S 0681 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUt LDING-ELEC I RICA PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT
MECHANICAL S 0681
BUILDING IB(IJ F:CT IIIEN'1'IN'ICATION
SANITARY NO. APPLICN'IONSUBMIPIAL DAH.
BUILDING ADDRESS: y
OWNER'S M1LE: ' P ONE: ONTRACTOR:S NAME LIC NOI/Vsd L IL [/��CONI/Roo�l.#
RCHITI:CT/EN GITR: v. \ ;.� ADDRE.: .yam t�yD / �I TS /
S G (j+L V I
C�]uTACT. PHONE: e O .� � BUILUWG PIiRh119'INFO
-�% P-(p•- J '-MJ el/17-77O Z I 'o 'u and Fees Patd Y PPlicanl(Initial) BLDG ELECT PLumn MUCH
/LIICCENNSSEID•�CONHRACTOR'S DEECLARAT t, QTY CLIiCPRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm,list I am licensed under provisions of Chapter (comm c g
OUZO with Section Division J ofihe Business and podcssio.,c Code.and my Imam.is RESIDENTIAL
OSFD _ ❑KI'I'CIIIiN RI?MQDEI.
WWoF in full force and dl'.t PIiRMIf ISSUANCIi
y<L Dorene Class mLick APPLIANCES-RESIDENTIAL ❑AUDITION [_1 PLUMBING,RE-1'11'17
Cnraalor CMUI.TI-UNI C
"f SIRUCTURAI.
ARCIII'I'ECPS DECLARATION PANELS MODIFICATION
Ozy� IwdcrdanJ my plane shall he u.,J ax Public records UPTO200AMPS
9'LRIVV CCHIMNEYREPOL
{qy . PROM?MI?N'1' SWIMMING POOLS
�0�6 hmcnccd hetsl'cxsinnd 201-IIXXIAMPS �'
Ca4�
� OWNIik"BIIIhUIiH DECLARATION OVIiR Iran AMPS I]BATH REM(IDI31/Rlil'NR ❑OIiM01.1'IION
y by d'firm Ilial 1 um cxnnpt hunt Ihc Com achn's h cenzc Law Por'he 00111H
X O G V fiIDuwing oc,our(Sceriun 911)15,11 ec,s and Poli nWions Code:An,city tar caunly SIGNS hij-Cl'RICAL
W3 LL H which requires a permit m ennxnu t.alm, uprove,demolish,or repair airy urocmm
q prasto its':. 'I donall,plicam,l hq II fl -g d:Pmnnnt SPECIAL CIRCUI I IMISC.
that be licensed Purolator t the provisionsuldne Contractor's[Jecew,L (Chapter to R I
�fyp0
(commervang withSect 7000)ofD 1 orth HossimessandP les ,Cism)or T17MR MCI EX OR POIX INST.
e C that h eseropl,hercf tat and the basic for the alleged exemption,Any nlmion of
aa�X [I NF BLDG/AUDI710N ❑OEh10 )N
N Section 7031.5 by any applicant for a peninsubjecrs applicant
_� the applicano a civil Penally of POWER DEVICES ENANT )SERVICE
not more than five hundred dollars H5001. PROMiMIiNT
❑ 1.as owner of the propcty,or my employees with wages as theircola compensation, SWIMM1IING MH)LIiLE [IOTHER
F. will do the work.and thouuaure is not intended oroRcred for sale Sac.?n .Business OUI9.1T5-SWI"TCHI? URES
and Professions Cut The Contncmr's License Law dreot,napply to an owner of
prni who build,m improves tbeo-m,and who docs such work himsdf.r through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENT L EL. f SQ Ff.
go prove SQ.FT.I'100R ANIS\ 5/SQ.FT.
owns Lhoweventheve building or mens ithat be idnot,neycerrimprovettopum-
weeof salderwill have the burden ul proving that he did not buil)or improve for par- V O Z
Ej 1 of salt.). �OTAL:
❑I.n sever of the property.vat esiness and
.morning wish licensed convadnr,m
cause a the project apply
LO so Badness and Preity heions ds or i The Cnntmeon.Li- FEE
whoclawdoesnotch mabaao with
a cu(pmpeny whosedpmimpto are thereon.laid QTY. PLUMBING PERMIT
who commas for such projttn with o cnnwetnrt,)licensed Pursuant m the Commewr's
License law. PIiRMH ISSUANCE
1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VIIN' ATI: ) VALUA'I'I`1N
weter v Dam {'VIV^A
WU KHR'S COMPENSATION DECLARATION BACK I:LOW PR(YfIfCI'.Dli C' /
I hereby affirm under penally of perjury one of the following decimations: y��1
CI have and will maintain aCerlificateaf Consent loself-insure for Workers C.mis:n- DRAINS-FLOOR,ROORAREA. Y)R ti9 '1')'fitI-ONSIRUCTION
',limn,as purvided for by Section 3900ill Ihc huMa Cala,[.r the peH'armtn<c of the �/ !O
work lin which this permit is issued, FIX'I URES-I'ER 1'RAI'
I have send will ,,.I uin WnvJet,Cumgcncal I law....c,as required by Section
17(X1 of lbe Labor Cu le.ho dhe perionu cut Jim work for is this permit is issunl. OAS-1?A.SYS'I'1?M IINC.40U'1'1.1?TS KV<;[I)t� AIN
etc Il
My Wrrk'(,'�/'t ' s PICA a wrri.r no Pnliey,mrmhcr(� '
Carrier:Wn,k � all I'no Nn:�( �j OAS-I?A.SYS'1'-M-UVI?R 4(HA)
GIiR1'119CN'li OFIiX1iMPHON FRO W L tS' GREASPIRIDUS1 RL WANT 17 NTERCI?ITOR
COMPENSATION INSURANCE V f1 .t) C.I N19iliS
(Thisxecdonnce,not becnmplaed iflM Permh is fomnehundrWJdlac,($HN) GREASE TRAP PLANCHECK PER
or
as")
IcetifY the in the ry:dnmmncenfthe work for which this permit is issued,lshall SEWER-SANITARY-STORM PA.2IX)IT. ENERGY FEE
note .yany P.ts.n in any^�nraf.,Wllln becomewbjectm,hc Workers'Compen- fJ
z c Caws dCalifomia.y'Y - WATER HHATER WNENDELECTR GRADING PER
OTICHTO APPLICANT:If, making Compensation p Ceniliczm Cf Exemplar.y.a should WATER SYSTHM1VTREA'TWG SOILS PIiIi
? bcc,nc,bje0 m the Worker's n,Intisprovision,of the Libor Code,you must
forthwith comply with such pmvisinm orchis ptnnit shall Mdttmei¢vokeJ. WATER SIiRVICH
qPAID
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PUNCH. SQ,FT. Date Receipt or
V z Ihereby a(fmr,hattman
hem is a construction lending agency frrtbe prefoce of
Us the work fill whi,h,hi,,pmit eris issued(Som 7(19).Civ.C.) TOTAL
U Lendtr,Nam. TOTAL:
} D.1 lenders AJdtass BUILDING PER �•
G I verify that I have mai this applieminn and ,are that the above information is
itt. y contract l agree,.comply with all city and county ordinance,and state laws existing u' QTY. MECHANICAL PERMIT FEE SHISMIC PER
V Z building construction.and hereby aahorim representatives of this city m on enter upthe
'� dmvomcmir ad pmpeny far inspection purpxxs. PERMIT ISSUANCE ELECTRICFEE
(We)agree In save,indemnify and keep haul...the City of Cupertino against
liabil'nicc,judgmems,costsund capen.ecc which may in any way acemea,mod,id City ALTER OR ADD1'0 MFCII. PLUMBING 197E
in cnn.ce9 em,of the granting.!this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POUR AIR HANDLING UNI'I'(TO 10.000 CFM) MECHANICAL.Hili
SOURCE REGULATIONS.
AIN HANDLING UNI'I'(OVER 10,I0NI CPM) CONS'I'kUCf[ON']AS
ignamrc of pPliMnt/Cantr.etnr Dale IiXHAUS'I'HO(IU(WNUCI') IIOUSING MI'IIGA'IION I:I?I?
HAZARDOUS MATP?RIAI S DISCLOSURE
Will the appll<edo,from huildinyttceupemetor,.,handle bavatJon,material HENFINGUNI'I'fl'OHNAX)RTU)
as defined by Ne Cupunlnn Municipal Cuda.Chapter 9.12,and the Health and Safety HEAHNG UNIT(OVER 100.000 R'IT)
CMc.Section 25532(a)"
[3 Yes f7No V17NI H.ATION PAN(SINGLE RESID) LAID
rte kuuipl p
Will the applicant,,future building occupant use equipment Cr devices which BOILER-COMPOHPOR IEB.INMIGID
it limardous air.nnwminams ax defined by the Bay Amu Air Quality Management 'I OPAL
District? BOILER-COMP(OVER 100.008 BTU)
❑Yee 0 N
1 have maul tht hioamou,materials pa uimments under Chapter 6.95 of the Cali-
AIR CONDIT IONER ISSUANCE DATE
forma Health&Safety Code Seai.ns 25505.25573 ani 25531.1 understand,bat if am NEW RESIDENTIAL MECIL
huildingdotev hat<urrtmly havcamnanlled itis fiyms "Tyr ail the«.pant
e rryuiremenu w t mat M met prior u - ante of a Cenif<ate of Occupancy.
t TOTAL: ISSUIiD BY:
)wncr. millb,cdagen, Dam
OFFICE