S 1271 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY no
CITY OF CUPERTINO BU11.IlINC.-ELECTRICAL Ping1T NO.
BIJILDING DIVISION APPLICATION/PERMIT i'LIIMIIING.MECHANICAL 1271
BUILDING PROJECT IDEN'I'IFFcxrFON
RUILDINGADDRESS: SANITARY NO. APPLICAI RON SUBMITl'A.DATI:
D0 W OL6'6 IZp pec U7t C� • �
O IRp'S�N�A�MI'; PRUNE: (IN I RAC'T0R'S NA MI LIC
l.� �� 't t) I� 11 �� NIC CON'lltOl.p
��A C TEC'UENG NEER: LIC NO: DRE":
F1 7{ ❑
S:b Q
CON'IAC'B PHONE: BUILDING PERMIT INFO
❑ Connullanl Fees Paid by Applicant(Initial) BLDG F.ECIPLUMB MECD
i D-I �GLTPA'�l4 IJ�- �sv - ❑
LICENSED CON"IRACTOR;S DIT-L 'LUN PV. ELECTRIC PERMIT FEE
I hamhy ad inn Hnal 1 deet than ad under,.Toch......or Ci apler 9 Qmtimeteing Q JOE DF.SCRIP'PION
C
Z with Sorinn]fXXBof Divixinn3 u(�h�n,'inexwnd l'nt@ssionx CtWc'mdntyliacnseiv' RESIDENTIAL:
1'ERh11T ISSUANCE
mut ;n occhcforceClass
and eOm Q ❑SIUWL ❑KITCHEN RIiAl0llfiL
¢VV Liccnw Class •1 LiaX APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIS PIPE
HHottaDana CnownIor
a ❑MUUH-UNIT ❑S"IRUC'U RAL
ARCIII'I'IiC'I"S DECI.ARA'1'ION PANELS
ZOyZ 1understand my plan.shall be used as public recordsEM(IUIFICAfION
OZ—n UP T02(XI AMPS E]OR ❑CHIMNEY REPAIR
Fail Fjq Lccnmd Pcofe.xinnal 201-1010ANIPS IMillOVEMENT C3 SWIMMING POOLS
OWNER.BUILDER DECLARATION OVER IIXXIAMPS ❑BATA RI:MODEVREPMR ❑DEMOLITION
6' ¢ I hereby nflum that 1 amt exempt rrnnt file Cnmrvemr'v License Law ter ma
ax O 6 U odic wing reason.(Section 7031.5.Bmine..and Pmexxinn..CmJc:Any city mr ummy SIGNS ELECTRICAL ❑O'I'I IIiR
'L a,� which regnim,a Nt m omom e.veno improve:,docan ,m repair any mmemre
'La, which
prior m it.issuance.also requires the applicant for such permitm file a signed statement SPECIALCIRCUFUMISC.
N}— ihm he is licanseJpumunno to the phokionx of the Com—En',Licane Law(Chapter 9
IyT�¢E (eonunencin,with Sectio 070WBA Dlvkind Sol the Buxmexsand Profession,Cn 10h, 'I EMP.NIIH ER OR POLItIN. COMMERCIAL:
y 6 o C that he is exempt IhemGom and the basis for the alleged exemption.Any violmiora of ❑NEW BLDG/AUDITION ❑DIiMOLI'I'ION
W H Section 7031.5 by any applicant An a permit subjects the applicant to a civil penalty of PD WF.R DEVICES El TENANT ❑FOOD S17RVICE:
not more than five hundred dollars(E500C 4=1IMPROVEMENT
=Q ❑ I,as owner tit the progeny.or my employees with wages a,their sole compensation. SWIMh11NGPOOLELECIRK:
S�F, will Antic work.undflu—trumnrc is not nmndederofendfrxalu(Sec.)044,liuxincs, ❑OTIIIiR
u�13
and rrmla..imn.Code "a cmmmemr'x Licon.a Lew time.on alroly m au mwnor or DGTLEI:a-SWITCHES-Plx'rmelas
pmpcny who builds or improves thereon,and who does such work himself or through
his nwn employees.provided That such impmvemmm arc ma intended cr olTated for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however.the an ilding or improvement ix%old within one ycmof completion.the SQ.IT.FLC0R AREA VSQ.IT.
a a-1, Aar will h:nc the burden of pnw.ng that he fid not build or imprnva tar per- it
goIc).
((_x] so, er mf Its,pooped, it,examloctl loolowdng with Been,ed ormmt,nmla
construct the pmjem(Sec.7W4.Business and pmfeaiuns CWe:)Tne ComrxmT's LI-
cenwLaw does not apply Ivan owner of progeny who build%or improves thereon,and QFY. PLUMBING PERMIT FEE
whoa armeo for such pn Jcep with n un[me ToI x)licensed Pur urnI In,the ContramoV,
Liccnw La, PHRMIT ISSUANCE
O 1 ant exempt under Sec. .H A P C for this maven
ALTER-DRAIN&VENT-WATER IIIA) C V kVAI ION
Owner Dam ` �•
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
I' I hereby affirm tinder penalty of perjury one ur the follnwing Jeclaratioate
❑IhavcandwillnminminaCenilicmcof Cnn..cnitosw)f-insumfnr Workels Cnmq:n- DRAINS-BOOR.R00FAREA.00bi /- STORM ' '1'YPECONSTRUCI'ION
sation.as provided ftor by Section 3700 of roe Lmmr Code.for the pert nn of
look l which his R'orm,I,i.. J I IXTURFS PER TRAP L/
❑ I have and will ovintain Worker's C tpr„t'on Usumn,v,a,c,med by Section
3700olIle Lab...C.k,for the Thaiiormunecol the work for x Halt do,'annt.I,"-d GAS CASYSTI;M-I INC,4 OUT].III S UCC.GROUP AI'N
My Workerc Coil Visit nsunmcc camaL'PJ PoIi<y ry �$' ' fix
Carrie�U '1 1111 No.: GAS�Z GAS-HA.SYSTEM OVER 4(1.
CIiRTIIBCATE ORIiXEMPf10 ROM WORKERS' GREASI%INDUSTRI.WASTE INTERCEizI'Ok
COMPENSATION INSURANCE BUILDING DIVISION PERS
(It,smnionnced not lw complc¢J it The permit lsf ranctrnndad Jullm'x ISlfXll GREASE'I'RAI' -
nrlc,..l !ENERGY
FEE r1
I certify that in the performance of the work for which this permit is issued.I shall SEWER-SANITARY-STORM EA.2W IT.
not enmloy any person in any dodder co,m Mcome subjm m the Workar�Comped-Z ,mien Laws of Gdifomla.Ilam WATER I EATERWIVEN'rIELECIRZZO A,icmnF.N NCTILI 'TO APPLICANT II ft mk Stin C nt care f L mpl you should WATER SYSTEM)TREAI'ING he bj n the x k I:C pa,t p s of The Lal, CW',you must 7 fan %fit Ply with hp is or tin pe Ish II h, d ked. WATER SERVICE
Z mar the Ills(PION LI NDIN( ng gency NEW RhSIDhNTIAI,i'LM1IIf. SQ.PI1 I hereby aflirm that there i,uetxwdimn lcnJinF agency limine perlimnuncc of am keceiplM
!UL - the work for which thispermit is issued(Set.3011.Civ.C.) 'I OPAL:
C) LS1 V lender.Name L
Lindar's Address
>aI cenify that 1 have real this application and sithe that tine above ina.rmalton is BUILDING TEE
F y correct.l agree m comply wou all city andaonmymnfnonae,end elate mw,ening m QTY. MECHANICALPFRMIF FEE SEISMIC FEE
V Z building construction.and hereby authorize mprc,enmtives of this city to enter upon the
aMrve-mentioned property for inspection par ousts. PERMIT ISSUANCE ELECTRIC FEE
W)agreetc indemnity an keep b Ics'the City rCpsnino against /y
ha lil 'I Jb ntn, t mens N m anyway 'b'ldl x 'd City ALTCR()It AD[)TO MECII. �V PLUMBING FEE
in n"m nce mf the granting o'thls permit.
APPLICANT'UNDERSTNI)S A' WII OMPLY NI'1'll ALL NO .'OINT AIR HANDLING UNITOO 10,000CPM) MECIIANICAL
SOU 'GITAll
[moi AIR HANDLING UN IT(OVER IU.(XX)CFM) CONST RUCTION Signature dAppinvnCot.¢tor Done EXHA US'THO011(WIDUCT) HOUSING MITE
HAZARDOUS MATERIALS DISCLOSURE
Wllthcupplicama,more buildingnecu...l me trundle hezmdualsmmarial HEATING UNIT 100.00u BTU)
u,Jvlmod by the Cti,amno Mmtidpal ode,Chapter 9.12,and the Health and Safety
CoJc,Scotian 255321aIP HEATING UNIT(OVER Infulti)IS I M
I]Yn I VENTILATION FAN(SINGLE RESID) PAID Ua¢ RcmiplM
a Will the applicant or future building occupant me equipment or devices which BOILER-COMP(31111 OR RAIN f1 BTU)
mit h:va dnue air conte ninanu as Jetrned by The Buy Area Air Quality Mnwm
gce d 'TOTAL
Dord! 1101LHR-COMPBWEN I00JxXI If'I'U)
❑Ye.
I have teal the hmmNnus nwmriab requircncnL.under CTapterfi95 of the Cali- AIRCONIAHONER ISSUANCE DATE
forma Health k Safety Code.Sectio,25505.25533 and 25534.1 understand mal if the NEW RESITHINTHAL MUCH, SQ.FT.
adding Ju: notcurmndy have late that it le my taalxm.ihility to nodly the nccgvIon
lot'thc requirenno,ty which must ba me Prinnn marine.of a Cenifcam of Ocunpuncy.
Owner or uuthot agent Dale T( AT I ISSUED BY:
OFFICE