29165 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. r
BUILDING DIVISION APPLICATIONAIERMIT PLUMBING-MECHANICAL. �� 11�Va•a
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
0L 60 vp
BR'S NAM PHONE: CON' ACIOR'S NAME:
G. N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO: OSS: `f� BI
W. a 4
CONTACT: O� �j BUILDING PERMIT INFO
�Oq." Q �. — f ❑ Consultant Fees Paid by Applicant(Initial) BL❑UG ELE❑Cr PLUMB MOOCH
f�J ` �v 4
LICENSED CONTRACTOR'S DFCLARA'1'ION QTY. ELECTRICPERMIT FEE W
I hereby informal 1 am licenced under Imnisimis of Chapter 9lcnmmencing JOB DESCRIPTION
MZZ with Section Division J ofthe Business and Profcssiom Cde•and my license is RESIDENTIAL:
W O p PERMIT ISSUANCE
F-� in full force and effect. ❑SFDWL ❑KITCHEN RIiMODEL
aUU License Class Lic.M APPLIANCES-RESIDENTIAL PIPE
yGi Date Contractor ❑ADDITION ❑PLUMBINGkE-
ARCHITECPS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
M7h PANE S
Z 1 understand my plan%shall he used as public records MODIFICATION
OZ=^Q UP1'0200AMPS ❑HIT PRIOR [_1 CHIMNEY REPAIR
11 Licensed Professional 201-I0110AMPS IMPROVEMENT
4a4 f OWNER-BUILDER DECLARATION OVER I"AMPS ❑BAT'H RL'MODEUREPAIR ❑DEMOLITION
C C 6 1 hereby affirm mat I am exempt from the Contractor's License law for the
x6x0iV following rc ..(Section7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
YJ 31LHQ which rcquves a Permit ID construct,alter,Improve,demolish.or repair any structure
to n
prino its issuance.also requires the applicant for.such Permit file asigned statement SPECIAL CIRCUIT/MISC.
Ny that he is licensed pursuant to the provisions of the Contractor's License Lew(Chapter9
0 (commencing with Section MR)of Division J ofthc Business and Professions Craft)or '1'1?MP.METER OR POLE INST. COMMERCIAL:
d y o c that he is exempt therefrom and the basis for the ulle,cd exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
uX1 li
Section 7031.5 by any uppli,ma for a peannil,abject,the applicant ma civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
y rot more than five hundred dollar(SSW).
I-.ZY IMPROVEMENTr �d - �
=Q ❑I,ouowner kfthe PmPenyormycntployreswith wages amcifwle contpemmion, SWIMMING POOL ELECTRIC lY4�f�
�p.� will dr lesions Code: he Coreearmes cndN trcawduc for ale(Sec.]an Business 0TH
tail—m end Professions CNB:Thc Coneacmrs License law does sol apply m on owner of OUTLL-fS-SWITCHES-FIXTURES
6 3 propeny who builds or improves thereon,and who docs such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL E"LECpR SQ FT
sale.If,however.the buildlagoriniprovement is sold within one year rfnnine'von,Ne SQ IOP FLQORARBA S/SQ.FL,
owncr-builder will have the burden of proving Thal he did not build or Improve lir pur-
e Tse of sale.). Y
01,as owner of the property,tan exclusively contracting with licensed comremors 10 TOTAL: MAR 18
construct the project(See 71114,Business and Pmfessinns CNmLi
CNet)The Ckacmrs - T99g
c se law dots not apply to an owner of property who builds or impmves thereon.and QTY. PLUMBING PERMIT FEE
whocolnracts forsuchprujects with acontmcmr(s)Iiccmel pursuanttothe Comm,mev CII/ lir VV
License law. PERMITISSUANCE A '��171 IIY(J
l am exempt under Sec. .B&P C for his mason
Owner Data
AM ER-DRAIN Is VENT-WATER(EAI VALUATION
WORKERS COMPENSATION DECLARATION BACK PLOW PROI'[CT'.DEVICE
1 heady amrm under penally of perjury one of the following d iukxr`iomu:
❑Ihave and will for by Section 37W of me Labor Code.for
are Workersce of me DRAINS-FLOOR.ROOF'.AREA.COND. STORIES TYPE CONSTRUCTION
smirk•as provided for mi Section J]UD of Ne tabor CNB,for me performance of the
work for which this Petah is issued. fTX'NRI3-PER TRAP
1 have and will maintain Worker's Compensation stock
ia,as required by Section
1]1X)af the Calan CN<,for IIIc peRo......f the work fur which this permit is ixmed. GAS-I'A.SYSTEM-I INC.4OUTLETS y UCC.GROUP APN
y Workers Compensation Insurance sorrier and Policy mmnher arc:
Cumcr, Policy Na: GAS-EA.SYSTEM-OVER 4(EA)
CEM'INCA'pIl OF EXEMPTION MOM WORKERS' GRIiASF/INDUSTRL WASTE INI'F.RCEProR
COMPENSATION INSURANCE BUILDING DIVISION FEES
Mus section need not be completed if me Permit is for one hundred dollars W) GREASETRAP
m lest)(ThPLANCH[CK FEE
I eciify that inthe perfnmanceofthe work for which this permit is issued.titan SEWER-SANITARY-STORM EA.200 FT.
not emplDany a9q mhccrme whjecno the Workers'Cnmpen- ENERGY FEE
ration La WATER HEATER WNIiNT/ELECfR
plicar, �1 GRADING FEE
ICE FO APPLICAMI':ll;after mokin"I'is C"fibieme of Exemption.you xhruld WAI ER SYSTEM?REAT'ING
a > become subject m the Worker'.e Compensation provisions of the Labor CNB,you rmstSOIIS FEE
forthwith comply with such provisions or this permit shall he deemed revoked WATER SERVICE
0
U0 CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMR. SQ,Er. PAID Date Receipt#
U� khereby
whaffimithat sptir ti isaconswninn lending agency for the performance of
F' Le work for which this permit is issue)(Sec.JfN],Civ.C.)
O U Lenders Name TOTAL'
IsnJcr's Address
0L 1 candy that I have read this application and etatc that the above inlirmation is BUILDING FEE
111"^"II y cored.I agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL PERMIT FEE
U z building conewetion,and hereby authrnrc representatives of this city it)enter upon she
SEISMIC IEE
Move-mentioned protan,for inxpccdnm furpous. PERMIT ISSUANCE
(We)ogtee m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities.judgmelns,costs and expenses which my in any w.ay accrue against said City ALTER OR ADD TO MECH.
PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL FEE
S( INCE R-\RCJ EQU.AT )NS.
AIIt HANDLING UNIT LOVER 10.050 CUM) CONSTRUCTION TAX
/ Signama DfApplicam/Concrctor Dmc EXIIAUSTHOOD(WNUCD HOUSING MITIGATION LLE
HAP.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle h mous material HEATING UNIT(TO 100,000 BTU)
as defined by the Capinino Municipal Code,Chapter 9.12,and the Health and Safely ti L rk
Code,Section 25532(0)] HEATING UNIT(OVER 100.000 BTU)
Ej Yes ONO
VENTILATION PAN(SINGLE RESID) . PAID
Dam Raccipl#
Will the applicant i furore building by the B use equipment or devices which
I hazardous air contaminants as define)by the Buy Arca Air Quality Management 001L1iR-COMP(JHI'OR Ilq,lgq PTU)
Doricl? BOILER-COMP(OVER 100.000 BTU)
❑Yin ON.
1
I have rewl the hamdoe,materials ¢under Chapter 6,95 of Ne Cali- AIR CONDITIONER ISSUANCE DATE
re.255
htmia Health&Safety Code,Sections 25505.25531 and 25514.1 understand that if the NEW RESIDENTIAL M[Cfi. SO.FT.
building
e,wremnot, Eiclyhaveatenam,IM1..itixmy oto.ol.CIritytonollfylhepancy. V .
ntthc rcyuircmcnta which nmst he tan prior m isuuncc nl a Ccnilicam nl Occupancy.
Owner or authonred agent Data TOTAL: ISSUED BY:
OFFICE
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
• �.- --
LOT NO,
OWNER
��-
PERMIT ISSUED DATE "ELECTRICAL DATE INSP.'
ui i.n�
ctrical
Plumbing Power Pole
mechanicalr un
Te—Trp as lec u firing
Solar Walls
Fire Sprinkler Ceiling
i fixtures nt xt
otors;
Misc. GroundPer
ower
Other
FINAL INSPECTIONS DATE INSP, Not Approved
Gas v= -a"srElectric
c4
..-fir.:.
Plumbing PLUMBING DATE INSP.
Mechanical J- y-
o ar Backflow
• ori r un
ra in Ondert.loor
anning Partialug
ire e t. o7�u h�'lete
He a t. oar u
icling w(. -:tw /o. Water *4 Insulation
Other Main Dra3n
oBrain
MF
Other
BUILDING DATE �,p of rove
Pad Certification
Foundation ELECTRICAL DATE INSP.
Pre-Gunite
Slab-Membrane Underfloor S.M.
Bond am Ducts & Insulation 6 -�
indererfloor Girders Fire Ders vp
Floor tee Fire laceace
ie owns — reas�e uct � Hoo
ac a our t
Re
ehmrcn Condensate a
in
a an ui ent
Anchorage
Frame Flues r
Lath t er
a- oar nt xt.
of prove
' ewal s
Other
of proved
-vi 5w PC&
'S 2f �vu`w2- -We>Rbo�SGa-4-'�aZr9 Z�e.t
BUILDING
� L s,
ELECIMCAL
PLUNKING
e MECHANICAL
TIISCELLANEOUS