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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
RUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING. PROJECT [DEN'I BFIC 110%
PllITlot O
cul
BUILDING
100 r)
f 1 1-11'IN7�(7
SANITARY NO.
APPLICATION SUBMITTAL DATE
OWNER' E'. 1'I I(INI::
CD[J'rRAC'IPooty Lo— a/v� I-�/SoUU
NIC
❑
(� CON 'rRI II,p
A IIsTECTEtNGINIiGk: LICNO'.
W�9-A .e.C�)5- 054,4&A -
ADPE.'S: IVC'
CONTACT PHONE:
BUILDING PERSf I'I' IN O
N
C �\
2 J
❑ Consultant Fees Paid by Applicant (Initial)
BLDG '. ELECT I-LUM� B' MECI
l6"
L CDNSEO CONI' ACTOR'S DIiCLARAI'IUN
1 torch, nmrnt man 1 alto imr,cd truer p (Mmon, m' Chn,te, 9 (..minemdeg
QTY ELECTRIC PERMIT FFF,
JOB DF,SCRIPTION
PIiRMIT ISSUANCI: r �� J
90007 of Dlvulon]orthe Bmuc,,or'dl'rotcudou, Crda,alod my Bloom In
in lull force and effect. 5��
RESIUFN'FIAL'
❑SPDWI. ❑KI'I'CHIiN REh10DELr
APPLIANCES -RPSIDEN'I'JAL
:ruesuc0en
iccl&b
Ciparpor
� �
Ek<)TION ❑PLUMBINGRE-PIPE
❑MULThUNIT El STRUCTURAL
❑X-rFRIOR ❑CHIMNEY REPAIR
IMPROVEMENT [D SWIMMING POOLS
ARCHITECTS DECLARATION
1 undersand my plus shall be used as public recordsMODIFICATION
PANELS
UP TO 200 AMPS
Licensed Professional
201-1000AMPS
OWNER-BUILDF,R DECLARATION
1 hereby of no Ihnl I auu exenpl from the Contrucnt'n License law fir the
ILIlo kat, ren.ou. (Scctinn 703 1 s, Business and Profcseion, Cade: Any city or county
A1 11 REMODEIJREPAIR DEMOLITION
O'HIER
OVER 1000 AMPS
SIGNS ELEC'1'ItICAL
weld, requires a "ton to cnns0uct. Ater. improve, demolish, o, repair any swcIrm
SPECIAL CIRCUIDMISC.
prim In its issuance,Aa,require. the applicant for such wrout to file a signed statement
that he licensed prs ell cr p r t ftheC clef I Law (Chapter )
(cog 'thS i 70009E fDi si 3 fm B near dPr f -:-ora Cede)or
that he is exempt lherelF m and the basis for he alleged couturp,cut. A . violation of
TEMP METER OR POLE INST
'R 1 1.
❑ NEW& WA ITION ❑ DEMOLITION
Section 7031.5 by any applicant for a ..moll suhjccls the applicant to a civil penalty of
POWER DEVICES
N ❑ FOOD SERVICE
nut more than Eve hundred dollars ($500)
❑ 1, a%eivircirtifIn p ,crY or toy craft. rc, so Ih ova'O'a, their R t
will tit) [tic viork,andthc4 I 1 t cl1 1f Jt rl (See 7044Business
and Professions C 1 II G urt : I L 1 ,ply I f
VEM
O
SWIMMING FOOL ELECTRIC
.
OUTI PTS-SWI'fCIIhS FIXTURES 0
NEW RE'IUEN'1'IAI. I:LI:CTR SQ 19'.
„ep.,,y who Imld,e, i ve,mcremand who does rich work himself or th,.ngn
his own employees, previd,cl Inas wch improvements aro nm imeadeA m offered for
fcplction.lbc
is sold within eycuroum
sole. If. however. the buildingnr impmvemem nn
SQ. 17. 1'100 AREA
$I$Q. Ff.
c s
ovoccolimider will have the burden of puring that he did not huild or improve for pus
pa, a of rade.).
-11. as owner of the pmpenY, am exclusively contracting with licensed contractions to
construct the project (Sec. 7(114. Business and Profession, Code:) The Contractor's Li-
3�
To
I
cause Law does not apply it) an owner of property whit builds or oipmvv% thereon. and
QTY. It RING PERMIT FEF.
who contracts for such projects with a enmmclons) Iicen.mJ pursuant to the Cunlmctor's
Licmtsc Law.
�1
PERMIT ISSUANCI.
❑ am exempt under Sec. .B&PCmrihlsmason
- Date
ALTER-DRAIN&'LN'I' WA'k (EAI
VALUATION
2C% oO
Owner
WORK17R'S COMPENSATION DECLARATION
1 hereby alfimt under penalty of perjury one of the following declarations:
BACK FLOW PRO[ENI. EVICT
Fl I have and will maintain aCrnificae of Conmrt tnself-insum for\Yorkers Compen-
.when, as provided for by Section 3700 of me Labor Code, Ter me performance of the
work f.. which this permit is Noticed,
DRAINS -FLO .R(A)F. AR_ COW.
STORIES
TYPE CONSTRUCTION
FIXTURES - PER T'RAI'
1 have and will maintain Workers Compensation Insurance, to, required by Section
3700 of or, Labor Cale. four he perfnnmenee of the work for which this,em,il is issued.
GAS- EA. SYSTEM. I INC. 40UTLCI S
OCCGROUP
APN
a
GAS - F.A. SYSTEM OVER 4 (ISA)
MyWorker 's Compensmiun Insurance varricrand Polity number arc'.
Carrier: Policy No.:
GREASF/INDUS'I'RI. WAST,, INTERCEPTOR
CP.RTIIICNI E OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION143r
('This malum need not he completed ifine permit is fnrnnchundreddollan($1101
nr In,,.)
GRGASETRAP
_
PLANCHECK FEE
SEWER-SANITARY-S'I ORM EA. 2W B7.
ENERGY RIE
I certify mar inlhc prHonnunce of the work for ishichurs permit is issued. I shot]
not employ any person in any manner so as to become subject the W'orkms' Comper.
WATER HEATER W/VENT/ELECfR
GRADING FEE
mtlnn Laws of Calif ..cia. Date
Applicant '
N(YITCP.'TO APPLICAN'P 11, aIle, making this Cenlfienlo of Room iplion, you aha..
brolo ce UpOlc to the Woke', Co r er,,,on provisions of the Lahor Code, Y^ t marl
,
WATER SYSTICM/1'BEATING
$OIL ti hili
WAPF,R SERVICE
forthwith comply with such pnrvi.i(sis or his pentad shall he dermad revoked.
CONSI'RUCITON LENDING AGENCY
I hereby affirm that there is a mnstmction lending agency for the performance of
PAID
1
Facthe
NEW RESIDENTIAL. Pi.MB. SQ FC
TOTAL:
BUILDL (; II:E
work for which this permit is issued (Sec 3097. Civ. C.)
LenNameders
(0-10 O
Iamdcr'c Address
1 certify Lha 1 have rwd This application vad rtnc Lha the shave rumination is
rmm.I aguruitampl, with all city andcoarlyonlirmwc,and ,,am laws retail, In
eunmmalon, and hem�by dulho,im reprsenmdvc onnix dly m enter upon doe
nbam-rJenk ed property fa ........ I to pu,n 11,
(We) agree to save. indemnity and keep harmless the City of Cupertino agrool
QTY. MECHANICAL PERMIT' FF;F
r Qbuilding
I'HRMIT ISSUANCE 0
ALTER OR ADD TO MECH.
Iiabilum,judgments.co,sutd cxpenw, whichmay in any wayzcfineagmmI,md City
in asequence of the granting of this permit
O
/
AIR HANDLINGUNH l0.q%1 CP]H-,.
C)
U
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT ((IVEkI CFM)
AX
Signature of Applicant/Comractor Dale
EXHAUST HOOD(W/DGcD
TION FEE
HAZARDOUS MATERIALS DISCLOSURE
W di me appllaun nr lmum building occupanl stoic or handle h:vardous in uenol
1 1
HEATING UNI'17 00 100,000 B I ll
nu oll by the Cupenluo Mmn1101re Code, Chap cr 9.12, autd the health and Spray
Coup, Section 25532(.)!
HEATING UNIT (OVER lot) (Mg B 'e-
0 Yes ❑Nn
VENTILA'1TONPAN(SINGLERF_S )
P
Date Receipt X
Will the applicant onodding ow future nodaxcupum tau eyuipmnt
e ed or devices which
hazardous air contaminants as definby the Bay Arca Air Quality Management
mit hae
MOILER - COMP (3HV Ok I(XI,IX1U T .
BOILER-COMP(OVER 100.001) BTU) '
Dilutor,
p Ye. C] Na
AIR CONDITIONER
I hammad,he nnnudoo, accruals trnluiremets trod,, Chum, 5.95 of the Cali
Iia . Health & Safap C to. Sectiorr, 25505 25533 d 25534 1 rracr,Und th t I the
bink) g does rat riumently late a mount, that t y:, hlhuy, ilY th Pent
ISSUANCE DATE.
� Q
Z.O T
NEW RESIDENT Al. MECH. SQ. FI'.
of the reyuirc rents which trust h. met poor to i... accent a Ccn Teale of Occupancy,
ISSUED BY: /
TOTAL: 1
Owner or numodzed a&em Date
OFFICE