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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUB.DB+C.. ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG. MLCUANICAL
BUILDING PROJECT IDENT'IFICV'ION
PERMIT' No,
S 2505
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
O 3 V I C .
� -ld
OWNERS NAN
GNC:
'R ,IOR'S NAME:
a .�O
N/C
❑
CONI 'ItOLp
ARCHI I PC DENCHINEEi
ADI 1}$,S, �! /I Q
r
CONT'ACI': Cht-fn 5 IIONE:
BUILDING PERMI'TINFO
a05; 1`1
_105;)_0
[:]Consultant Fees Paid by Applicant (Initial)
HL❑OG ELE ' PILUMH MEC 1
LICENSE CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
QTY ELECTRIC EIERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE t
with Smion ](010 of Division 3 of the Nu,ine,s and I'mfessinm Code, and my license i,RESIDENTIAL'
in roll force and eR•ct
ki
Licca, lays 1.icN
Uum
❑ SFDWE ❑ KI'ICI TEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑ANLTI-UNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR ❑ CII IMN17Y REPAIR
IMPROVEMENT []SWIMMING POOLS
APPLIANCES -RESIDENI'[A).
TSINelhr
ARCHI ,use DECLARATIy
I uI I 1 my plans tiny I e u.wJ � (�Ik rcfnrJs
ars nm ,
PANELS ^7
GP TO 200 AMPS Z QD
Liansel/1.pa
201-1000AMPS
OWNIiR-If1111,Ulilt UliCLARAq'ION
ehy affnm Nat I .,it c,etnpt from Tho Cmnracmr's Lice^se Law for IM
(nllowi^g maul.. (Section ]031.5, Rudness end I'mfevninm Crx1¢ Any city or euumY
❑ 13ATH REMODEIIREPAIR C1DEMOLITION
OTHER
OVER EROAMPS
SIGNS ELECTRICAL.
which requires a permit to constra n1ur, improve, demolish, or repair any .ttunure
SPECIAL CIRCUI UMISC.
prior In ifs iauance,also requires the applicant forsuch permit to file asignedstmhment
that he is licensed pursuant to the provisions ofthe Concavities License Low (Chapter ')
(commencing with Second 7001 ofDivi.inn 3ofthc Business and Professions Codd or
TEMP. METER LIR POLE INST.
COMMERCIAI,
That he is excespt therefrom and the basis but the alleged exemption, Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
POWER DEVICES
❑TENANT ❑ FOOD SERVICE
On,'marc Nen five hundred ddWrs y e 00.
Lae I, work, lie property, mboom my employees with wages
wit l duthework, and I isdid In red fo,aIc(Sce. compennminit,
J,nota(Sec.]Baa,R
IMPROVEMENT
❑OTITER
S\4'LMMING POOL ELECTRIC
—no,
Licenxc Law docs not apply In, an owner o1
Cade: The Cnm J,en,o Laws
nrA Pmf CoeThe ....
OUTLNTS-$W I'fClll?S-PIX'1'111tES
ou la firma
pmpuny who build, nr improves lhetcain, unit who cities such work hitmcll'nr Ihruugh
his own moployces provided Ihet such imprnvutnents oro not intended 'a n Led lar
luta lfhowevor,thebuildingurintpnwanem ix null within nuc yearn[cmnplctinn. the
NEW RESIDENTIAL 171.17-!1[ SQ Pf.
SQ. FI'. FLOORARIiA
$/SQ. ET.
er-hnildcr will have the burden of proving that Event not huild or intpnrm for pur-
Pwc of calci.
❑ 1, m owner of the property, am exclusively contracting wind licensed commetors to
TOT
nrvnuct the project (Sec. 7044. Business and Prdesions Code:) The Contractor's Li
ase Law does not apply to an owner of property who bunds or improves themon. and
QTY. P UM N�1)FRMIIT 17EE
who routines, for such projects with a contractors) licensed prosaic to the Comramnrs
PERMIT ISS P
I.hT^"x Lt.
ImnexanSurrder sec. ,R&PCfm1n,.ram
Owner Date
ALTER-DRAIN&Vii A'lll tA)
VALUATION
WORKER'S COl,olpr Al'I(IN DECLARATION
HACK PLOW PROIIiCf. PIiVIC,I'
of nn-
I hereby of f irm under pmmlty of Pctjnry onu nl'the following d
..k,r,
❑INnu andcall( I., by Labor iunmli�msmvf^efforr',Cmtytche
sada^, as provided for by Semina 3]00 Of she Labor Code, for the performance nl the
DRAINS -FLOOR, BOOP.AItIlA,COND.
S'T'ORIES
'I'YI'13 CONSTRUCTION
work for which this permitie ork
FIXTURES-PER IRA['
I have and will maintain Workerr 's Camphor[lie Insurance, required by Section
ruof she work for which this permit is issued.
PINI of the Lahr Code, for the permmnce
OCC. GROG P
APN
GAS - EA. SYSTEM- I INCd OUI'LBfS
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. Foley No.:
GAS - EA. SYS I"EM-OVIi . FA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
.,pp,,
CRF.ASEIINDUSTRI. Win.. INI'IIRC
BUILDING DIVISION FEES
fDli, section need not be nnnplcmJ if line pi is for onehundred dollars 1811110
or fun 7
GREASE TRAP I
LANCHP.CK FEE
I certify that in the p,,fonmone, mine ,irk for whish(his permil is iswed, lehull
nm untploymty parson in any mannero rob, becnrno inject to the Workers'COntpmt.rml
SEWER - SANI'FAItY - .l E
NEItGY PEE.
WATER HEATFIt WOVEN 1 dLIIC'1'It
ItAUING PI3B
,union Luwx of Califamin. Date
NO ICF In APPLICANT: If, Aur making This Cenlfiwle of Exempting you sI old
heenme,ubjun to she Worker, Cnntponorimr provision, of the Lahr Code, yo^ mu,t
WATER SYSTFNVI'R17AI NO
ALS FEE
WATER SERVICE
fnrhwith comply wind inch pmet siansnrIli, procia,dull he deemedrevoknd.
CONSTRUCTION LENDING AGENCY
1 hereby of irm that there is a constriction lending agency for the permor anee of
NEW RESIDENTIAL PLMB. SQ, FT
PAID
Date Rccei to
P
the work for which this Pemtii is issued (Sec. 310)], Civ. C.)
Lem Joe, Name
TOTAL:
Lenders Address
TOTAL:
BUILDING FEE
1 rectify that I have read this opplicmion and euro that Be above nomination is
QTY. MECHANICAL PERMIT ITE
SEISMIC FEE
ren. l agree to comply withal) city and ontyordin:mce,ind,late law, relating In
huudina,om m tied, and hominy amharizc o prelenutive, of this ehy to Inter upon Ne
PERMIT ISSUANCE
131.1?CfItIC
^bnvo-ntu cur ed properly forin,prolon, pnrpns^'
( We) agree m, ive, Indemnify mrd keep ltamdms the Ciry m Cupertino nguinsl
ALTER OR ADDTG MBCI I.
PLUMBINGeV
liabilities.jmlgmenlLavteaudaapi whiuhnuty nnny way accrue aguimlmid City
to anw,prence of the granting unit, permit.
AIR HANDLING UNIT CTO IO.0d0CFM),
MECIIANICA .
APPLICANTIk ERSTANDS NIND WILL COMPLY WITH ALL NON-POINT
SGURC � UfA'fIONS.
AIR HANDLING UNIT (OVER R1,0R0CFM)
CONSTRUCTIO TAX
�- ('
Sigmm�rh pelican cont
HA'LARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(WMUCI)
HOUSING MIT'ATION FEE
HEATING UNIT (TO IDkWU BTU)
Will the applicant or more budding occupant,mrc or handle hazonlnu, material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health tend Salety
Cade, Senior 25532(a)9/
HEATING UNIT (OVER INo,INN) H'1'U)
VENTILATION FAN (SINGLE R IHSID)
❑Yee Ism
PAID
-
Date Rcceipta
BOILER- COMP (31111 OR 1000010 BIT)
ent or Quit,,, viro,whie.I
ct Byse Are.
Wndurl!in Imhm Or unumceml a building wittlby
mil hamNnus oh conumimnls al def nal by the Buy Arcv Air Quahy Mtmogernent
Uvtricl]
Yes
BOILER -COMP (OVEN IN) (IN) p'fU)
f
AIR CONDITIONER
1 have read the hazmdom materials requirements under Chapter 6,95 of the Cali.
mmio Honth & Safety Co&, Section, 25505, 25533 and 25531. 1 understand that Vthe
huildingJm,nen amnJy have thin it is lnyrespnnsibility to motif'armoven vin
ISSUANCE; DATIE
_j O Q
iC. (C/ f
NEW RESIDENTIAL MECH. SQ. FT.
rent
of the m is which mu t Issuance of a CeniR a kcuryy.
ISSUED BY:
TOTAL:
Owner nr prized agent me
OFFICE