aillitist S NAME: LIC NO:
may.
NIC
❑
CONTROL Or
�ARCHI'I'ECT/ENGINEER: LIC NO:
AD�R��F.�S\Sq
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ll 1 T\
CON'I'ACn PHONE:
BUILDING PERMIT INFO
❑ CUnsultnnt Fees Paid by Applicant (Initial)
BLDG ELECTPLUMB MECH
yyO1ZZ
F00
,—
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LICENSED CONT'RACTOR'S DECLARATION
I hereby ammt that l am licensed under provisions of chapter 9 (commencing
with Section 7W0)of Division J of the Business and ProfeiimumN Code, and my license is
in lull force and effect
LicennC Class I.a,#
Darc Cnnlmdr
QTY ELECTRIC PERMIT FEE
JON DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION [I PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAI,
MODIFICA'1'I(lN
El INTERIOR [I CHIMNEY REPAIR
IMPROVfiMiiNT 7SWIMMING POOLS
El13ATH R IHMODFIJREPAIR L1DEMOLITION
❑ O'1'11ER
PERMIT ISSUANCE
APPLIANCES -BESIDES I'[A],
1FzW
,O -Z
:Z-—
ARCHITI:CPS DECLARATION
daz public occor
IunJerstandmy plareshall he meN
PANE( S
UP T020(IAMI'S
Licensed Prof e..anal
UWNIiR-BUILDER DECLARATION
i C IY Q I herchy affiml (but I am exempt from Ne Cnnuaaar's Lieensc Law for the
O M U f flossing ren70JL5, wn. (Section Business and Professions Code, Any City or county
3 O y which require%a permit m construct. alter, improve, demnlish, or repair any swcmre
mJ Prirl a.. "Nonentities the ppl antf h Nearmiam fileirsi,redmirvorne,
that la, 11 ilemodp II he p I InCrxinacla, , Lic,me Low (Cbmter9
4� no 6 withS....... 700a.flaskion J fthe limints,andPrf.: sCodc)Or
201-EVOAMPS
OVER EPOAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMI'.Nil; I'1:R OR POLE INST.
COMMERCIAL:
that he is exempt dradro n and the b.,i, for IIs rivaled exemption Any violation, Of
^LL Section 7031.5 by any applicant fora pemlit mbjects lbe applicam us scrod penalty of
Z not marc than five hundred dollars ($500).
F 1�dI, ax owner of the a
iG`❑❑ pr psay. or my emlluyees with wages as their sole compensation,
coil do Lha work, vnd tM xu'uclinein nun intended nndfurcd farxule (See 71W4, Business
❑ NEW BLDG/ADDITION ❑ DEMOLITION
-
'I? ANT ❑POOU SGRVICIi
I 'ROVE ENI
OTHER
POWER DEVICES
SWIMMING POOL ELECT
m and Professions Codd the Cunlmmnr's Liefnee Law docs not apply to Int owner of
3 r prolan, who builds Or improves thereon, and who does such work him Cr through
his own employees, provided that such improvements am not intended or Offered for
sale. If,however, the building or improvement is. sold within nneyearof amlplmiov.ilia
OU'I I.E'I'S-SWITCHRS -FIXTURES 77
Ns IL W-Ak
NEN' RESIDEN'T'IAL IILEGI'R
SQ. Ff. FLOOR AREA
U$Q. Fn
htildfr will have the harden of prom, that he did nil build nr irnpnrve fur pur-
pueo
e of sale.),
❑ [.;is owner of the proper, am exclusively contracting with licensed couracmrs noP
p'
�.
, Business and Profe.r, CWe:) The Cornasna l Li-
otimm� the project (Sec. 7f Wma
N D
ecroo,l.aw does not apply noun ownerofpropeny who builds or imp ... camereun. wait
who contracts forsuch projects with acoonna is) licensed pursuant to the Commens''s
QTY PLUMBING PERMIT
PERMIT' ISSUANCE
License I.aw.
❑ Iunlexcnrptinder SCC. ,Ii&PCfor Ousicaan
Date
ALTER - DRAIN & VENT - WATER (HA)
Lilt -VALUA'I ION
�UrCfl�IlyV
WOR KHR S COMPENSATION DECLARATION
BACK PLOW PROTECT. DEVICE,
•Owner
I hereby an on under penalty of pe jury one of the following dedan tiom:
(] I huvcand will nwinwin nCeniticum of CanedLLm sell, lnsumfor Workeri Cnmpem
smion, as provided fir ty Suction 371X1 of he Labor Code, for the perfornwnce of the
DRAINS- FLOOR, ROOIs, AREA, CONI(.
STORIES
TYPE CONST, UCTION
work for which this permit Is issued.
FIXTURES -PER TRAP
❑ 1 have and will maintain Worker's Compem. ion Insurance, as required by Section
37W) of the Labor Calc, for the performance of the work for which this pcmlit is issued.
OCC. GROUP
N'N
GAS -IiA. SYS TEM -I INC. J OUTLETS
My Wnrknr'ZCorype�iyllniun lyyy'ananm, uji, Niey numbee era:
Ea••J �LJ* e Pond Policy
CAN - HA. RVSTEM{)yl!B4EA)
GREASIVINDUSTRL WASTE LNTERCEIITOB
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FIEFS
('(Tissmion need not becompineJ ifthe permit is fnrone hundred J011aa ($10(1)
or las.)
GREASE'IRAP
_
I'hANCHECK FEE
I certify shat in performance ofnhe work for which l his pdmit In ewed, I shell
non en 1,1, any person In any manner.,, as no became sal,ei IC the W aloe, Comper.
SEWS -SANITARY-S'I'ORMHA.20OFI'.
ENERGY FEE
OZ
Z
N
abecome
W
a
U O
O ULenders
mlion Laws of Califmoi.. Date
WATER I IEAI'ER WNENTMLECR
GRADING FEE
Applicant
NOTICE TO APPLICANT. If, after maAing this Certificate of Exemption, you should
subject to be Workers Compensation provisions of the Labor Gale, you must
owli.11hdunply with slmh p....N Uor lhinpennu xhall he dcemednesoked.
CONSTRUCTION LENDINGAGENCY
1 hereby affirm thatrune i is s amamc. 30 7. agency for the pedonnan¢ of
the work Na which this permit is issued (Sec. JfN7, Co.Crv. CJ
NameTOTAL
WATER SYSTENVTREATING
WATI7R SERVICE
SOILS FEE
PAID
Date ReceiplM
NEW RESIDENTIAL PLMIi. SQ. PI'.
LenJfrn AJJmA9
_
BUILDING FIil3
>� WI
a,
E5F Z
I eci ify that I have mad this application and nude Ilial ole above Inion uumn is
comm.l agree to comply with till city and county oNimmres nnJ sum lows relmingm
building comeaction. and hereby amboriu representatives Critic city m enter upon the
Ury. MECHANICALPERMIT FEE
SIJSMIC FEE
PEBMI'1' ISSUANCP.
ELECTRIC FEE
ahovcrnenooned pmpeay for inspection pmryrses.
(We) agate 10 cNe, indemnify and keep harmless the City of Cupertino ogaiml
ALTER OR ADD TO MECI I.
liahilllics, jud6mdv....rune and Caper,, which may in any way acerae ugninst said City
Consequencein of le graming of this pknu.
PLUMBING FEE
HANDLING UNIT CFO 10,000 CFM)
APPLICANT U DERSTAN S AND WILL COMPLY WITH ALL NONPOINTAIR
SOUR R- LATION$
MECHANICAL rIi
AIR HANDLING UNIT (OVER I0NX) CPM)
CONS 'fkllCTiON'I'AX
i
Z �
Sigr urenfAp w Conlmdor Ilam
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST'HOOD(W/UUC'p
HOUSING Nil I'IGAI'ION FEE
HEATING LINE 'TOM 100,000 BTU)
Will lheapplicam or furore building use.,annmirenr handle hazanhm, mammal
ac defined by the Cupsrhmo Municipal Cale, Chapter 9.12, and the Health and Safety
Calf, Section 25532D)?
HEATING UNIT (OVER UMAX) BTU)
❑Yes El Nil
Will the applicant or Ibmre building y rise B use equipment m JMana which
<mil IlurarJous air conmminams us defined by the Bay Area Air Quality Management
District?
❑Yes E] No
PAID
Uma Reeclly#
VEN'I'lLA'I'If1N PAN (SINGLE1tESID)
BOILER -GDM11P OHP (1R 1118,008 BTU)
TOTAL:
BOILER- COME (OVER I01000 BTIO
AIR CONDITIONER
I hove rdtd the hazardous mulmid, requirement under Chapter 695 of the Cali-
ISSUANCE. DATE
NEW RESIDENTIAL MECH. SQ. Fr.
tannin health & Safny CWC. Sections 25505. 25533 and 255311 undendand that if the
building does not currently have a tenant, that it is my msrymsibility to notify the occupant
of the requirements which must be met prior to issuance Of a Cenifievte of Occupancy.
I
ISSUED BP.
'I (yfAL,
Owner nr amhoJzeJ agent Date
OFFICE