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CITYOF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIOWERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
lawww"r imp
BUILDI�NGAUDRLSS:
SANITARY NO.
APPLICA'T'ION SUBMI AL DAT
i/
21I � e /49-
W
L ((
OWNER' AM'- PEON':
NTRACIOk'S NAME: LTC NO
N/C
CONTROL#
a1
❑
RCBfTECTfENGINEEK: LIC NO:
QD RtiSS
Co PHONE:
BUILDING PERMIT INFO
k
❑ Consultant Fees Paid by Applicant (Initial)
BIAG Ei IiC'I' III UMt BB MECH
s V/
❑ ❑ tl ❑
LICENSED CONTRACTOR'S D.CLARATION
1 heresy of firm Inas 1 am licensed under Provisions of Chupmr 9 (Cmmmencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
with Sccron ]aro) of Diviwi0n J aflhc B.,Incssnnd�Pn,fisrion�r Crwc, one my Ikcnsc ix
holl -H4Hi'
RESIDENTIAL
❑SFDW. [I KITCHEN REMODEL
APPLIANCES - RI?SIDENTIAL
Livemse ClassC-- YnL o
Dae CCo.'nt .mr I
❑ADDITION [I PLUMBING RE -PIPE
❑MUI1H-UNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT C] SWIMMING POOLS
ARCHIT[CI'S DECLARATION
I understood my plans shall M used as public record.
PANELS
UPTO200AMPS
t Licensed Profooinnal
201-1000AMPS -
OWNER-RUILUGR DECLARATION
nreaso . (Sect Ina 1 1.5 aBusiness an the Cnmrns Cc I.iAry v Law co the
and Professions Cole: Any citynr county
t following reason. (Section 0onstr
❑ BATT] RF.MODEUREPAIR ❑DFMOLITION
[]OTHER
OVER 1000 AMPS
SIGNS [LF,CI'RICAI.
.ihe
i which requires permit to coname, alcor, improve, demolish, rtpah any swment
SPECIAL CIRCUIT/MISC.
HiQ
It
issuance, fi
' thil he slts esedp..lmit... the the applicant for such petor, icense ae Law (Chapter
#Section 0thc(if Diviam of the eRusiucrsndfsroc Luw(Chamcr9
(cot he is ingwitM1hereirom and of basis] raflha Business ption.lcsy i l.,i.nCo1if
tcounneliang with
that he is exempt therefrom and the basis for the alleged enemptinn. Any violainn of
TEMP. METER OR POLE INST.
,v—�.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑DEMOLITION
POWER DEVICES
• Section 7031.5 by any applicant for a permit subjw% the applicant Io a civil penally of
t more than five hundred Jollurs ($501). 1
1 E]I, ax owner of the
far sale(Sec.2044. Business
pestruc,mmyot intende withwugasrsale(sent. wvrmpcusines,
will Jn work, and the structure is not intended or offered
El TENANT ❑ FOOD SERVICE
IMPROVEMENT'
❑ OTHER
SWIMMING POOL ELECTRIC
OIITLEfS- SWITCHES - Fl%TURFS
License Low sees nor apply to an owner of
i and fie whom Code: The do
oomraaois
• property who hail,, or aided h thsuch i and who docs such work himself or Through
ony
his own employeese provided ohm such nsom is sold. arc not intended or offered for
yule lT. M1uwevpq We building orimpmvcntem is solA within nneywr nfeomplution.the
NEW RES IDENTIAh 10,GCT
SQ 17. FLOOR AREA
$ISQ. PT.
ton o-timilder will have the burden of proving that he did not Wild nr improve for pur-
pose m wale.),
I] 1, as owner of the property, am exclusively cnametin, with licensed contractors to
O
mu not Inc project (Sea 7044. Bovines, and Pmfeweunits Code:) The Camuao', Li-
seLaw does oro apply to an owner of pmpery who builds or improves thereon. and
QTY, PLUMBINGPERMIT 'EE
who contracts for such Projects with a contract -TO licensed pursuant o The Contractors
PERMIT ISSUANCE
License Low.
O I ire, ese,nm muter See. ,B&PC for reason
ALTER - DRAIN & VENT- WATER (EA)
Owner nae
VALUATION
'
WO COMP ENSATION DECLARATION
BACK FLOW PRITf[CT. DEVICIi
1 hereby affirm under penally of perjury one of the Billowing declarations :
tunde,S
Iha,cmm will mminaina Ccrtllicumof CnnserHowd-iamre fm Worku', Cnmpeit-
ration, us provided fur by Section 3]011 of the Labor Code, for The performance of Te h
DRAINS- FLOOR, ROOF, AR EA. COND.
S'1 ORIFS
TYPE CONS"TRUCTIC
work fur which This permit is Issued.
FIXTURES - PER TRAP
1 have and will maintain Warkds Compnation Insurance, as orsimmd by Section
3700 AIhe Lubar Coda for the perfo ranco fthe works r whichh thhlx peon, it irrurd.
I�
Carriur:rkdC peu'i ran a cy NoPolic.: q,9pyeJ/w-31
GAS-ITA.SYSTEM-I INCA OLI1'LETS
OCC. GROUPMy
/�fP /�
..J l/
GAS-17A.-OVER4(EA)
CERTIFICATEG(EMEMON FRO INWy#*' V79
COMPENSATION INSURAN h l�� -'
(This,ectinn nmJ not bac complutaJ if The pemuit la for one hunJrtd dolluca ($IIID)BUILDING
or less)
GRGASfIINUUSTRL WASTEIM'ERCEPTOR
DIVISION PEES
GREASE TRAP
PLANCIIECK FEE
SEWER - SANITARY - STORMFA. 200 F1
I certify that in the performance ofthe work for which this permit is issued. l shall
not employ any person in any manner so as m become subject o the Workers' Compen-
ENERGY HE
WATER HEATER W/VENT/P.LECI'R
satins Lawsof Culd co, Dam
t Applicant l
GRADING FEE
j NOTICE TO APPLICANT: IL after making This Cenificae of Exemption, you should
become suhjeft to the Worker's Compensation provision, of the Labor Code. you must
NATER SYSTEMOREATING
SOILS FEE
WATER SERVICE
forthwith comply with such provisions or this permit shall he deemed revoked
NEW RESIDENTIAL PLKIB. SG, FT.
wr
CONSONLENDING AGENCY
j Thereby affirm that then isisaconstruction lending agency for the performance of�
119],
The work for which this permit is issued (See, 3Civ, C.)
nder
Lender's Name
PAID
DoleReccipTp
TOTAL
t LcndcLs Addrcwr
TOTAL:
1 certify that I have read this application ani state thin Ne abrve informaion i.
BUILDING I EE
eoRCcn.l agrcn eccomply wnh �llnry and county ardinnn<cs and wm¢aws reliningm
QTY. MECH NICAL PERMIT FEE
building construction, and Thereby utuhoriac representative, of this city to enter upon the
'SEISMIC II!E
-_
abwoo-mentunced prcpeny for inspection purposes.
(We) agree to save, indemnify it keep hammeas the City mCupertino against
PERMIT ISSUANCE
'
13LECT&'. FEE
Ran ilitiew'udgments, costs and expenses which mayin any wayacemeaipime said City
nscy n o the gmmingof Mupermih
APPLICA 'I C DE STANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE i .ATI 'S.
ALTER OR ADD TO MECH.
TUI
\
PL.UMBINOIFE Ll TC1
AIR HANDLING UNIT (TO I0.000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TT
gnus plicunUCnnwmur Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT) Al
HOUSING MITIGATION FP.
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occuped Aare or handle Infamous material
as iefoed by the Cupertino Municipal Coda Chapter 9.12, and the Health and Safety
Cock, Section 25532m)^
HEATING UNIT( OVER 1(10,0(10111' U)
_1 Yes F1 No
Will the applicant or future Wilding occupant use op ipmem or devices which
thm:Wous air contaminate. m defined by the Bay Arca Air Quality M .... enter,
isniclLI -1 No
PAID
Dae Receipt #
VENTILATION FTN (SINGLE RE.SIU)
BOILER- COMP QHP OR 100.00 BTU)
UTA �
HOLLER - COMP (OVER 100.000 BTU)
CONDITIONER
I hav air -hrutines materialsAIR
rcquimments under C'haptn 6.95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL. MECH. SQ. FL
forma Ilealth u y Car, . odious 25505, 2553] and 25534. 1 understand that if the
buildingJcex ;rvca notion, it is my restihil
nmlrym notify the occupant
/ ) r /1 •Q Q
G
or the require 'ch most be mer prior It, issuance of a Certificat9 of Occupancy.
ISSUED BY: (�
raanorimd.,cut Date
TOTAL:
OFFICE