S 1210APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. - ELECTRICAL,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. -MECHANICAL
IIUILDINC PIRIBEC'P IDEN'TIF'ICATION
PER�11'C NO. 210
BUILDINGADDRESS:
6'Al-
SANITARYNU.
APPLICA'TI ON SUBMI'MAI. IIAI'E
Z-�9$
OWNEWS NA PII(INE:
CONTRA ORK NAME'. LIC NO: �...�'
2O
N/C
ElA
CON'I'ROLk
CIHTEC'T/ENGI EER: LIC NO:
ADDRESS: U r
CONI'ACI': PHONE:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
❑ L� ❑ ❑
❑ Consultant Fees Paid by Applicant (Initial)
LICENSE[) CON'TRACTOR'S DECLARATION
I hereby ritual that I a. teemed under pawoinn, of Chapter (cm.nendng
with Scalon900j dDlvn,inn3ufihc Btsincxv and Prolaslunx Cads,, and myliccmdn
in full force ;mA dluc 30577
Liec "Class Lick
Dam Contmctnr 9 roes
---,':-_'�-��`
Qrpy ELECTRIC PERMIT FEE
JOB DESCRIPPION
RESIDENTIAL:
❑SFDW'i, ❑KITCHF,N REMODEL
❑ADDITION ❑PLUMBING 'REPIPE
❑ MUCfI-UNIT El STRUCTURAL
MODIFICATION
❑ PIT MPROVE ❑CHIMNEYREPAIR
OL
IMPROVEMENT ❑SWIMMING POOhS
woo
F1-
�UU
F w
IL
F ion 2.
OZ4�'
t:ai
RiRh11'T ISSUANCE; l �,/
APPLIANCES-RESIDEN'I'[A],
ARM411 I?Cf'$ DECLARA'T'ION
I understand illy plan, shall he used as public records
PANIiIS
UP TO 200 AMPS
Licee,ed Prnfo,ional
201-1O)t1AMP$
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OWNER -BUILDER DECLARATION
I hereby affirm that 1 mil exempt frim the Contractor's License Low far the
following a t. (ScI ion 9031,5. BusOas, and Pod .. s Colic: A., city or county
whi h tip is shouturn, aha p J obli p ny snrtlure
pro junk '1"- q theppl t1 hp' tt fl b da renom
thatl licensed n d : n Int Contractor L I' (ChtpterY
p pCOMMERCIAL
(connvningwo Scdon 91X10) ofDvsian 3 u1 the In .n dP Irvions Curd)or
that he ix carrai t therefor. and the basis foo the alleged eaemptiun. Any Inflation of
Section)031.5 by any applicantforapermit subjects me applicantto a civil ulry of
art anon, than five hundard dollar, ($50(p.
pnapc y, er my cnaplayma with wag. as iheinnlc compcnsndnn,
n, owner of the n
will Jnihcwork, anU the xlrvcwrcixnrt imcndW ur offcmJ fnr.ulc(Scc.9fW,Busincas
and Prof snail, Code: The Contractor's hlccmc Law does not apply to an owner of
property wlm huild, ur improves thereon, and who does such work himself rrthrnugh
his own rnaployccs, provided then such improvement. as, not intended or offered for
min.if, however, the building or unprovernicat is sold within oneyear of unnplctima,the
Ll OTHER ❑BA'TUREMODEL/REPAIR EJ DEMOLITION
AVER Ili0l1AMPS
SIGNS ELECTRICAL
SPECIA L C I RCUITIMISC.
TCMI'. METER OR POLE INST.
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT E] FOOD SERVICE:
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLE'T'S -SWITCHES -PIAT
NEW RESIDENTIAL Id-ECTR
SQ. IT. FLOOR AREA
$ISQ. Ff.
ownralludder will leave the burden of provc reving that he did not build or implir pur-
ir
TOTAL:
pow ,I erlp,),
[_]I, a rf the propertX a-le,"clY ton eraill with Iicurod contact to
construct the project (Sec. 7044, Baines. and Pndessea, Code) The Contractors G-
criseLaw d -ss nmapply to an owner of property who hula or Improves thereon, and
QTY. PLUMBING PERMIT FEE
who contract, fnoudt projects with a contractors) licensed pua,nant to the Corhkc cr'v
License Low.
PERMIT ISSUANCE
❑ I all, c..plunder Sri. ,B& P Cfnr this reason
c
ALTER - DRAIN & V 17N'I'- WATER (EA)
VALUATION
3 O Q
Dale
Dole
Owner
WORKERS COMPENSATION IIECLARA
HACK FLOW PR(YTECT. DEVICE
1 hereby affima under penalty of pc Jury ane of the I0111w1al dcelaratilar
I M1uvc trod will ma;muinn Cenifcurn of Cnrmcanmsell-iarvum our Worked Cumpcn-
sation, m provided tor by Section 3900 of the Labor Coda for the perform.. a the
work lin which this pu.nn is ismcJ_
DRAINS- FLOOR, ROOT', ARI?A. CONE
S'PORIES
TYPE CONST RUC'I ION
PIX'fURES-PER'TRAP
GAS - PA. SYSTEM -1 INC. 4 OU'TI.HIS
❑ 1 have and will opin i in Werke(, Compcnsmion Insurance, as required by Section
391%ief me Lah.yur CWo_ds,� tor which (his permit is issued
OCC GROUP
APN
GAS - EA. SYSTEM -OVER 4(EA)
yfyo3ryduvp�crufour�.anmofthework
C rWnkC z47 Fln/'Y/AlO Inlay No. /tOrrlf�3Z _
]PER'IFICATE
GREASPIINDUSTRL WASTE INTERCEPTOR
OF F,XEMI'I'[ON FROM WORKERS
COMPENSATION INSURANCE
BUILDING DIVISION FIVES
GREASERAP
PLANCHECK PER
1Thi,acetion aced no. ac...nplcmd i f tho permit;, intone hundred dollars (S UXb
nr Ica,_)
I cenilythot inthepadia0nanee ill the. orknme fnrwhich this puranit is i.ouad, lshall
fol employ any person in any tnanntt" a to tccsub3cct m the Workers' Chi
SEWER - SANITARY - STORM EA. 2(X1 IT
ENERGY FEE
WATER HEA'T'ER WIVEN'I'/ELECTR
GRADING FEE
SOILS PEE
Z
O 2
N
�i ti
PW Gi
W-
satinn lows orcalikarla. Date
Applicant
NOTICE "TO APPLICANT: .00 C 'dicatea- Eacoaption, you .should
become radial to the Worker's Co; p namirn pro "ion, of the Labor Code, you neon
hmhwith enmply with ,act, to....ionv orchis pcount Qjdl bedue 0nfit rcvokul.
CONSTRUCTION LENDING AGENCY
I lwvcby uffma mea mere i,u crnxwctinn loading agency for the performance of
Om well, for which thi, permit ds in,acd(Sec. 3099. Civ. C.)
Leander', Nac
WATER SYSTEM/TREATING
_
WATER SERVICE
PAID
]).,a R' 0ptp
NEW RESIDENTIAL PLMB. SO 1-1.
'IOTAI-
'TOTAL :
llU''
Qm
U
V Z
Lcnder's Addrevs
BUILDING PIA?
I caddy mI havc rend thi. npplicatirn and ratite then the uhrvc'mralkan n I.
m
Incl lagena w comply with all city and eountyordinnnre.and .mm to..rdoin, It,
haddingt n,uocGma. and hereby auderrize[eprescnmtiv- of,liNcity, to cndrupon the
shove -mentioned property fur ln.peit aPulpnw..
(we) agra lir save, inchill fy and keep horndas. the City of Cupcn'mo against
Ilubittiex.judgment,,cnu. and caper.. which ntay in any way accrue against said City
QTY. MECHANICAL PERMIT FEE
SEISMIC THM
PERMIT ISSUANCE
Aid ilk OR ADDU) MECH.
Ed -E7 IRICPEE
PLUMBING FEE
in nsegncncc critic grnating of tins pcnnit.
APPLICANT UNDERSTANDS AND WILI. COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT (TO 10,0001 CFM)
MECHANICAL FEF,
SOURCE REGULATIONS
AIR HANDLING UNIT ((1VER 10,000 CFM)
CONSTRUCTION TAX
Signammof ApplicaiiUCentractnr -Data
E%HAUS'I'HOOD (WIDUC'13
HOUSING MITIGA'11ON FEE
HAZARDOUS MAI ERIA1S DISCLOSURE
Will the upplievnt or beam bullJing occupwn smro nr handle hazaNuus nw¢dul
1IEATING UNIT (TO I W.O0O BTU)
a, defimal by the Cupertino Municipal Code, Chapter 9.12, and be Iicalar and Saldy
Code. Seniors 25532(a)9
F-11Yus ❑NnVHN'TILKDONFAN(SINGLFRESID)
HEATING UNIT (OVER 100 ,000 BTU)
PAID
Uwe Rue0p0 s
Will the applicant or future building nccupana use equipment ordr,ne, which
and hazardous air wrnmminants s defined by me Bay Arco Air QuaBty Marsd an rat
BOILER-COMP(3HPOR 100,001 BTU)
I'AI
BOILER - COMP (OVER IOI(HOBTU)
District?
Yu,; No
AIR CONDITIONER
r 5"YSSDATF:
aY/fomiaHcahh&Safety
I have rend alae hAF,,,.quir ncnts nndcr Chup¢r 695 ofme Cnll"
3' 125594.1understandThatifthe
NEW RESII)FN1IAI,MECH. SQ. FT
buildingdoe tot,li n
efma.griremertwhiofa ifi,old ofGeru tmey.
lin.'
ISSUEDBY: ✓
TOTAL.