S 1515 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
Y CITY OF CUPERTINO BUILDING-ELECTRICAL Pe IT No.
BUILDING DIVISION APPLICATION/PERMITPLIAIRING-MECHANIC L 1515
BUILDING PRO.IECI'IDENPIFICATION
BUILDING ADDIU�S.s: SANITARY N[I, AI'PLICAI'ION SURMITIA I,DAI'It
'2c- /•�j ta/rTJS C L&ry. &.do C: f-_>is A-ll
NEWS NAME: PHONE: C( RACE SNAME: IIC NO: NIC CON'I'NOLM
sem UNC snem ZSS-4100 �r MNY Co�+snwcsgc�
ARCH rpm/ENGINEER LIC NO: ADDRESS: El8-Mo S
'1 f1E: evt.l G Iwu C.41Ca 5
II CONTACT: PHONE: HEILDING PERMIT INFO
. N �
� • qg g ❑ Consultant Pces Paid by Applicant(Initial) ELPL nt[CH
'_" Z41 -IJF33
LICENSED CONTRACTOR:S DECLARATION QTY. ELECTRIC PERMIT FEE
1 herchy Boron Ohm 1 an licensed fade,lin vi,iar,..of Chopmr 9 r:,r1 Nocing _ .1013 DESCRIPTION
0 wiN Section 90)0)of DivisARCHITECPS DECLARATIOinn.Co gond mylicensees RESIDENTIAL:
WON PERMIT ISSUANCE
in full force and ellen. 3 (,7 O ❑SIUWL ❑KITCHEN REM0DIS1.
QUU Pat Cl
Lm.N APPLIANCE_S—RE,SIDENT[A]. []ADDITION E:1 PLUMBING RF.-PIPE?
N Q d Oats Convector
ry MULTI-UNIT [I STRUCTURAL
(..D N PANELS
Z C y z I omm
dnsnd min y Pla %hell doused as public rec.nds I MODIFICATION
OZ4— UP FO 200 AMT'S f �0 ❑INTERIOR [:1 CHIMNEY R17PAIIZ
l=4 W Llcemed Prnfexeional 201-1000AMPS IMPROVEMENT E]SWIMMINGPOOLS
OWNIiR-BUILDER DECLARATION
C C .,] OVER 1000AMPS ❑HATH REMODEUREPAIR ❑DEMOLITION
C Q 1 hereb0 ady aRnn Nat 1 am exempt from the Clarnamar's License Law for the O
W 3 LL U fallowing(damn.(Section 703 I.S.11u.iness and Prof sdons Cade:Any city or county SIGNS FLECI'RICAL T ❑(TI'FIER
m which reywrvs a remm m con.tmct,alter,improve,Jemalish,or repair uny armature
��� Prior to its issuance,also rnprira.the applicant for xutlr,conic,Bleasignwl.mternenl SPECIALCINCUI'1'/MISC.
that he is h,eu,Wm mmdauhofrovloomei t he Co mm tore License Low Chain,1)
W 0 (commencing with Section Mahal D'rvicon 3cdthe amideoi and Professions Code),, TEMP.ME1'IB OR POLE T. F
y a e that he is exempt therefrom and the breis for the alleged exemption.Any vi,Mti,n of ,W BLDG/ADDITION ❑DI?MOLITION
^y Section 7031.5 by any applicant for a Permit subjects Ne applicant to a civil Penalty of POWER DEVICES TENANT ❑FOOD SERVICE
not more than live hundred doll...($500).
F Z>• 0FHER EMIiN'1'
Q (]La.ownenafthI Pee,umeonnyempinyeen with wagcsas Nei( ee.canpenioness SWIMMING IN)01.ELECTRIC
HD will du New,rk,Coe:The
taSols Licenvd se
awdon cadl fmsal,pill, ],94,all tusiter
o� ❑0'THP.R
aropert le,,i Cale:imp Conuvereo ,and whLnwdam,nnrpplymun,wncr of ba OUTLETS—SWI'T'CHES—FIX'1'IJItE5
his own who builds or improves thereon,and who nts a such tints hiniintended
or or through -
sal oxo employees,ep ildin,l that such improvements hi not intended orplfareJ for NEW RF.SIDIiNT'IAL ELECPR SQ FT.
sale,If.hnweveq the buildingmim,revenant is sold within one year of completion the SQ.FT.FLOOR AREA—` $/SQ.PI'.
moser-builder will have the harden of proving that he did not build or improve for par- /'/�� ("�
pox of sale.). ec
J4��\-1WT1
❑ I,m owner of the property,um exclusively mnhnning with licensed anummor to f
coast mcl the,oupo Sri.70,14,1{adnenx and 11 le,cons Code:)The Cautruutor's Li-
stlawdocs not apply ma a Owner m,imperty who build-O initiatives(be,do,and QT' MBING PERMIT FEE
who contract%for such projects with a contractors)licensed pursuant m the Contmcmds
License law. j PERM ISS CE
C]Iameacept Unlcr Sec. ,B&PCfo.thl acrem.
Owner Date ALTER—17MCWENT—WAI'1?R(CA) VALUATION
WORKER'S COMPENSATION URCLARATION j BAC to TI DEVICE I
I Herchynflirm ander pensltyofperjuryoneof Nv following Jeclantions: `t
�(]Iheve and will mainmin uCenilicam Of Cunsenno wlhinsure(or Wnrker'.a Compen- —MOON,ROOF,AREA.COND. STORIES T'YPH CONSTRUCTION
ration,as hick this
far by is issued
J](NI of Nc Labor Cocic,far the pedonnance of the
I t.,.whiched for by eelion d, 10X'IVRF.. 'TRAP O
work
�I have and will ode,li n Workers Cour,Oarue f he w work
Nance, h mq.u,san by Senior
3]INl of the lahur Code,for rhe lwrfonnanco of Na work lar which Chia leaner is issued. GAS4q$ STEM-I INCA Dt1'ThIfS
Lit
MCaYrtWienr:rvurylyc cnnrelpntnNnc,Y:num
V GAS—EA.S Of VER4(:A) OCT.Ct1J' APN
loI licY
CERTIFICATE Or EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREAS STIR W'ASTF.IMIiHCEPTOR
HUILUINO DIVISION IIiFS
(l his ttction neW not tk cnm,leted if the permit i.4none hundreAJallnrs lSltl(q GREASETRAP
nr less.) PT CHECK Plill
I mrtlly thin in lhepeditmnmmofthewarklot w160,this pventitsdoal,]shot1 S13WER—SANI'l'AR — tM HA,YBII FT.
not employ uny person in any am u,r.,asin becnm,subject 1,the Wnrkarn'Compen- O O ENERGY FCC
0Z smion Lawsol'California.Dale Z WATER OEM ER W/VENT/F.LECR
Z O Applicant GRADING FLIT
rNr NOTICE TO APPLICANT:If.nrmr making this Ccnifieme of Excrrpliun,you should WATER SYSTEM'BEATING
I"' > become subject In the Worker's Compammiml provisions of the Label Cadeyou most SOILS FEE
AL
WfonhwiN annply with.ucM1 Prnvi.inns nr this pcnnil%hull he deenmJ revoked, WATER SERVICE (/
Ps Q
CONhcm,,C'HON LENDIeading NCY NEW RGSIDIiNI'IAL,LMH. SQ,IeI'. PAID
UQ sour which
Nanhemi..nc, (Sec.3nlending agency fnrlhe perlimnancc of Dn RmeiPtp
92
the work for which this perms is issued(Sec.3097,Civ.CJ
ULender's Name 'POCAL:
U Lender's Address O
yI certify that I have mod this application and suac Nm the ahovc Information I. ( BUILDING IT
rHi0 rates, Iag,wmw.nply w➢h rdl day and...Oiy....lion id:md.mlolaws,cluingm QTY. - MECHANICALPHRMIT FEE
U Z milsingmna nnlon,and herehymNomam,iscoulivex of thisciry torn...upon the SEISMIC F a �m0
above-mentioned Pacifica,for inspection pu,mvit. Cans "PERMIT'ISSUANCENCISSUANCEQ�
(Wee)agree m save,incident and keep hornless the City of Cupertino against ELECfRI 'II 5'
Ii.bilihvs,j.dgmam,coas.nd eapcnus which m.y in any way accrue eguin....id City ALTER OR ADO TO MECI.
in comeyuemnnf the g.n,ia,Sf this Permit. 1'LU BING t?E?
14 V2
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'P(TO I0JXX)CFM)
SOURCE REGULATIONS. ANICA.I�EIi
Z Atli HANDLING UNIT(OVER 10,000 CPM) OO/If CO VUCTIO X
Si namreofA Iicant/Cmurartor Date 'L EXHAUST 11001)IW/DUCT) C'/LJL
B PP HOUSING MITIFAT10N FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the e Cupertino
Manobuildingoccupantmoreor anodic bd faith and Safety
HEATING UNIT(TO IfN1,IXN1 ,,
as defined by the Cupertino Monicipul Code,Chupwr 9,12,and the Ilurllb and Safely a�
Gde,Seotlnn 25592(n)r � IIIiATING UNI T(OVER IINI,INNI II'I'U) f U
E)Yes 0 N PAID
VENTILATION MN(SINGLE HISID) Dam
Plp
Will the air contaminants
future defined
by the B are ea Air Qu o. Mara which
emit hamrdnus air ronmminan¢cur defined by the tlny Area Air Quality Management HOLLER—GGMP(THP OR 100,00OBTU)
District?
❑Vex ❑Nn MOILER—COME'(OVER 100,000 BTIJ)
- AIR CONDITIONER a
I have read the limitations muchals requimmmru under Chapter 6.95 of the Cali- SU 'E
fomin Health&Safety Craft,Sections 25505,25533 and 8511.1 understand Nat if the NEW RESIDENTIAL MECH. SQ.FI'.
building does not currently have amount that it is net responsibility to notify the occupant
of the r quirummnts which must be met poior In issuance of u Certificate of Occupancy.
Ownenvu,Nn.rout agent Me ITO 1. V ISSUED BY:
OFFICE