S 2069APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMuwc- MEcxnNICAI.
NUIIAING PROJECT IDENTIFICATION
PE IT NO.
2069
BUILDING ADDRf:Ss.
SANITARY NO.
APPLICATION SUBMITTAL DATE
yrs- �S"�a����
OWNE lq E Pit( es
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CONTRACTOR'S NAME: LIC NO:
NIC
❑
CON 'BOLp
/ARCHITECT/ENGINEER: LIC NO'.
�7
ADDRESS1114, : eAl eve
caNTna': PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
ELECTPLUMB MECH
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LICENSED CONTRAC'TOR'S DECLARATION
I hereby affirm drat I am Beensal ruder loci,ioa, of Chatter o mammenciag
withSsfion9BlHq of Divixi.n3of thcRminOvs anJ Pr..fkssi.ns Cade, unJ mylicemcis
in full (ors and
Liansc Cles Chain 1
4/n
Dnl CanlmCln
ARCHITECTS DECLARATION
Icode ... Gamy Plans shall be .,oil as none me 1,M1
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑ SPDWI. ❑ KI'I'CHIiN REMODEL
❑ADDITION [I PLUMBING RE-PIPE
El MULTI-UNIT ❑STRI] RAL
'[CATION
El INTERIOR CHIMNEY REPAIR
PERMIT' ISSUANCE
APPLIANCES
PANELS
UP TO 200 AMPS
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ij
O G U
3 m m
ijOd
my•1
dO
{y Qo q
admW
til ..y
Hyp.
�dElIasownenIfB
W m
IMPROVEMENT SWIMMING POOLS
[I BATH RF;MODIiVRIiPA1R El DEMOLITION
❑ OTHER
Cj/L/�+yi /Z[I�ls/L
Lact... it Professional
OWNER-BUILDER DECLARATION
I hereby closer dim 1 am radio, roam Inc Cmnrmhurs License Law for the
following reason. (Senior ]0311, Business and Przdeasiane C.du: Any cit.... .nuns,SIGNS
whim requires a pumit t. construct, alln,, improve, demolish, ar repklr hey errcfu a
poiorlea,,,maneG also requires the applicant batch permit to file it signedxWtemcnt
that heis licensed pursuant to the provisions ..fthe Contractor 's License Law (Chapter 9
(commencing with Section 7000) of Division 3 offle Business and Pmtcssion, Code)or
that to is exempt therefrom and the basic for the alleged exemption. Any violation of
Nation?031.5 by anyappli7m far apcountnibla¢ theupplioant Carr civil penalty of
nal marc,ban tied hundred dollars ($500). -
y reproperty, or memploys, I in wage as their coloeterco,atirn,
will dothe work, and the snncmm is nor intended or offered for sam(Sec. 904, Business
and Professions Cade: The Contractor's License Law does not apply In an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for
sale. If, however. the building or impmvem..n(issold within one year ofcomplGiae the
cf-builder will nave (he brander of to Air, Ibal he did had huild or improve for par-
201- Bud) AMPS
OVER IfHH1AMl'S
ELECTRICAL
SPECIAL CIRCIIITIMISC.
a
"I EMP METER OR POLE INS'K
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑'rE:NANI' ❑FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOLELGCTRIC
OUILHTS-SWITCHES-FIX'1'UR
NEW RESIDNNTIA), F.LECTR P1'.
SQ. FB FLOOR ARTA
VSQ.pr.
pow of ,ala).
❑ L, ac owner of the property, am exelrowely corwming with licensed mnnfor mb m
TAI'
cold...[ the prjsl (Sec ]M, Buslkeas and Profeounts C.de) The Contractor's L1-
nse Law does no, apply toxrowv,ol properly who build, or improve, mercon,aad
QTY. PLUMBING PERMIT _FEJP
who chambers for such projects with a contractions) licensed Inicamon to the Contract., s
PERMIT ISSUANCE
License Law.
❑ I am exempt under Sec. ,B& P C for this reason
Owner [IIIc
ALTER - DRAIN & VENT - WA'T'ER (EA)
VALUATION
WOR KERS COM DE CL
BACK PLOW PROTECT. UEVICIi
ll unn ender peachy of my on folhavON
a", or Pon, of the fol having declarrWorkers Co
ve and w ofComene
[have parvidl for by Sectirli 3700 of the Labor Code. bum for Worker'e Camped-
smirk, as hwOhd for by Sermon 1700 of the Labor Codd, far the peri iron.. of the
war
Worker's reame n Insurance, as required by Section
kem,canch turret oriental. aster
�havc and will
DRAINS-FLOOR, ROOF,AREA, COND.
ORIpS
'L
TYPE CONSTRUCTION
/� ✓
FIXTURES-PER
rod,, for
3'100 nr the Lebon Cude, for the perfomance of rhe work lbs which this permit is issued.
nDIE,
GAS-EA.SYS'[EM-I INC.40U'I'IE'TS
OCC.GHOUP
APN
My Wrrk Cninpmrsmjan Insurance enrriernnA Policy number arc:
Car rieA/Hua- Policy No.d2l'�-29D30^�
GAS -EA. SYS'I HMOVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
INSURANCE:
CRIiASRIINDIISTRL WASTE INTERCEPTORCOMPHNSAI'ION
" BUILDING E N SION_PEES'
(This section haul not becomplmcd ifthe Perini( is intone hundred dollars(S100)
ar les,.)
GREASETRAP
-
PLANCHECK FEE
I certify that in,hepenbrdnanee offer work form hich this permit is issued, I sthdl
annerso as subject to the Workers' Comped-
not employ any person in any me b
SEWER-SANITARY-STORM IA. 200 FL
ENERGY F[N
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aalion Luwaof Callfnnia. Date _
WATER I IEAGIR WNIiNTIEL laiii2itGRAT
NG FEE
NOTICE TO APPLICANT: If.utlermakikgthis Commraeor Esemphr I, you should
become subject to (hes Work,,', Compensation provisions of the Lati Code, you mus,
forhwith comply with such pr..vi4me..nhis penni(sM1nll bedecked reversed.
Cattle isacIONLENUINCACENCY
Ihereby affirm hdelfachdreiaawnsfee 3097, Ce, agency fine. perfommnsof
me w.', far which thio terndt a„aw (sea. 3pH), cie. c.)
Lender's ddre
WAI HR SYSTEVPTREATING
FEE
WA'F'ER SERVICE
1
Urate RsciplN
c
NEW RESIUENTIALPLMB. GGIFV 1
TOTAL:
n padre=s'rargl.:
LewerA
.I ING PHH "! •Oo
SEISMIC FEE
I srtily that l have read (Insapplication and slate thin One have inrabouli i is
correct, I agrectoa.nply with all city and county omlkunces and share laws relating to
budding cob,tmction. and hereby awhnnrercpmsenlalivesol di, oilym enter upon the
_
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
FEE
above-ormlibi al propety for inspection putpow,
ify and keep harless the Cil, of Cupertino againstELPUTRIC
, indnnm
(We) agree m sivam
ALTER OR ADD TO MECH.
PLUMBING FEB
Iiabl fies,judgments,cna,e and expenses which may in any way accrue against said City
anenee of the granting of des pann(.i
In ..r.y
AIR HANDLING UNIT CFO 10,010 CPM)
MECHANICAL FRP. -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL. NON-POINT
SOUR%REGULATIONS.
AIR HANDLING UNI 'I'(OVER 10,000 CFM)
CONSTRUCTION TAX
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®/p�q�p.
V V,
&gnmure of Applies bnuneror Date
AZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD OVIDUCT)
HOUSING MITIGATION FEE
HEATING UNIT CIO ((10,010 H' IVF
Willme applicant or future haildingasrrolidsme, handle hsvmloasnuuenal
is dermal by the Catoctin. Mericiprd Cade, Chapter 9,12, and (hes Ilealth and Safely
Coda Section 25532(x)9
1 Y" E] No
Will the Dmad, or fume had Ding.aupam use ema,unem or devices which
chahairdens air concomitants; as refund by [tic lin, Area Air Quality Management
❑Ycs ❑N.
HHATINO UNIT (OVER 100,000 BTU)
]
PAIIII�6%51_k2
Dae Resif, p
VENTILATION PAN SINGLE REBID)
BOILER- COMP (THP OR 100,000 BTU)
IOTAL.�,r Sq
BOILER- COMP (OVER 100,000 BTU)
AIR CON Of I'ION EH
I have hwmdonc underC fl95 of the Call-
ISSUANCE DATE
NEW RESIDENTIAL MECH, SQ. PI'.
Safer n..materials 5, 2553 a 1 mid ,hocif Ono
the
building does nomurandy hove a mnanh,bm it is my msponsibilify fa notify the auvpanr
IN. Heals&SnfrreCode,Sections,fouri 25533and 25534.1 to notify
t
nf,he requiraneat, which mrd be mel poor,. lasmn.e or. Certificate of Occupan,
s
I�tObsadccr
NSUEDBY:�e- 'T"�'�-C
TOTAL:
or authoI agent Dare
OFFICE