29878APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. -ELECTRICAL
PfiRMIT NO. /� }8 (� /� � f1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-Ml!CHANICAL
BUILDING PROJECT IDENTIFICATION
L J a
BUILDING ADDRESS:
2. lilt STcvcs eil
SANI I'ARY No.
APPLICATION SUBMI'I-1'AL DTI
E F:D� NJ
Cf OAST�SN �.Git.NlS LIC NO
�g L&5070
NIC
CONTROL p
%RCHTI'ECT/ENGINEER: LIC NO
ADDRESS: P
zss
❑
CONTACT: PHONH:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
LUG ELECT PLUMMECH
LICENSED CONTRACTOR'S f h,i
thereby lion Nm1 runfeasedanderpmei,h,nsarchalner9 ityImcndng
with Sution]IXNry ofDivision3ofthe Rosiness end Profcxsions Gale, and my licenvc is
in full force and effect.
License Class Lick
Dom Contmctur
QTY ELECTRIC PERM IT FEE
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JOB DESCRIPTION
RESIDENTIAL,
1?FNT�A�
❑SFDWL ❑KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
E3 BATH REMODEURF.PAIR [I DEMOLITION
❑ OTHER
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
1 understand my plana shall he u.ad as public rcoNa
PANELS
UPTO 2n)AMPS I
Licensed Professional
OWNER" BUILDER DECLARATION
1 hereby affirm Nat 1 mi exempt from the Contractor's' License Law for the
following rtuon. (Section 7031.5. Business and Pmfeaions Cod,: Any city or county
201-1000AMPS
OVER IINN)A •S II!/n nn
I _
SIGNS ELE ICA A / 1 J.' 't }I V
1+13 LL It"n'
F�0¢
E >
0O
a e e
W M LL
1-ZY
_<Ql.asownerofthepmpcny.ormyemployec,wlNwogesestheir.solecompcnsaiion,
fFca
{ail o��p
d
which teyalax a permit m construct. alcor, improve, drion i.vh, or repair any structure
prier,,it, isaumuro. also resiite%theapplicaut fmwch permit m Eleasigned statement
not he is licensed parsannuo the provision, of the Contractor's License Law lChagcr 9
(commencing with Scctlan ANNq of Dlvlsion3ot`mcRunimes .uI Prom,sions Calc)or
Na he is exempt therefrom and the bust, for the all,g,d exemption. Any violation of
Section 7031.5 by y applicant for a permit subjects the applicant to a civil penalty of
an
, r than five hundred dollars"($500).
N
will do the work. and the swcturc is not intended or offered for vote (Sec. 7(W. Business
and Professimis Cod. the Commnor'.s Losins"e Law dues not apply to on owner of
who builds or improves thereon. and who does such work himself or through
SPECIAL Cl LT�fNISCI �I
(`'
1
..
'TEMP. METER OR POLE 1NSTw
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑ MPROVE TENANT [I FOODSERVICE
�J C`►,
❑OTHER 'rte+M� �+•
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SW ITCHES -FIXTURES
property
his own employees, provided that such improvements me, not intended or offered for
safe. If, havew,theholdingnr improvcmem i„old withinone ycarofc„meletin i,
NEW RESIDENTIAL ELECTR SQ ET.
T. SQ. FT. FLOOR AREA $/SQ. FT.nerbuilder
will have the burden of proving that he did not build or improve fur par -
pose of titled.
❑ 1, as owner of the pmpeny, am exclusively contracting with licensed contractors to
construct the project (See ]($W. Business and Profina ons Cradi The Co micas a LI-
cemeLaw does not apply to an owner of property who builds or improves thereon,and
whocoraamslirtsueh pouch, withocomrv,burx) license pumuonuodw Gmhactor'a
..
QTY. PLUMBING PERMIT zsf
PURMI'IISSUANCE
License Low.
E] I am exempt under Sec. .B& P C for this reason
O
ALTER - DRAIN & VENT - WATER (BA)
ALUAN�fy�n
199c
Owner Dae
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration%:
HACK FLOW PROTECT. DEVICE
X111
.'
E3 [haw and will maintain a Ccufficate ofComem to self -insert for Waders Comp,m
autiun, as provide for by Section 371X1 of the L.abm Code, for the performance of the
DRAINS- FLUOR. ROOF. AREA. COND.
STORIES
IT�YPfiCONS'I'HUCI'IOP
' `V
work for which his permit is is,eaoil
FIXTURES - PER TRAP
Fl I have and will mainmin Worker's Compensation Insumstce, as squired by Steffan
3](X)nrlhe Labor Codc, he the perfunnmm,of the w„rkhewhichthispermitisiau,d.
OCCGROUP
AVN
GAS - EA. SYSTEM -I INC. 4 OUTLETS
GAS -EA.SYS'I'EM.OVGR4WA)
My Workry tiuMt�wi�urunce carrier Pand Policy '
Cvncc%iL.V olity m+yx'�re�/
GREAS IVT NDUSTRL WASTE INTERC1I
CER'1'IFICAT It OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(ThisseaionnemombecompletW Hthe permit isfmonchundreddoiles(SI00)
or Icsv.)
GREASE TRAY
.ANCHECK ITE
SEWER -SANITARY -STORM EA. 200 FT
ENERGY FEE
Iwitify that in the perfmrnance ofthe work for which this permit is issued. I stall
not employ any person in any manner so as to become subject to the Workers' Comport.
WATER HEATHR WNENT/EI-IiLTR
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F ycorrect.
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sation Lows uI Culi ...mit. Done
Applicant
NOTICE TO APPLICANT: If, ager making his Certificate of Exemption, you should
bee N mItjea m the Wmkcr'.v Compeneodon poitimone of the Lobuf Cudc, you must
forthwith comply with such prevision% or this permit shall Is, deemed revoked.
CONS
iatmem is. couN LENDING AGENCY
I for which thi NatthemisacunswetiS leading agency for the performance of
the work for which this pcnnit i, issued (Sec, 7(19]. Civ. C)
Lender's NameOTAI:
WATER SYSTEM/IItEATING
WAT12R SERVICE
SOILS F
PAID
NEW RIi51DiiNTIA1. I'LMP. SQ E7.
[)am Receipt p
TO'T'AL:
I<tdcr'Adify
BUILDING ItiE
at I have real this application and nate Nm the above information is
I codifyr that
l agree to comply with all city and county ordinances and state laws relating to
building conswetion and hembymhhodeetepattntaivsofthis city to enterupen the
QTY MECHANICAL PERM IT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC F131?
nbova-mentioned Papery for inspection Purposes.
(We) agree to save, indemnify and keep hurtnless the City of Cupertino against
ALTERORADDTOMECN.
PLUMBING FEC
liabilities.judgments, costs and expenses which may in any way ,cant against said City
in nwipwr of the gmmi"g of this permit
AIR HANDLING UNI "T (TO 11,1X10 CI'M)
MSCI{pNICA1.FEE
APPLLC IT UNDERSTA$ AND . C A1PhY WI'T'H ALL NON -POINT
SOURC i( )LAl'IONS.
AIR HANDLING UNIT (OVER 10.0)() CFM)
CONSTRUCTION TAX
'ignam of ppIwamoc 1, t r Date
BAZAR f US MAT L LALS DISCLOSURE
EXHAUST DOOD(W/DUCT)
HOUSING MITIGATION FEE
HE -ATI NO UNIT (TO 10(),”131 U)
-01,11,
1,11, - liewt or (u budding occupant store or handle hatandous material
u, JefinW he Cupxr iso Municipal Cole, Chapter 9.12, and the Health and Safety
as
Sc Ii. 2553$u}P
HEATING UNIT (OVER 100.(MN)BTU)
VENTILATION FAN (SINGLE RESLD)
EJ YO, El No
PAID
Date Receipt#
W III the applicant ar furore M1 defined by the B use e a Air Qu or devices which
run huznnlous air contaminenty us JcOocd by the Huy Dao Air Qoulity Manugcman
BOILIiR-COMP (3H1' OR IINLIXI) ii'N)
TOTAL:
BOILER - COMP (OVL'R 100,003 BTU)
\00Uimrict,
❑Yc, E] No
AIR CONDITIONER
I have mad the mcmdaus materials m under Chapter 6,95 of the Cali
re.255
ISSUANCE DATE
NEW HIisLDliNI'1A1. MECH. SQ. ITT.
m thm it the
s 25505, 2553] and 25534. I to notify
fomiu gdoes & Su@Code, have m nmify
building currently huve a tenant. Nato is teeofa
iswhich ua Certificate Occupancy
of the reyvirtmems which mus be run prior m issuance of a Certificate of Occupancy.
requirements
TOTAL
ISSUED BY:
Owner or mabortiee agent Doc
OFFICE