S 0822APPLICANTTO'FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILMADING - ELECTRICAI,
BUILDING DIVISION - APPLICATION/PERMIT PLUI NG -MECHANICAL
' •'ilUilA1NC 1'RIIJECT IDF.N'I'IF'ICA'FIIIN .r.='r
1 PES"
l ND 0822 � nL L n
J
RUILDING ADDRESS:
'L�AL_E
SANITARY NO.
APPLICATION SUBMITTAL, DAT,
OWNER 8 NAI(`E: PHONir ch•^�
vV 1 1314, S /
CO RACTOR;S NAA1c2- LIC NO:
U'SS
NIC
❑
COM'ROL p
ARCHITECDENGINHER: LIC NO:
A
App
21iS5:
CONTACT', PHONE'.
' 'i-" --. �,BUIISDING PERMIT INFO
3 O
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MITCH
❑ ❑ ❑
I hereby ERrmLIClNSED thetlamCl craw unJRProv Cnm of CM1vLARAI Nrcomme cn
ya p g
QTY ELEC'PRICPI:RMIT/t'/{!-rlii ji, flll:..�+
JOB DESCRIPTION
with Section 7000) of Division 3 ofthe Business and Professions Cod,,mi my lice.¢ is
'n full G•mc and o(fwLA -iLo
l-
RESIDENTIAL:
❑SPDWI. El KITCHEN RIiMODF,I.
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
Licens ✓Y Lic.p
Dale Coalmemr
s ARCHITECTS DECLARATION
I tmdarammmty plans,loll he weds+public recited,-
❑ ADD] TION ❑ PLUMBING lil-PIPE
❑MULTI -UNIT ❑STRUCITRAL
MODIFICATION
PANELS
UP TO 200 AMPS
El INTERIOR El CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
Licensed Professional
201-IBfX1AMPS
OWNER -BUILDER uthe DECLARATION
1 hereby offtent that 1. exempt ss an the Cssions Code: license Law for the
followingtimeort ionshorqny city or county
]1131.5.Bnsincsx and ve,
❑ BAI'H RFMODFIJREPAIR ❑UPMOIATION
❑0TIIlek
OVER ITop AMPS -
_
SIGNS ELECTRICAL
which rtquirts n permit to rnmaruca, alma improve, demalixh, rn repair any someone
ermitt do
prior to its issuance, also requires the appliamt for such Permian filo ou,nalstatemcm
O
SPECIAL CIRCUI'UMISC. zZ�ZO
'
that he is licensed po....m to the previeioar of the Contractor', License Low(Chaptar9
TEMB M171 ER OR POLE INST.
(commencing with Seetimm700s)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
NEW HLDG/AUDITION ❑ DEMOLITION
POWER DEVICES
S.1cm WHlsby ony applicant for apenoul x thj tis the applicum b, a civil ptnaltyof
Dat more than than five hundred dollars ($500). -
I, as owner of the pottery, or my employees with wages as their sole compensation,
.NANT ❑FOOD SERVICE: '
OVENIE '1' - ..
❑OT '
SWIMMING POOL ELECTRIC
will do the work, and the structure is not intended or offered fbrsole Se1:70cf4, Business
anti Perfesnimts Code. 'Dm Contractors License Low doer not apply to no owner of
OUTLIHS-SWI 'I CUES - IgX'fURES
NEW RESIDENTIAL. ELECfR SQ FT.
pmpany who builds or improve., Ihmenn, and who does such work himself or through'
his own amployeex, prewired teal such improvereems are not intended or offered for
sale. IL however, the building or intprocrome is sold within one year ofcomplction,0th
.FLOOR AREA
S/SQ.IeI:
cn-louder will have the nurdun of proving that ha did not build or improve lot par-
pswa1 sownerd t
❑fthe p pentexclusively lycontracting with l' I tn:
-
..
OTAI. _
construct In, project (S 9044 Busiressand Profession, C 1) m C t t I'
Pony chill+ int Canto J.
prof
,/ N1
QTY. i'iwio PCUMHINCIFRMI'I'_ 1 fPEli'
tovw
who mmmcaa for projects with a connotations) licensed pursuant m the Contractors
who contractsnn
. I1
PERMIT ISSUANCE
License Law.
❑ I um exempt under Sec. I1 k P C for his nelson
ALTER - DRAIN & VENT - WATER MAI
Owner Date
VALUATION
_
BACK FLOW PR(lI'ECI'. DEVICE
WORKER'S COMPENSATION DECLARATION
omen penally perjury intent fnBowior
1 hand
�-STORIES
elfflue
w lWinn
le Worker a Cri.
�Ihave orivide maintain stion 37M ofComent to
LaborCode,for the Wforma Crimper.
for by Section 3]fXl of the Labor Care, for the performance of the
workf mer hick his
work for which this permit is i.rwed. -
DRAINl- ILOUR, HOOF, AREA, CUNEI
I YI'Ii CONS'fkUCT10N
IrIXTURliS-PIiR TRAP 0
❑ I hove trod will maintain Worker's Cnnpension. Insurance, us rcquifed by Section
3ID0ofthe Labs Coda Estate efformanct,ofibe work forwhith this nail is iasucd..
My Werke'. y'apenrx�l'o dPoliep�ny�PF lac
Carries: LqX pclgB tNnsurance conic Policy Na WS-s����VeO
bCHRrT'ICFIICCAAIIz
GAS -EA. SYSTEM -1 INC. 4 OUT
(^
C. ROUP
APN
GAS-IiA. SYSTEM-OVER4(EA) 0
OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
r
GREASHIINDUSTRI. WASTE INTE ITOR
❑IIILDING DIVISION FEES
- ('this section head Dol be wmplemJ iOhe Ix•.it is (more hunrmd Anllws (511X1)
nrless.l A
I cenify that inlhe pcafnrmanccef the work for which lot ls.I, is issued, I shall
mu employ any person in any manner sn as a because subject ao aha Workcri Compere-
CREASIi II'RAP
-
-BLANGHIi Plili
SEWER -SANITARY -STORM FA.
ENERGY FEE
station Laws of California. Date
Applicant
WATER THEATER WIVENT/Ii1.liC1'R
GRADING FEE
NOTICETO APPLICANT. If, alter making this Certificate of Exemption, you should
become subject ns the Werkeh Compensation previsions of the Labor Codc,'you muss
WATER SYSTEMo REATING
SOILS PFa!
WATER SERVICE
forthwith camply with such provisions or this permit shall he (teemed revokal.
- CONSTRUCTION LENDING AGENCY
I hereby affirm that here is a construction lending agency for the performance of
PAID
Date Receipt If
NEW RESIDENTIAL PLMB, SQ. FT.
_
that wink for which this Granth, issued (Set .309]. Civ. C)
LendersName
-
DOTAL
Lender's Address
I OTAL:
BUILDING FEE
1 cenify uh:n 1 have read This applicmime and some mallow above infotmaion is
rrect.l ugreemumtply with all city und county nnlinunrex anti smm lawn relining e.
buildingmnsuominn,avdhetehyeuahnrirc rcpresenaaaives of this cilymenmr upon the
._ , - t
QTY,': 'MP.CIIANICAI.PERMITr.
- t
SEISMIC IgiE
e .10
ELECTRIC 1
• 70
aar;c-memimed property for inspection purposesPERhVI'ISSUANCE
I We) ogre to svve, indcnnify and keep harndess the City of Co,nino against
I'LUMItIN : IrE ,
udged I+,costs... expenses whkh may in unywuy:¢crue ugnins said City
nia n the 6mming of this jMmtia.
IAPPILI,
ALTER OIt MSCI I.
AIR HANDLING UNIT(TO Io,00ECPM)
MECHANI PEIC O
AT U DERSTANDS AND WILL COMPLY WITH ALL ALL NON -PC NT
EGL .ATICKS.
AIR HANDLING UNIT (DYER 10,000 CIF
CONS '1'10 'PION TAX
^
/
St marc fApplicanUContractor
HAZARDOUS MA'I IiRIA1.S DISCLOIURli e
tltneepplicum or fulurcbbilJing sstcupumstare nr M1uithellealoual
EXHAUST HOOD(W/DUCI')
HOUSINGh TIGA'1'ION FIiIi
( 11HA'I'INC, UNET(TO 100,IIIXI BTU)
Safial
as deft nest by the Cupertino Municipal CMC, Chap¢r 9.12, anA the Heath and Sefey
Code, Section 25512(a)P..//
Yes No
❑ GI
-
HEATING UNIT (OVER 100,000BTUI
PAID
Date
VEN'I'ILA'f10N PAN (SING1.13 RES ID)
HOILF.R-CONY (J1fP DR IIX).f10(10'I'U).
Will the applicant or future building oecupam use equipment or devices which
mit heounlous air cnnarr nwms os defined by the Bay Arai Air Quality Managen®m �
Try
BOILER-COMP(OVER 11m,00o BTU)
Dislricl'! ,/
Yea L]'M1'O '
AIR CONDITIONER
Ihate cuJ the h:v.anlo Chupour M195 of tic�'1i
ISSUA Cfi DA'Ili
NEW RESIDENTIAL MECH. SQ. FL
erum,2555, 255mcrosun553
fol Ilcahh Sefay Code, Sermons 255115.25537 and 25534. 1 t Ac dat if the
buil ing Jens oat currently have a tenant. that it is my mspm" wool thececuparn
/ , _ /7
�-�` 'I
ofth t, "To f ney.
,
ISSUED BY.
amher,esl agent Dm
OFFICE