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CITY OF CUPERTINO BUILDING - ELEcrRICAL
BUILDING DIVISION APPLICATION/PERMIT 1•INGPROJECT MECHANICAL
BUILDING PROJECT IDENTIFICATION
rltRntrr No.
BU
DINGADDHP_ S
Or /S r - �` �� ! O 14
No.
=APPLiCAI
fIONF'
�-ARCIfITECr/I:NGINEIiR:
OTN®RAR'ti NN M'' hIC >:�
LIC NO:
, 11� y•�a4
Ill`L✓� 'wM /
CONTACP: PHONE:
��� (, 1� ..-/ fj(/jQA
(l(fOL
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PER INFO
HL❑DG EIO ' eLun ntO I
LICENSED CON'TRACTOR'S DECLARATION
1 herchy pffino thw ImoIccn ed under provjxm, of Chaptef 9 (camransientg
with Section7aXgnl Division} of the Huvine, and Pm@esl mJ myliccosc is
in full force and ��PiccL
C'';� - Lick
QTY ELECTRIC PERMIT FEE
—JOB DESCRIPTION
RESIDENTIAL:
CSI°OWI, ❑KITCHEN REMODELhicetn''lu.v
❑ADDITION -1 PLUMBING RI? -('11'1?
1'EHMII' ISSUANCE
AI'I'I.IANCES-RESIDF;NTIAL
Dntc�X.-.Zi�.--�-- Cnnvucm
CodulT'hHNI'1' ]STRUCTUkAI.
(BOAM/���qy/��,� MODIFICATION
I'ROVIiMIiN'I' CSWIMMING POOLS
""app Pk0VI: CSWIMMING POOL
C BATH RFMODF,IJREPAIR ]DEMOLITION
❑ rnTIl
Al
A
A CHI TEC'("S UECLA I'I
uole,latd myplansshill beusednspublic remrJx
1'ANIiIS
UI1.10N)AMPS
hicenxJ Pndc.vsion;J
OWNIER-BUILDER DECLARATION
hereby . Seim that I am eBemnl from the Control-', Licence law ... the
fallowing Mason. ld an thatt I L5, Business and he Conon Code: Any city w amnlY
2HIdtNN)AMpS
OVER NX)AMPS
SIGNS E1.HC1'RIGt.
Which requor%a permit In consort. ober, improve. demolish, or repair any atmeorc
prior to its i .... nei... requires the appl icanl for such N.iuo fileasigncdstmcment
that he is Iieensad pursuant o the provision, or the Contractor's License Law (Chapter 9
(commencing with SanionHXXB of Division 3 of the Businay. and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 71131.5 by onyapplaor,for. permit xubjOO,, the applicant a civil penahy of
l ;-C�yP
SPECIAL CIRCU I Did ISC.
TEMR METER OR POLE INST.
COMMERCIAL:
EW BLDG/ADDITION C DEMOLITION
TENANT ❑ FOOD SERVICE
POWER DEVICES
t more than five hundred dollars (SSBH).
n1, as owner of the property, or my employees with wagesustheirsale crmpenvtinn.
will do the work, and the swetur, is not intended or offered for sale (SeeJUW. Business
and Profession, Code The Comtnclnls License Law does not apply m an owner of
PKOVEMEN F
❑OTHER I
/
OAS
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR SQ FL
pmpvny who builds or mar mve. flona n, o nd who dues such Work hiraw f or through
hiss own employees, provided that such improvements am not intended or offered for
,de. If. howmxr, the building or improvement is sold within one yetu completion, the
%Q, FE FLOOR AREA &ISQ. F1'.
owner builder will have the burden of proving that he did not build or improve far par-
RECEI D
SEP 2 4199
"o,ofn
❑ L a.. r of me prolrcdy ran e,ew.avely anmmming W;tn lieenaed aomranon n,
censtrun the project (Sec. VWq, Busincs, and Pn+fesdoas Cum:) This Contractor's lis
c se Law due% nolapply to an owner of propeny who bolds or improver thereon. and
who contracts thr such pn+jccts w hh a aammctms)licensed pursuant the Connawor.
QTY. PLUMBING PERMIT E
License law.
I an, canna under See. . B & P C for this reason
FERMI I' ISSUANCE
AM ER -DRAIN A: VHN'T-WATER(EA)
BY: VALUATION
BY : -
Own" Dam
RACK FLOW PROI UCT. DEVICE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following det laral onr,
I have and will maintain aCertllicmnof Convunlmself-Insure far W..kaas Cotnpan-
cation, as provided for by Section 3700of the Lahr Code , for the peffmmancr of the
work for which his named i,,,sued.
I] I have and will nmimuin Workers Compensation Insurance, as required by Section
3700af the LOW, CMe for the performance of the work for which this permit is ;scans.
DRAINS- FLOOR. ROOF, AREA, CONO
STORIES
TYPE CONS'I1R,CT10N
PI%'PURLS -PER TRAP
GAS - PA. SYSTEM -I INC. Y OUTLETS
OCG GROUP
AVN
GAS -13A.SY5'fF.M-OVER4(EA)
Co Workers Cy�lpn hyo huuryn�r�[��'^,,9�G� wy No,y numb^ awl
Cartier: h }♦_ns/ IIIJ/1'olicy No.: ✓1 kms"
CERTIFICAITO" EXEMPTION FROM WO ER,
COMPENSATION INSURANCE
GRF.ASEIINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PEES
GREASE TRAP
PI.ANCBECK PHI;
(Haissectionnednnlbecumpleted ifthepemtiti.foronehuW¢ dolls (SIM)
or less)
I ccnify that in the perfonname f,he work for which this permit is issued. l shall
not employ any Person in any manner w as to become subject to the Worker; Compen-
vnnnLawsofCalifnmia.Data
SEWER - SANITARY - STORM EA. 200 It
ENERGY HE
GRADING FEE
WATER ((RATER W/OENT/ELECfH
Applicant
j NoTicr;TO APPLICANT. it. are, making Thi. Ccnificate of Exemption. you should
s become sahjwt to the Workers Compensation provisoes of the Labor CMe, you must
a ronnwith comply with such provisions or this permit shall be deemed revoked.
WIN] 17K SYS' I'EM/BEATING
SOILS FBI.:
WATER SERVICE
NEW RESIDENTIAL PLACE, SQ. P.
CONSTRUCTION LENDING AGENCY
g gamy per
I Larchy uflinn that lhore inucnrotmninn lcndin•a for the formonce of
the work for whiaL (Liv pcnnil is innunl ($ac. J1197, Civ. C 7
('AID
Date
TOTAL:
Lender's Name
Lenders Address
1 curl it'y that I have tend this np,I,cmioa and slate that the above iaft ,rmahnn is
trccn l agree tit comply with all city and county oninances and state laws retailing to
! building conanuction, and Lerchyamhonva representatives nfthis city to enter upon the
abovc-owntioned pmpeny for inspection putpnves
(We) agree to st , rade adf, and keep harmless the City of Cu,mm, against
liabilities.jud tWe pemay many way accrue againstsaid City
onseyu Genf cgrum +ga thivpe It.
N AN LL COMPLY WITH ALL NON -POINT
'IDTAI to
Ii1111.DING 11-H
QTY. MECHANICAL PERMIT FEE
SEISMIC IPI?
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
ELECTRIC HE
PLUMBING PER.
AIRHANDLING UNIT(TO IR00rCFMI
MECHANICAL FEE
SOUR iREGUL TIONS,
,Lf(flI7
AIR HANDLING UNIT (OVER In.t](MICFM)
CONSTRUCTION TAX
Signature of Applicant/Commctnr Dare
HAY.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle ha>arJous nmmrial
as defined by the Canadian Municipal Cone. Chapter 9.12, and the Health and Safety
Coda, Senion 255320)7
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO IBB." BTI)
HEATING UNIT (OVER 1(00,7400 BTU)
VENTILATION FAN (SINGLE RESID)
C Yes No
PAID
Doc Reaiptk
Will the applicant nr future building necupnnt use equipment or device. which
emit strontium, air .,alumina defined by the Bay Area Air Quality Management
IIOIL ER -COMP (3HPOR 100,Dq BTU)
'I OT
It011.I3H-COMP(OVER I(X),(XX)BTU)
District!
7,
❑ Ye,
AIR CONDITIONER
ISSUANCE DATE,
J !
`L _I
ISSUED BY:
Ihuvc 1'.. Not tnmcriuls reyuircn¢nts under CLnderfi95olthc Cali-
li,miu flcul Snk CMe, 5 ctinm 2 . 1. 25533 and 255$1. wdcrstanJ fund the
In tit w linty Ln amna ,dr illy my resryosibilitytonatify 0ctncupmn
of me meta wnic int ton on coracedirm+'(xenh: c
Owner nr .,cutmhorieeJ ugc Daa
NEW HI?SIUISN'IIAI. MECII. SQ. FI'.
'I"TAI.: