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CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION)TERMIT PLUMBING. MECHANICAL. •,
• BUILDING PROJECT IDENTIFICATION
PERMITNOrx2,0291
t
SO0Q0I
BUILDING ADDRESS:
3 ,arc sB �,Q y P�.ac�. C�PEJ�T.✓d CA
-"'
SANITARY NO.
APPLICA'I NSU ITIAI, UA'I'f
7 %L %�
O NE 'S NAME 7 Gf�lONE:
!,, K
CONTRACTOR'S NAME: \LIC NO:
NIC
❑
CONTROL6 �� //,.
.•�IV //
RC ".�/ENGINEEk: C - 1 _ 6O� O7�
/JJ /4'/d�IRL—
ADDRESS:
Co TACT: PHONE: -
-
.BUILDING PERMIT INFO
%1itRICi11 SZC2Yk' 7.30 - 72b5
O Consultant Fens Paid by Applicant (Initial)
BLD ELECT PLUMB MECH
ly/
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed muter provisions of Chapter (commencing
QTY. ELECTRIC PCRMiT FEE
_ _ _ _
JOB DESCRIPTION�
{^ O
PERMIT ISSUANCE, 1
with Soetion (0007o[Dlvision3 nl Nc Bosiress end Pmfesainns @de, and mylicensc is
in fall farcoffer(.
e and
RESIDENTIAL' ,
El ❑KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
Licence Class Lia#
Doe Contrast.,
El ADDITION El PLUMBING RE-PIPR
❑MULTLUNIT, ❑STRUCTURAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
ARCHITECTS DECLARATION
I umlervtand my plans shall be used w public records
II
PANELS
UPT0200AMPS I
Licensed Pmfc,sional
201-1000AMP5
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Cwhactw's�Liccwc Law I., the
fallowing reason. (Section 9031.5, Business and Professions Curb:Any airy or county
rub,
which requires o permit m eonsvun, nlmr, improve, demolish, or opal, my dhm
OVE -
❑RA'I'N REMOD L/ :PAIR ❑DEMOLITI N
OTHLR
SIGNS ELECTRICAL r
poor to its issuance, also requires the applicant for such Perini( to file a signed statement
SPECIAL CI ML .
,but he is licensed panoral m rba prrvimma of the Counselorls Licence Law (Chapter 9
(commencing with Section700(ral Division3 td Ec Businessnnd Pmfelime, Code) nr
[]ter he is exempt therefrom and the basis for the allegal exemption. Any violation of
TBMP.MBI'ER OR POLE IN'T
Wl in
COMMERCIAL,
❑NEW BLDG/ADDITION ❑DEMOLITION
Sermon 0091.5 blue, applicant fora permit sum,01(he applicem to n civil penalty of
POWER DEV
❑TENANT FOOD SERVICE
not more than five hundred dollars ($501).
I, vs owner of rhe properly, or my empinyces wish wuge.c as their sole uampensmion,
will do the work, and the structure Is not intended m uh red for side (Sec. 9044, Baeines,
and Professions Code: The Contractor's License Law does not apply to an owner of
IMPROVEMENT
C1 OTHER
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW -RESIDENTIAL ELECTR SQ FE
- '• '
property who builds or improves thereat, and who does each work himself nr through
his we employees, provided marine); improvement, are not intended or offered for
sale If, however, the biillding or improvement is sold within one yew ofmmpledon,the
SQ.FP.FLOGR AREA
$/SQ. Fr..
ownectimilder will lav the burden of proving that he did not build or' p e for put
f the property, am exems vel, contnmt ng with licensed c ur actors to
pro) ((Sec 9004 Business8fproprty who ons Code.)TT C vctard1.
atm.bu Law does
ad Lawdnea no(applY man owner rf properly who builds or improvesthereon, and
- o
QTY. 'PLUMBING PERMIT `a FEE
u
who contracts for such pmjechawith scontralmo) licensed pursuant to the Commmars
[JR01�A
�rMlr axemp, under Sea _ , B & P C Z d 4ase
,
-
- nn
TISSU r�0/
( ^
cones �/M - Date
WORKER'S C117FENSATION DECLARATION
- DRAIN& -W 1'�R TEA
- VALUATION
Lr�
KP
I hereby affirm under penalty .(perjury no of the fallowing dcclvmtinns,
0 I have and will maintain a Certificate or Comemmself-insam for Workers Cramer-
shorn, as provided far by Section 3900 of (be Labor Code, far the perfnm,amo rf the
work for which this permit is issued.
RAINS -FLOOR, RO A. N
STORIES
- '
'TYPE CONSTRUCTION
-
URES - PER TRAP Z
I fiave trod will maintain Wrrka2s Crmpensntinn Insurance, a, required by Section
3700 f,he Labor Code, for the performance or the work fnrwhich this permit isissvedZGRHASEdNDUSTRL
-
- J INC4OUTLETS
OCG GROUP
APN
My Worker's Compensation Insurance carrier and Policy number me.
Carrier: Policy No.:
-E .SYSTEM OVER 4(B
,
WASTE INTERCEPTORCOMPENSATION
. _ CERTIPICAI'E OF EXEMPTION FROM WORKERS'
INSURANCE
IT ) GDIVIMONFEES
rrlcss)
ASETRAP . -
PLANCHE �.�I
certify that in theperfomannce of the work for which (his permit is issued, Lv
employ any cenan in any manner yr as to become subject m the
TORMEA.200FT.not
ENERGYy'Iion
IIIiATER WIVENT/F.LF.CTR
CRAIIIN EE
LawmCm,inER
Applicant
NOTICE TO P LI T. If a nakin Caddrace of Exemption, you should
become subject m the Worker's Compensation provisiem of the Labor Cale, you mast
p' ,R. BATING
-
SOILS FE
forthwith comply wuhsuch provisions ofthid permit drop he demnedrevoked.
WATERSERVICE
CONSTRUCTION LENDING AGENCY
I hereby nffimuM1m(here is vconswe(ion lending agency fonheperfonnancepf
B1 LDING.�ELMB. SQ. Ff.
PAID
A Receip(p
thr work for which this permit is;dared (Sec. 3092, Civ. C.)
Lender'sName
-TOTAL'
I'A
Londe', Address
BUILDINA6V -
I certify that 1 have read this application :rad dente that the above mountain. is
a , -
'^
SEISMI F t V
buirect, l tagree ba comply with all city and county whiteners and state laws refiring in
lding coustruction,and laaby authorize representatives ofink airy to enter upon the
above-mentioned property for inspection purposes.
grce ve, indemnify and keep hvrmlece the City of Cupertino against
(We) nm sa
QTY, MECHANICAL PERMIT FEE.
= '- '
PERMITISSUANCE, F O
ELECT FEE 2-
PWMBIN'PEE
Iiabiliticcjudgmema mnv and expenvev which ntey in anyway acemea,mrs(said City
nnwyrance of the groin, of this permit
......
AITERORADDTOMECU.d
AIR HANDLING UNIT (TO I(I,OIIO CFM)o
MIiCIlAN1C PEE ( r Q
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT
SOURCE REGULATIONS,
'AIR HANDLING UNIT (OVER 1(1,000 CFM)
CONSTRUCTION TAX
-
Signature mAppliwnOConbacto, Data
EXHAUST HOOD(%/DULT)
- -
HOUSING MI'HGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Willtheundeantrrfuram building occupant smreor handle hazardous mwatild
f HEATING UNIT(to 100,000 BTU) 0
1
a, defined by the Copenine Maniei�I%Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(x)'! _ /
HEATING UNIT (OVER 100,000 BI
y,v
VENTILATION PAN (SINGLE RESID)
•
'j]Yes - Nr
Will the applicvnl or(town building occupant use equipment or devices which
mit bramoRus air contanrwda ed by the Bay Area Air Quality Mwagenrmat
District?
El Yes Nr -
PAID b \ —
Data -^u�Rcceipt#
BOILER -COMP (3HP OR 100,000 BTU)
'JlOTA: w
_
BOILER- COME (OVER 100,000 BTU)
AIR CONHA HONER,
1 h d the hazardous materials req ' t t: d Ch pr 6.95 rfth Cali-
ISSUA CE��C 4TH r
NEW RESIDENTIAI. MECH. SQ. FT.
fora a H lth & S ferry Cod "S i . 25505 25533 d 25534 I nde rand ti9V t ta�t it the
bullding i mefA" not currently havee Te LihIn" ta
aft hen iaaaanveara Ceml Brans.
mlryt/-9
A� r V •v'
ISSUED BY: 111111
TOTA
disiffer of h dNal��
OFFICE