B 0167 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDING-ELECTRICAL PLR?90.�0167
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-51ECHAP CAI, x7l//
IIUILUING PROJECT IDF-MrTCAT10N
SANITARY NO. M'PLICSTION SUBMITTAL DATE
BUILDING ADDRESS:
O N 'S NAM ) s PH NG: CONT'RACTOR'S NAMIi:_ s LICNO.
/VA N/C COMBOLH
' I
•ARCHITECT N.EWER. LIC NO: ADDR S: Lit+ ❑ .
CONTACT: PHONE: B LDING PtiRM El INFO
�r10J J � ❑ Consultant PcOr Paid by Applicant(initial) HLOG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARA ON QTY ELECTRIC PERMIT PL'E -JOB DESCRIPTION
1 hereby affirm the I am licensed under Ptoviziom of Chapter 9(commencing
ZZZ with Smann7fl(N)lof UivisionJof the Business and Professions Code,nnJ my license is RESIDENTIAL
WOO PERMIT ISSUANCE
F UJB in full force and effect. ❑SIVWI. ❑KITCHEN REb10DIi1.
�U Fj License Class Lia# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPli
HZW IJula Canunetor
6 ARCHIL EC'I"S DPCI. RATION PANELS ❑Ml1Cl'bllNl'I' ❑S OINFTURM.
ZO Z IundcrsmnJnty pIars,hul be used as public mr-od, M11 CHIMNEY
REPAIR r�i UP 70200 A1 ION
MPS ❑INTL'RIOR ❑CHIMNIiY RIiPAIR
OZ-0
yl Licensed Professional 201-10WAM1'ti IMPROVEMENT 0SWIMMING POOLS
CY�� OWNER-BUILDER DECLARATION OVER 10110AMPS ❑H,\TH RIiAfODE1lREPA1R El DEMOLITION
C C Q I Imaxb,affind that I am exempt 1 a the C o m L Law for thea. ❑OTHIiR
{yKj 3 N U follow g (Simon.7031.5,tl : J H f.:� C d Any city aunty SIGNS EL17C1'RICAL �•l l'/q 1
which q pc I I construct, 0 p demolish, p ys cmre J /�
0ol ol p-ort t'i"a...I,alkooe'rom,th ml icantl h permitt it To a signedsttement SPECIAL Cl RCU I'I'ds!ISC.
Shymr,he is fiec dp : ama-Twovi,iorsol he Common,,Live,ow,Law(Chplar9 COMMERCIAL:
W 0 (emo musing with SW nn 90001afDvsi ) fthe Businco dPr f. CeMP
lc)or TEMITER OR POLE INST.
a E c C that hen exempt therefrom and the basis for the alleged emanation.Any violation of El NEW BLDG/ADDITION ❑IIIiMOLITION
Wim Section 7031.5 by any applicant for afvand subJeers the applicant o a civil Penalty of POWER DEVICES [-]TENANT FOOD SERVICE
not mom than rive hundmJ dollars($500). IMPROVEMENT
Fz6 E] l,as owner of the pmpcny.ormycmployccswith wages ns thcinnlccompemation, SWIMMING POOL ELECTRIC
x0 will do the wmk,vnd thumuamre is not intended m offered hurele(Sec.9WJ,Bmines. [:1 OTHER
,F„ ContractorOUTLETS-SWITCHES-FIXTUR[S
li] m and Professions Cndc:The ove%themo .and w Law Jncn not work
hi to if owner gh
'3 property who hods.nr aided that
tM1such i and whodoes such work himself oc tbnmgn
his own employees.PnrviJcd that mch improvements are not intended nr offered for NEW RESIUIiNTIAI.ELECfR SQ FT
side.if.however.the building or improvement in sold within one year ofcoundclion,the 50.17.FLUOR AREA S/SV.FI'.
owner builder will have the hmden of Proving that he did not build or improve for pur-
1 0 1,vs of own the pcapeal am exclosivoly cnmmaing with licensed contractors to TOTA.
nvo-ue,the pn+Iect(Sce 9144.Bminma ani Professions CW-t The Conazmur'1 Li-
cer.e Low does nmapply to an owner of property who wihk or hmprovus momon.and QTY. PLUMBING PERMIT PEE
who commets bnsueh pmjems with a contramngs)licensed pursuant b+the CommmnT's
License law. PERMIT ISSUANCE
1 am exempt under Sec. .B k 1'C for this mason
ALTER-DRAIN K VENT-WATER(EA) VALUATION
Owner Data
WOR RERISCOMPI?NSATZON DECLARATION BACK FLOW PROTECT.DEVICE
1 retch,of0 on under pewIly of perjury one of me follswng dcchloomn
I hnvc and wi It ;,in a Ccnillcatuol'Cor+scnno roll-invurc far Wnrkcr's Compen- DRAINS-FLOOR,ROOF AREA,CONU, SO IBS 'IY1117 CONS'IRUC'I ION
sutiun,as provided for by Section 3700 of the labor Code,for the pehmmance of the
rtk for which this permit is issued FIXTURES-1'IiR TRAY
1 have and will maintain Workers Compensation Insurance,as required by Section
371 o,me
lvMa Csde.for the performance ofthe work for which this Permit is issuN. GAS-EA.SYSTEM-]INCJON LEIS (ICC.GROUP AYN
My Workers Compensation Insurance tamer and Policy number art: GAS-EA.SYSTEM-OVER 4(EA)
Cartier Policy No.:
CER I'IIgCATE OF EXEMPTION FROM WORKERS' G R E A SPIINOIJS'BL WASTE INI'BRCEI'TOR
COM PENSA'I'I ON INSURANCIi BUILDING DIVISION FEES
(Thissution need not be cantdchsi fthe pewit is for nn a hmdmd dollars($100) GG iI ETRAP
PLANCHT:CK IIAi
or."t
(cenify ohm in the perforrrence of the wad forwhich this peewit is issued.(shall SEWER-SANT TARY-STORM HA.21g1 FT. ENERGYlE
not employ any person in any manner so us to become subject the Workers'Camper-
Z ration laws of Califomia.Data WATER HEATER WNENT/ELECTR MPTEZApplicant .NOTICE TO M'PLICAN'T:If,after making this Ceniftcam of Excimmor,You should WATER SYSTFXhrTREATING become object m the WnrkcTs Compensation provisionsof the Labor Code,you mustforthwith comply with such provisions or this permit shall he dcamed revoked. WATERSIRVICECONSTRUCTION LIiNDING AGENCY NEW RI'SIDENTIAh PLMB. -g agency M U O IbcmbyalBnn thanhem is a cnnswction leadin fn the rfmmauenff•' the wrk far which this permit is issue)(Su.3197.Civ.C.)ender's Name .TOTAL:� ender's Address
I cenify that 1 have mad this application and stat that the above infoon,ac a in O l Sp
tom/] anrcc0lugrccmcontply wl0+all city and county ordinances nnAstale laws relatingm QTY. MEC a,Tx (CAL PER M IT FEE SEISMIC THE
U Z Building construction,and hereby authnri a representatives of this city h+enter upon dhe
aboveametnioned property for inspeamn purpnms. PERMIT ISSUANCE ELECTRIC hili
We)agree to save,indemnify and keep harmless the City of Cupertino again,
liabilities,judgnanu.rasa and expenses Is Bich may in any way acme against said City ALTER OR ADD TO MECH. PLUMBING PEE
in em queue ofthe granting of this permit.
APPLICANT UNDL'RSTA NDS A N D W ILL COMPLY WHIP ALL NON-POINTAIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEF.
SOURCE REGULAI'TONS.
AIR HANDLING UNI'T(OVER 10,ky)CFM) CONS'IRUCI'[ON TAX
Signature ofApplicarmCImmannr Dam EXHAUST'[To()[) HOUSING MITIGATION FEE
HAZARDOUS MAI"ERIALS DISCLOSURE
Will the applicant or future building(weeper store or handle hamrdous material HEATING ON IT 100.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health ands Safety HEATING UNIT(OVER 100.000 HTO)
Code.Section 25532n)9
❑Yes 0N VEY]ILA'TION FAN(SINGLE RESID) PAID
Unle Receipt
Will the appllcam or fumrc building xovpam me cyuipnmm or Jeviax which BOILER-COMP(31IPOR I00.00011TU)
emit hawdous air conmmients as derincJ by the Bay Arca Air Quality Management 'IDT
Distrito? BOILER-COMP(OVER 100.000 It
El Yee, ON.
1 have mad the h ode,S z lions 2 5 m.25533 raxan u2M34.1 and rsta of the Cali-
AIR CONDITIONER ISSUANCE DATE
famia Hcae,&Safety Code,Senium 255115.25513 and 25534.I understand the,lithe NEW RESIDENT IAL MECH. SQ.Fri.
hf The 6 ine not currently hove u tcnun0(hut it Is ua c e'If a C rlit u+nofdy the mutlpum
of the rcyuiamemn which mu,q bemvprior In issuvneeofuCrnifieum of Occupancy.
Owner or authonoed agent Date TOTAL' ISSUEDIO,
OFFICE