B 0468�i APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY •'I -
CITY OF CUPSRTINO BUILDING-ELECTRICAL - PERMIT NO�0 4 6�8
R Y OF C DIVIS3oN APPLICATION/PF,RMIT PLUMBING-MECHANICAL SOOO1
[BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
ooio CA MC�-V /Q D• 42d.,` eezTwe
WNE1lt'SS NAME: PHONIi: CON]"RACfOR'S NAME: LIC NO:
C�MfN L E.—g a.S O D >�(-p� NIC CONTROL#
r0 3 RCHITELT/ENGINF:BR: LIC NO, gDDR ESS:Q uPG'�T/NU LalvGj- � 3. .
LY
CONTACT: PHONE: ' BUILDING PERMIT INFO
a�^JSdY G mrd- 900 0 El Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB
o
LICENSEDCONnsed order .,acres
ION QTY ELECTRIC PERMIT FEF,
I hereby(loan thm 1 am uaered ander pd Profo s or chapter 9 ammmensers JOB DESCRIPTION
OW a'Z with Secrecast offs Division 3ofthe tlusinws.na RvfessiomC e,an m licensers O RESIDENTIAL:
�00 �s1 PERMIT ISSUANCE 0SFDWL D KITCHEN REMODEL
BI r in lull forecast eRcu!f 6
aU License Class l� Contract.
APPLIANCES-RESIDENTIAL ,,..,,��
yea Dam Comracto ISAUDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLAR TION ❑MULTI-UNR ❑STRUCTURAL
I Z O m Z 1 understand my plans shall be used as public records PANELS
O Z=.. UP TO 2001 AMPS
MODIFICATION
pD INTERIOR D CHIMNEY REPAIR
F�4 :1 Licensed Professional 201-10(10AMPS IMPROVEMENT
�=Zac OWNER-BUILDERexemptm DECLARATION TION UDEMOLINGPOOLS
C�6 1 hereby affirm that I am exempt from the Commnars License Law Be the OVER IfgO AMPS ❑BATRTfEX10DEVItEPAIR D DEMOLITION
a0) U
.X36 adder
following reason.(S«tion ID3LS,Busisessand Professions Code:Any city nrcounry SIGNS ELECTRICAL ❑07fHER
F_W O m which squires o permit to construct.alar,imfi demolish,or repair any swcwre
thathesliconacipsur arequires prevision ofthe CchpermiuLfiense Lredsmpdcr9umum, SPECIAL CIRCUIT/MISC.
SM} that he is lioxnsed pumuam to the provisions of the Commanrs License lww(Chxpmr9
U�GOIs
(commencingwith Srvion7000)of Division 3ofthe Business and arofeisiom Gdc)or TEMP.METER OR POLE INS COMMERCIAL:
a X m that he is exempt therefrom and the basis far the alleged exemption.Any violation of AD D NEW BLDG/ADDITION D DEMOLITION
--m Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES
F_Z} not more than five hundred dollars(25x10). 4ki D TENANT D FOOD SERVICE
F_< 1,reowtterofthe ro n.orm loses with woes ustheirsole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
RO ❑ t art Y Yti Y B ,cora
Cao ill do the week,node:no Cum jaunt ts License Law reoesull not apply 7044,anowner of []OTHER
6 3 m and Professions Code:The Contractor's Lind w Law Jens not apply s if owner of l OUTLETS-SWITCHES-FIXTURES O D
hpropertyis own who builds or improves thereon and who dors such work himself or through
_ his awn employees.the Provided that such improvements we not intended of or nRercd for NEW RISIUEN]IAL ELECIR SQ Ff.
min.ILhowever the buildingor rden of improvement he did non dear fcompletfonthe SQ.FT.FLUOR AREA S/SQ.FT.
sof Balder will have he burden of proving thm he did no,build or improve for Pur-
0 1 of ratan).
❑I,u r jot(S .704 an exclusivelynd convecting with licensed oCond raclwn ro AL:
construct 1heePmj«t(Sm.]BW,Business and Professions Code:)'Ifie Conwnnr's Li- "
ase Law does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBINGPERMIT FEE,
who contracts for such projects with a contmetor(s)licensed pursuant o the Commetor's
License Law. PERMLTISSU CE
D lam a opt under Sec. ,B&P C for reason
ALTER- VENT-WATER(EA) 11 VALUATION
WORKER'S OMP SATIONDECLAR p' 3 4'
wnerl hereby affirm under suit f of roll n declamations: BACK PR .DEV
ya p
airy perjury one g '
❑ [have and will maintain a Certificate of Consenuo self-insure for Workers Comped. DRAINS-FLOOR,ROOF, .GOND.
ration,as provided for by Section 3700of the Lab r Cede,for the pcBotmance of the S ORIES TYPE CONSTRUCTION
work for which this Permit is issued. - FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's ComPenratma Insurance,us required by Section
37M fthe Labor Code,forthe erformance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My We mpe I tion I a std, PolcyoBO �/Cenier ]icy Ne.
GASB-EA.SYSTEM-OVER 4(EA)
IFICATE OF EXEMPTION
FROM WORKERS'
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(Thn,co.tre need not he complelodlfthe permit is fmone hundred dollars 1$100) BUILDING DIVISION FEES
or less") GREASE TRAP PI.ANC .CK FEE of O
. I cenify thtin the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.2001FT.
not employ any person in any manner so us m become,subject to the Workers'Cnmpen- FEE
Z sation Lows of Califomia.Date
!] t WATER HEATER W/VENT/ELECTR -
0 Applicant A NG FEF.
ti NOTICE TO APPLICANT:If,ufmr making this Ceni(icme of Exemption,you shoed") WATER SYS1HM,TRI APING
h
become subject to the Workers Compe yearn provisions of the Luba Core,you mail O .S FEE '
1 W Q fonhwilhenmplywilhsuch provision bis Permit shall he Jcemcd revoked. WATER SERVICE
CONSTRUCTION[.ENDING AGENCY NEW RESIDENT[At,PLMB. SQ.FT. PAI
V Q Iherchy effum theuhere isaconswction lending agency fnnhe Fort name of Or -Receipt#
Lks H the work for which this permit is issued(gee.3097,Civ.C.)
0Lenders Nume LA TA . / LO
U Lender's Address - TOTAL:
G1 cenify that I have read this application ami suite that the shove informmion is BUIL F
M correct.lagmemcomply with all city and county nNinanms and nmelews rotating m QTY. MECHANICAL PERMIT FEE
V building convection,and hereby amhon;ic representatives of this city to enlorupn the
ahnve-mentioned Property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE XMECNICAL
liabilities,judgmems,costs and expenses which may in anyway regime against said City ALTERORADDTOMECH. f
in consequence of the granting of this Permit. E
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE REGULATI 'S. / FEE
✓ S QAIR HANDLINGUNIT(OVER 10,000 CFM) N TAX
Signamreof ApplicaoVContmcmr Daa% EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATE AIS DISCLOSURE
Will the applicant or future building accupont store o handle hsmrdous material HEATING UNIT(TO 1010,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safny
Code,Section 25532(x)7 HEATING UNIT(OVER 100.000 BTU)
D Yes 215. VENTILATION FAN(SINGLE RESID) PAID _
Date Receipt#
Will to applicant orfuture Willing occupantvuequipment litydevices Management
BOILER-COMP(3HPOR 1110,1#q BTU)
emit hamrdoos air contaminants as defined by the flay Area Air Quality Management
Disvicr7
❑Yes BOILER-COMP(OVER 100,01013TU)
I have read the hamrdous materials requirements rode,Chapter 6.95 of do Cali. AIR CONDITIONER ISSUANCE DATES
From.Heave&Safety coda Sections 25505,25533 sed 25534.I understand red if the NEW RESIDENTIAL MECH. SQ.FT. p¢��_ / ✓/ 4
buildingdoesndcunmalylutslowed mitismyrespnnsibilirymnotify theater. at
o the tremcros Nch rods ie vora CenificuLm of Occu cy.
autbonmds .1 6 -/ at� TOTAL:1 ISSUED BY:
OFFICE