S 3054 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PH ITNo
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIIANCAU 3054
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICAt'ION SUBMITTAL DATE
Zoo
OWNER'S AME: PHONE: CONI ACTOR'S NAME LIC NO:
Ammalbi 11270-
O& NIC CONTROL#
IIT;CT/EN (NEER: L
IT ADDRIAS: ❑
CONTACT: NONE: BUILDING PERMIT INFO
TO
°I" `/' '0 ' ❑ ConsWtant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
T/ ` ❑ �� ❑
IACHNS FD CONTRA TOR'S DF.CLARA'D ON QTY ELECTRIC PERMIT FEE
1 herehy arfirm that 1 am licensed ander provisions of chapter 9(emmmencbg JOB DESCRIPTION
M4iZ with Section of Division Sat the Business and I..fecsiona Code.vndmy license is
k 00 PERMIT ISSUANCE 3 RESIDENTIAL'
KWF in full farceand ellecl. !�. '1 ❑SFDWL ❑KITCHEN REMODEL
a>>>U>U License Cla" Lic.p C APPLIANCES-RESIDENTIAL ❑ADDff10N El PLUMBING RE-PIPE
E�41 Dale Conlrucmr
d
ARIIHfICPSDECL RA 1)N ❑MULTI-UNIT ❑STRUCTURAL
Z OmZ lundervand my plans shall be used as puhlic records PANELS MODIFICATION
OZ4q UP TO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
P a,I „"Iq Licensed Professional 2(11-10(I(IAMPS IMPROVEMENT SWIMMING POOLS
QS' •.I OWNER-BUILDER
an he CoATION OVER Gran AMPS ❑BATH REMODEL/REPAIR [I DEMOLITION
Gst I hereby affirm lltm 1 tun exempt from the Cnmmcmrr e,Anse Law for the
�f W U following reason(Section]1H15, t.li er,and ,.,demand hale:Any city s county SIGNS ELECTRICAL El OTHER
W a W h which mquimr o permit In wnsaud,alta,improve,tlemolisM1,or repair any swemre
F 19oV�� prior to its Issuance,aha requires lheapplicaut for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
y but he is licensed put theprovtstonsoDhe Contractors License Law(Chapter 9 n
W C)a odmmeneingwith5 India)o eBustnessanA Profcsimbx Codger TEMP.METER OR POLE INST COMMERCIAL: iior Vo Ej
6� c W that be Is exempt Ih f u and the 's or the all ,Any violation of ❑NEW BLDG/ADDITION ❑DEMOIJ TION
'^II• Section]031.5 by al p t icvm C 'abcod, It ,he to'civil peralty of POWER DEVICES
..y ❑TENANT [I FOOD SERVICE
not more 11 five dollars(5500). IMPROVEMENT
E.
Las owner of lh � o,QQ'�'�my x'pemipt%loye es with wag es as Gird le wmpen.afon. SWIMMING POOL ELECTRIC
will de,the work,an a so-ucjuyiEln ity'c t Bored far t�e c.9014,Business ❑OTHER
we aadP r C : Ih C'''�TT(/ eAT '�I11 yt mer of OUTLETS-SWITCHES_FIXTURES Z
property h b '1 p :Ih d h I If Ibrodgh
his ply provided that: h p I ra d 1 n d for NLW RESIDENTIAL ELECCR SQ PT.
sale If.M1 B improvement Id )h' pl r the SQ.Ff.PLOO$AREA $ISQ,FT.
b'Id I fp gthat hA'I Ib'I p f pr
Foe f.al )
❑ 1 f act P . ty excursively - 'eased l t L to 5mg Ir T7
na I the prejectapply
7844 Business and Profession,Cal improves C smre4o ,Li
c does chplr man itha ofpnTeny wemseddrorthereon,and QTY. PLUMBING PERMIT PEE
who contracts lot such project with a wmreelor(s)licensed pursuom to the Cenmaomr'r
License Law. PERMIT ISSUANCE
❑ I an,extract under Sec. ,B&P C ror this.,..
ALTER-DRAIN&VENT-WATER(Irp VAL
Owner Date
WORKER'SCOMPENSATION DECLARATION PACK FLOW PROTECT DEVICE (� 0 ro
1 hereby alErm under pmmlty of perjury nuc of the followingic k,afions:
4101 Inseam]pro will mein ml nation 37M of the LatwCode,surae Worker'sce of the DRAINS-FLOOR,ROOP,AREA,GOND. STORIES TYPE CONS'I'kUCTION
Mira, r provided rnr by Section 3]00 of the Lnhor Cale,for the performance of the ,^
work hih this permit is issued. PI%TUkES-PGR TRAP I ll
[-] 1 have
and vnd will maintain Worker's Gate of the
w lk for a e, li required by Sceli
My ortheLahm Ctde,for.the
surancrmame,and Policy
for two permit isirsuod. GAS-EA.SYS'I'HM-1 INC 40VCLGTS OCC.GROUP AIN
My Workers Compensntinn Insurance carrier and Policy number are:
Carrier Policy Nn: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE.INTERCEPTOR BUILDING DIVISION FEES
(This section need mol be completed d the permit is Intend hundred dollars($100)
or lc,,,) GREASE TRAP PLANC111?CK PER
Icenl(y halo the perfommnce nflheworkfnr which 0is permit is issued.)shall SBWHR-SANITARY-STORM EA.200 FT.
not employ any person in any mammy sn m m become abj ict a�be W kers s en- ENERGY PEG
p C) same Laws ofCWllnny.Dale — WATER HEATER WNENT/ELECTR
z Applicata GRADING FEE nl
wy y NOTICE EDA T:If,after m ,this Cendicrac of Exempmon,you should WATER SYSTEM/TREATING
ahewme aubjec to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
{ZI forthwith comply with such provisions orthis Permit shall be deemed revoked. WATER SERVICE
yz CONSt'RUCTION LENDING AGENCY NEW RESIDENTIAL TIME. SQ,FT. PAID
U 0 If which
thi thmlbere irammawdi3097.Cin,agency(nrthe Perhnmamce of I Dm Receipt#
U the for which this tis issued(Sec.309].Civ.CJ # I II
� Fermi I I
Lender's Name TOTAL:
WLender's Address # TOTA f -
1 certify deet 1 have read els appllmtlon and rare that It.above information it BUILDIN
aVi comm".1 agree to comply all all ctry end county oNlmtvcc andswte laws relating to QTY. METH NICAI.PERMIT FEE
L) Z building umstruction,and hereby authorize representatives oflhiscity toctaeruponthe SEISMIC FEE ZS 0
above-mentioned property rnr inspection purpose,v PF,RMIT ISSUANCE.
(We)agree lesave,indemnify and keep harmless the City of Cupertino agalnet ELECTRIC FP.
Iinhifines,judgments,costs and expenses which may irony way accmcagainst said City FLYER OR ADD TO MECH.asequence ofthe granting of this Trion, ALTER (
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CTO 10,000 CPM) MECHANICAL FE
SOURCIiR' AT NS.
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Signalurco ph a mm7nr e EXHAUST HOOD(W/DUCE)
HAZARDO S MATERIALS DISCLOSURE HOUSING MITIGATION PHH
Will the applicant or table building occupant store or handle hazardous material HEATING UNIT(TO pal BTU)
as dctimed by the Cupmtinn Municipal Code,Chapter 9.12,and We I Iedth dad Safcry
Code,Seelion 25532(x)? HEATING UNIT(OVER 100.000 B'I'U)
El Yet, km- VENT]LATION FAN(SINGLE RESID) PAID
� Date Receipt If
Will the applicant or future building occupant use ea At,Qu or devices which BOILER OHP OR 100,000 BTU)
400 nit District,
us air wnulminonta its AefineA by the Boy Area Air Quality Management TOTAL
D'suia?
❑Ye- Po BOILER-COME(OVER 11%1,(NX)B'NJ
1 have read the Inventors materials requirements under Chapter 695 of 0e Call- AIR CONDITIONER ISSUANCE DATE
fornix Iltalth&Safety Code,Sermons 25505,25533 and 25534.1 mndersmnd than if the NEW RESIDENTIAL MECH. SQ.FT. f9
building does not currently have a tenant po
that it is my resnsbllity to rally the occupant ( o^ 2 7— O
al the requirements which must M mel poet to issuance or a Cenifieate aroccuparty. 00
Dialect baml...ised.,,at Dole TOTAL: ISSUED BY: 7-7—,
OFFICE
O
C
E cam ' Q
C P P O
'J O
en
RM
a m
ISO
\ _� m _ •? C
�w _Z L
m z a
-- i •� i � �2,ctow wLL
LL � a �+
\ / _ g 6 55
w
_ ,„ C7 rz
s I Y� �•' i .u`pC I �� � N�'��
aO
2ND
® I • a I �� � �Ns� � in � 2
, . o
� WD
...................
ze «« ww =
_„
w
Darn-,arc
E IS
�M
un tat
Zbr I
>N 114-
01'
1 o' O i
ra� "
0 co
woo was
rx u rat x v pg—Z
,- o4.4a
rU,o
a
W z�
0
AL
06LL lAL LA
�\ ----------- ---------
O 0
ui
p coLUVIs o
09D c CD V
rh
r A � L CA Q> C 0
I
e
F—
F-
8
I a ~ x
M. I a "— � m
Got
OL,LL
I aao iL o-A
mm;; CO
I c �i � 0
�m ' \\\ 6 t m LnCNS CO
F 8 UC-4 04
ewL Q, oerz U M N aD N
o
I cm
`D m o
% \� ? �UNu. � U
-------------- ------- -- 10
z
BAL ezL 1 I 2 F-
r AL _ Cc
Lb Oz L'S
(j ��
i L O U
• C3w O cL
JLI
r z �
n