S 3936 (2) pPPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT N0.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL S 3936
t ii.,fi:71i;,(BUlI,DING d'ROJIrCTdDRNTIFICAT10Nii:'t:`+":'iIN!
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
r OWN'RSNA PHONIi: U)M'RACTOR'5 NAME: LIC NO:
ZNIC CONTROL#
ARCHIFECT/IiNGIN1iER: LIC NO: ADDRESS: ! ❑
CONTACT: PHONE '{ii'j,/{!(!+t{aBU1liDING PERMITHNPO „+P nJ{�
❑ Consultant Fees Pard by Applicant(Initial) BLDG ELECT PLUMB
❑ ❑
+ - -C r r ITJ' J rq ' -/ (1
LICENSED that I CONEl
TRACTORS UECLnR ION QTY-,',' f IPI LCfRIG PLRMIT{, { trtl l' t4 ?tfPl E'.t,tJ;
1 ne.70 0)o that l a n licensed ander provision,
Chapte Icontme c g f a f.uI_f r, r t{ ..r.Jr., r n, t JOB DESCRIPTION
M{�l P4z to Sui on]OBB)om v.nn3ofine Bus nese road fes.ons Cod andmylice RESIDENTIAL'
1-�� ntfall to"aiml eficct I'IIRMII ISSIIANCIi
yyy¢�UU Licenu mss Lic,x ! ❑SFDWL ❑KIT iN REMODEL
N�a Date Canaumor APPLIANCES-ftF:SIDF.NTIAL ❑ADDITION ING RE-PIPE
pm
RCHITECT'S DECLA A ON ❑MULTIUNIT ❑STRUCTURAL
F I nnJerrwnd my Plnns nhnll he ural as Public raoNs PANELS MODIFICATION
pZ-I UPTOIWAMPS C1 INTERIOR El CHIMNEY REPAIR
d'`F.U4 LicemeJ Profeaxional 201-INRIAMPS IMPROVEMENT E]SWIMMING POOLS
CSI
OWNER-BUILDER DECLARATION OVER I"AMPS ❑RATH REMODEUREPAIR ❑DEMOLIT[ON
C W Q I hereby affirm thin 1 am c,amam from the Comracmd License Law for the
O L U Ibllowing reason.(Senion 90315,Haemes,and Potifwxions Code:Any arty or county SIGNS ELECTRICAL C1 OTHER
Oy which requires a permit to construct, ,ct,alter,impart demolish,or repair any structure
.F.^w< pdraloasissuance.also requires the applicnmtforstmh .it to fileasignedsmmmcnt SPECTALCIRCUI'I'/MISC,
thin he is licensed punmant to the provisions of the Contractors License Law(Chapter 9
W !commencing with Satinn]0110pd Division]ofthe Buvinessand Prnfessioms Code)« TEMP.METER OR PO .INST. COMMERCIAL:
d y a ev That he is exempt anyflarif
applicant
li and the basis far the subjects
the
exemption.Any vinlut lty of ❑N OLIT N
W rte nor.,n90l.5hy anyapplicam,(SI ), suhjceathe epplicannu ucivil penally of I'OWF.ft DF.VICF, ❑ "f Q ❑ DSE
minora than flue hundred Aollxrx l55W). I TEMP
F'S 14 I,as owner of the progeny,or my employees with wages as their sole connEemedon, SWIMMIN5401.ELECT RTC CIO
do the work,and the svucmre in not intended or offered for sale(Sec.7014,Business
3g. trod Prnlussimnx Code:The Cnnaadors 1-Icense Lnw J«s int apply m an owner of (IUTIP -SWITCHES-FI%TURES
property who builds or improves Hereon,and who does such work himself or Ihmug r
In,.,it cmployces,provided that such Intproventoms mm not Intend ii m offered for N RESIDENTIAL EHCTW SO FT.
edc.If,nnwevin,the building a,improvement issold sinum one yemofeompled, the Q.FI'.FLOOR AREA WQ.IT.
ownervhuilder will bmve the hmdm of pnrving that he did not build or improve for,m-
pwsecfsme.). BY
❑ 1,ax owner of the progeny,a .show ly convecting with licensed contractors to 000
const mtheimpact(ST]044 Business a d Pronfitota,C Ic)The Cont'amo Li-
” :f -xIT?'pts N 3:'
ounceL d I pply taw fpperry h builds n imposes thereon d Q'fY Irl( j,PLUMBING PERM
wo contracts fu such projects w'th a camr t r(s)Iam,ad pursuant the Comracm/s
License Law. PERMIT ISSUANCE.
❑I an,exempt made,Sec. ,B&P C for this reason
Owner Dim VALUATION
VALUATION
WORKER COMPENSATION DECI.ARA'I'ION BACK FLOW PROTECT.DEVICE
1 hereby aRmt under Penalty of perjury one of the following declarations:
I hmva and will maintain aCeNticmte of Connemmsclf-mare fm Werkeis Camren- DRAINS-FLOOR,ROOF,AREA,CONE). STORIES TYPE c: UCTION
sa on,as pid
roved fr aby Section 37W of the har Com,for the acrania ve of the
Far which this permit k aimed FIXTURES--PER TRAP
Ej w 1 have and will maintain Worker's Cmnpensation In...ame.xc required by Section
]]Wofthc labor Code,forth erformance of the work for whichmis permit is issued. GAS-HA.SYSTEM-I INC.4 OU FLETS OCGGROUP APN
Ca Worker'' tnf'mian s ,resod Policy nuts"R .1
tq' GAS-EA.SYSTEM OVER4(EA)
Carrier: t Policy No FROM
CER'I'IFlG\ .(BM1DR'ION FROM W R CERS'
COMPENSATION INSURANCE ORF.ASF:/INDIISTRI.WASTE.INTERCEPTOR
phisscaion rte nm hz mplmedif Nc rcnnit in fonine hundreddollats($I W) p .` :BUILDING DIVISION FEES
roles.,.) GRF.ASETRAP PLANCHECK FEE -
Lcenifythmi M1e perfo ante ofthew rk for which this pcnnit is issued,Ishall SEWER-SANITARY-STORM EA.200 ITT
notentploy nnyp tit t annex sn nam em x.Ej io nkma Camara- ENERGY FEE
Z sxtion laws ofC iR niaulm WATER HEATER W/VEYVELECFR
O Applicant GRADING FEE
NOTICE TO AP AN'I:If,afar mxki This Cenllieute tel'Cxem t should g p ion,you s ou WATER SYSTEM/REAPING -
become subject m ITT Competes tion provisions of the Labor Code,you must SOILS FEE
orto,th comply with such arviaons or this permit shall be dccmed revoked. WA9'I?R SGRVICE
Q
7z. CONSTRUCTION LENDING AGENCY NEW RESIDEM'IALPLMB. SQ,FT. PAID
C..1 0 l for hichinn shaman i is sued(See
30 len Jing agency for performance of Ila Receipt p
D.
he wars Na which this permit is issued(Sac.]fro].Civ.CJ
Leade0 U Lcm1cr's Nuntc TOTAL:
IsnderI Address TOTAL
Hd I«slythat
nnap read this palet dsone
ces the above relal Lf.tr,pL t' t 6 'P '; I t t,tt BUILDING FEB '
m coned 1agree mcnmpry 'm n l4,and t4, m' the satin lawn salad gt QTY MECHANIC1LPERMITIN f `11 t71 PE��,J
V z haddi g commoctlan.and hereby andurve presentatives ofthis city to enter upon the +"- t 1 n.�l. t / . SEISMIC FEE
.1 me-mentioned property for inspection rurpn+ex' PERMIT ISSUANCE
(We) gree to save.indenmify and keen hamtless the City of Cupertino against ELECTRIC PER
liabilitirn,j Igments.m Isundeipensarwhichnayin:nty way Tree ruuaguinasniJCity AIZ17R OR AUD'IYI MECH,
in nsequ cc oflhcg doting of this permit. PLUMBING I'IiE
APPLICA TUN STANDS AN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Iq(XM)CFM)
SOU iI EGO 'IT)NS. MECHANICAL FEF.
AIR HANDLING UNIT(OVER 10,000 C ] CONSTRUCTION TAX
mu Applten nmtacmr V EKIIAUST 11001) W/DUCT) HOUSING MITLGA'I'[ON FEE
HAZARDOUS MAI ERIAI ti DISCLOSURE.
Will the applicant or future building occupant store or handle fluctuations material 14EATING UNIT(IE)I W,BW I' )
xs defined by the Calamine Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532my? I(EST ING UNIT(OVER ,IHXIBTU)
❑Yes ❑No PAI
VENTILATION FAN INGLE REMDI I m Rattier M Will the air traam or furore building occupant au Area
Air u or Mara which
emit huranlnus air uunmminams us detinet by the Buy Amu Aiv Quality Mawgemmmt BOILER-CO pHP OR IIXI,000 BTU)
District? TOTA4
❑Yes 11 No BOILER- MP(OVER HILM,or
I have ml the bee Mous material. quiremenu under Chapter 6.95 of the Cali- AIR C DITIONIiR ISSUANCE DATE
romiu Ileahb a Sufay C:la Sachem 21. 15,25533 and 25534,I understand that iI'the W RPSIUFNTIAI,MI CH. SQ.FC.
building man ntl haveutenanl,tl nit is my responsihilirytmtmifythe«engem
orthe snow is t.a he met tri stn Issuance of Cenif. 'mf ancy.
i
> e Jac
to TOTAL: ISSUED BY: V
OFFICE