99100122 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY �J G / 2_
CITY OF CUPERTINO 2—
BUILD NG-ELECTRICAL t Pli M T
BUILDING DIVISION APPLICATION/PERMIT 1'I.IG PROJECT IDHANIFIC SOOOI
111111.DIN1:PROJECT IDf:NTIFICN'ION
mom
BUILDING ADDRESS: SAN]I'ARY NO. APPLICATION SUHMI ITAL DTI
/,
7.4
OWNED NAME: j PHONE: CO 'RACTOR'N NAME: LIC NO: D ^ -
S NIC CONTROL
RCfl1TEC1'IF ]INFER: LAC NO: ADDRLSS: i'll ❑
CON'1'ACn PHONE: BUILDING PERMI•IINFO
❑ Coagullant Fees Paid by Applicant(initial) BLDG 1!LIiCT PLUME MECII
h' /g6 ❑ W__� ❑ ❑
LICE IT) )N' RAC']Y)R'SDI?C.ARNHON QTY. 1:LEC'TRIC PERMIT FEE
I hereby z1Gmt mat I am hcensed model provishins of Chapter v mommcneing JOB DESCRIP'T'ION
Ix�l Q
2 Section](XX))of ion Divis3 offs Baxme%x and rrnfesxionx Code.and my license i. PERMIT'1&ISSUANCEISSUANCERFXIDENTIAL;
QC
.vim in lull teres nnJ
dl'cct, p n 7 Lr ❑SPUNL xl:aCHiN RI!MODEL
l• A''LIANCPti-RISIDINTIAL []ADDITION PLUMBING R17-PIPEUZ Um ;aaCtc Imarac
STRU
URAL
'mad ARCHITECTS DECLARATION ❑MULTI-UNIT ❑MODIFICATION 1'ANFI\ 1fODIPICATION
ZOfNXaZ IundcamnJ my plans shall be used as public recordsOX Ez UPTO 200AMPS [I INTERIOR C3 CHIMNEY REPAIR
7-jl4 I Licensed Professional 2040MAMUS IMPROVEMENT 0SWIMMING poom
�Y, � OWNER-BUILDER DECLARATION OVER IINOAM]'g ❑BATH REN I.P)IR ODE 101111
C C @ I hereby affirm Thal 1 am exempt from to Convacmr's Licenselaw fur the El OTHER
XIL V following reason.(Senion 9131.5.Business and Professions Coda:Any city or county SIGNS ELECTRICAL
Wla.❑O Fy' which 1 la 'u c t t II p d I 1.h p m
y m arc
y6 prior to itsI. 9 rc the applicantfor such Permit file a vignedstatemeal SPI.CI AL Cl RCUI'I/MISC.
•..11 [butt Ip a thep Ilh C I I (Chapter 9 COMMERCIAL
,�'C iron w 'b vidoScow.9X)po1 Dimoiun 3ardhe B : II t -C dc)or IEMl1 MCH:R OR POLI:INS']'.
E p�m a Thal lie is exempt Therefrom and te hhook Ino the alleged em not L Any v'r ,lofnr of ElNEW BLDG/ADDI LION ❑DIiM(11.1'I ION
iC 4.
Scoria,71031.5 by any oppherm for a permit suhjad,the npplicaul lu a civil pcnall,of POWER DEVICES [I TENANT 1:1 pool)SERVICEnonnom than lisp hundred dollar,1$500).
IMPROVEMENT
=M Ol.an owner of the pmpeny.or my employee%with wage.%as their sole compensation, SWIMMING POOL ELECTRIC El OTHER
t- will dolhework.and thcsounurcnnm immndedoroffeed let.ale(S«.]044.Business
W m and L'rofession%Code:The Commctors License law dues not apply m an owner of OUTLETS-SWITCHES-FIXTURES
6 3^ pmm:ny who builds ar improves Hereon,and who does such work himself or through
his own mnployees,provided tin such improvements am not intended or offered for NEW RESIDENTIAL FLECIR SQ
.sale.IL however.the building or improvement is sold within one year of completion,the S FT.FLOOR ARBA LSQ.IT.
.
nernuilder will have the burden of proving mat he did not build or improve for Por-
pweo(ule.). T AL:
Fl 1,as orwner,of the property,am exclusively contmming with licensed conlmatprs a
instruct the project(Sec.7044,Business and Professions Cale:)The Contrai Li-
se law does not apply to an owner of property vho builds or improves thereon.and QTY. PLUMBING PERMIT •FE 7
whocontmt%fnrxuchpmjcctswithacmnradc)(s)liccn%cd punuammme Contmctnr'x - ---
Licens Law. PERMIT ISSUANCE nr
I am exempt fast,,Ste. .II A P C I. this m:xcan �I
ALIB8I R-DRAIN VENT'-WAfHIt(EA) VAI. A' N
)wnct Data
WORKER'S COMPENSATION DECLARXI'(ON BACK FLOW PRO]17CE DEVICE VCT 2 2
1 hereby affirm under Penalty of perjuryone of he Iidlowing declarations:
I hnvc nnJ will nminmina Cenincmc of Cnnunno xdGinwrclivr Worker's Compere- DRAINS-FLOOR.ROOT',AREA.COND. STOR]E.g 'I YI'Ii CONSRIICIIU
xadon,m pmsbad for by Seelion 3700 of the lata,,Code,for the pcd'ormance of the
walk far which tris pemtit is issued.
FIXTURES-I'I!R TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section GAS-I!A.gYSTI!M-I INCA OUTLET'S 4 t y--—
J]1N1 of to IaMor Gde,for the perfommnee of the work for which This permit is issued. ,• AI•N
My Worker' L-n nsation threose carrieroli Policy nu GAS-EA.SYStT!M-OVER 4(EA)
Carrier Pansy No.:
CERT IFIC TE OF EXEMTION FROM WORKERS' GREASFANDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEI-S
(*Ibis section need not be completed ifthe permit I%Intone hundred dollars(SIM) GREASE TRAP PIANCHF.CK FEE
or less
Ia,any
that in the arrenmanceohne ber,auork r,oijoct,o le W iser,'Curpe.ssued,I l SIiWER-SANITARY-STORM1t LA.2(X1 FT.
not e:npiny any person in any manner n,as m b«unm subject to the Wnrkcrs'Compere- ENERGY FEE
Z xalinn Lnwxof California.Date WAH!R HEAL ER W/VENVELCCI'R GRADING FEE
z Q APPIic'ant t
NUI CH 10 APPLICANT:If,after risking'I'll CMilica a of 17xcluln" , ,,.,should WAI'I7R SYS')FM/1'REA'IING
F ; he, Ile subiro ht the Worker's Compamation pnomorr ol'the Labor Code.youmm� SOILS PFT!
Iimhwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
D]
PDD Z CONSTRUCTIONP
Dam Reeipt p
U O l hereby
affirm and is a consumption lending agency for the performance of
IL — 'he work far which his permit is issoed(See 3097.Civ.C.) TOTAL:
Landcr's Name TOTAL:
Isndci s Addres% F BUILDING ME
1 I certify that 1 have read this applirofion and nate that the above information is
Ern correct L agree t,,simply with a 11 city and county mdinances and stem laws rearing m QTY. MECHANICAL PERMIT FEF- SEISMIC FEE
V 2 building cnnnmetipn,and hcrehy aathmaempresenmtivesof this city menrer upon to
uMne-mmafioned pmpeny for inspection purposes. PERMIT ISSUANCI! ELECTRIC FEE
(We)agree m save,indemnify and keep hamdess the City of Collura against
liabilities,judgments,cans and expenses which may in any way a«roe against said City ALTER OR ADD TO MECH. PLUMBING FEE
in........ of the srarring of this panni.
AI'PLICAN'I'l]NIJI!R$LANDS AND WILL COMPLY WI 111 ALT,NUN-I'OIN'f AIR HANDLING UNIT(TO 10,10)CPM) MEC{IANICAI.FEE
SOURCI!IIT:GLH A'I'IONS.
AIR HANDLING UNI'I'OVER 10.11011 CPM) CONSTRUCTIUN'TAX
Signature of ApplicanVContmeror Dae EXHAUST IIQOD(W/DUCT) l 1OUSINGMITIGAT1ON Rip
HA9ARDOUS MATERIALS DISCLOSURE
Will thcapplicanf 0rfrme hailditigoccupam,l a or handle hmalloos material HEATING UNIT(TO I M. 0B1U)
no defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely HEAPING UNIT(OVER 1(X).000 BT117
Code,Section 255321x1'
Yes VENTILATION PAN(SINGLE RESIDE IAID
Date RccciplM
Will the applicant or fo ore building occupant use equipment or devices which BOILT;R-COMP p11P QR 1 W.1100 BTU)
calif hmmodum,pit cnnmmmantx as defined by the Bay Arca Air Quality Management 'I UITL: N
Distrin't BOILER-COMP(OVER 100,100 BTU)
❑Ycs 1-To
AIR COND]I'11)NEN ISSUANCE DA'I'S
l have rend the hmaNnux mamriall rcgniremenM under Chapme 6.95 of to Cali-
tumiu Ilmd t A Snrcly Cude slier 2550.5,2553]and 25534,1 undcoumd that if the NI?W RES I OEN'I IAL MECH, SQ,PL Z 2
hald' ,1 "nal yr all t mmmu,lhat don r mi bhhyt000dly,theoc«,mil
ol'Ih r % Lie ban t of orcopnt,r.
'v'
own car authnri'md ag 1 Dam TOTAL: ISSUED BY:
OFFICE