00050134APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
INV ✓�
SANITARY NO. C NTUBWMALDATI
BUILDING ADDRESS;
10000 C) iz- A E uE
5 -/3--6v
WNER'SNAM:: PHONE: e- !
PPLE m vTt� �1 -3 �l
CONTRACT(IHSNAh1G LIC NO:
So ni DI 1 6-3we
❑
/% CONTROL #
4 4/
RCHITELT/ENGINF:F;H: LIC NO'.
$O
ADDRESS:
511 VIVA in 5 - L -
CONTACT: IVON,{{Ii:
I - g65
❑ Consultant Fees Paid by Applicant (Initial)
HUIhUING PERMIT INFO
BLDG ELECT PLUMB MECH
&Cf 4'b%-(A1BM
[2� TB IS to
LICENSED CONTRACTOR'S DECLARATION
hereby arum that I am licensed ander provisions of chapter 9 (commencing
with Section71XXB of Olviom,3uflhe Businexsand PadaWair, Cedle,and my license rs
Clrxand ufYec'. a IJa# s5oit 7.4-
Utile �� Contrucex G"�I'1 13N CawT(
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL,
CSFDWL CKITCHENREMODEL
CADDITION C PLUMBING RE -PIPE
(I MULTI -UNIT []STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
O BATH REMODEUREPAIR ❑DEMOLITION
❑OTHER
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PERMIT ISSUANCE
APPLIANCES - RF,SIDENTIAI,
ARCHITECT'S DECLARATION
I undcnJyi�Lrd my phos shag b,/Ised as Public mc.ros
`.I/J /l. �//
PANELS
UP TO 2q)AMYS
Licemed Pm�
OWNER -BUILDER DECLARATION
I hereby .111 mal 1 am exelnpl mmI'lc Commnmrx LI ave Law for the
lotowing rcas.m. (Section 7031.5, purines, and Profession, Code: Any city or county
which requires u p[nnil In construct, alter, improve, demolish, or open, by vinn ure
h permit'. flcsigstmeml
s.an.al.so requires the applicant formcaneden
prior to itsrtce
he is licensed pandentto the provisions ofine Contmctorx License Low (Chapter 9
(commencing with Section 7000)of Diviona 3.fthe Buxineoinnd Professions Cale,.,
'hat he is exempt'hercOmm and the hmi% for the alleged exemption. Any violation If
1591101tsh%uhie.¢'he nppllnnuu.civil pcm'Ity of
thala5tti ap,linno
ern Section
Lns owner ofine ntnnn lis 'th wu•es w'M1air rolernm 'run.
pn4< e Y n is of in ndedwi b Mn*'
will dnlh.wmk. node: The m rano intended se Law doesed atasale ply to an Business merif
wdsuch-ak hams an.wner.f
ono Professions Code: The selthereo Lind who
progeny who builds or improves thcrcmn, and who cites such work himself or through
his own employees, provided that such improvements am nm intended or uffertd 4n
sale. If, however. the building or improvemcm is sold within one yem ofcomplc'ion.'hc
201-11X0AMPS
OVER Ilast AMPS
0 SIGNS IILECIRICAL
)0 SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST
COMMER.IA
C NEW BLDG/ADDITION C DEMOLITION
''TENANT ❑ PO(1U SERVICE
OTHER EMI?NT
❑OTHER
1'091?R DEVICES
SWIMMING POOLELECTRIC
Z OUT LETS-sWITCNLS - PI ES
NEW RESIDENTIAL EL[CTH SQ Ng
SQ. FT. FLOOR AREA
b/SQ. FT
+want-huilder will have he burden .I' proving (hot he did not hold or improve far pur-
poseof sola.).
C Las owner nf'he progeny, am exclusively eontmaing with licenced comrasuu%m
TO
QTY PLUMBING PERMIT Qv
mmuctthe pmjeal (sec.7014, Bnsiows and Professions Co e:) The Cortwor's IJ
se law d«snot apply t. an owner nfpmpcnY who huBds or improvevMrcun.and
who contracts for such projects with a connotations) licensed pursuant m the Con'racmrx
t PERMIT ISSUANCE
License Law.
❑ 1 am exempl under . B An P C fill 'his reason
W' KER'SCOMPENSA'11ONDECLARA'1'ION
A A 171 - DRAIN & VENT'- WAJ ER (EA)
VALUATION
,�BACK FLOW PROTECP.DEVICE
I hereby trm under penalty(if Perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consenttuself-inmrt for Worker Campcm
%mien, as provided for by Section 37M ofine labor Code, for the performance of the
work for which this permitis ismed.
!
L}- DRAINS- FLOOR. RODE AREA. CONE.
STORIES
TYI'Ii CONSTRUCTION
FIXTURES -PER TRAP
C 1 have and will mulnmin Worker's Cmrgensntion In.annme, ax requital by Section
3IDO.f the lama C,,de,I...In, gcrt',,rnonalo011e work liar which this pcnni'Is issued.
GAS - PA. SYSTEM -1 INC. 4 OUTLETS
OCC GROUT'
APN
AYGAS -IiA. SYSTEM OVEHJIEA)
My W'nrkcr's Comrynsmion 1pxurun Yrimr.By,Ntiy nye M1c�r :Ju
CatrWb �Uk�Xnch ND,O "'�IZL Z,OS
1�q••O,g���
J I L
GRE ASEIINDUSTRL WASTE,INTERCEPTOR
CERTIFICATE. OF F,XEM PTION FROM WOR KERS
COMPENSATION INSURANCE
BUILDING DIVISION FEES
Z
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Z'NOTICE
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C�Ccorrect. teI
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(This section need not be compleod ifthe Permit is for one hundred action D100)
nr In,,)
Iccnily that In the peraminincral liewerk forwhich this permit is issued, l shall
nut employ any pv,,air many manner so as to he�y £Fst�) '' m the Wurkeel Cnmpen,
cation lawn nl Calilirtnia I b 11 T1�
GREASE [RAP
PLANCHECK FEE
SEWITR- SANITARY - STORM EA. 2W FT.
Iils ii PEE
WATER HEATER W'NEM'/ELECI
WATER S1'STEM/BEATING
GRADING FEE
Applicant r }�"
TO APPLICANT': It: tier raking this Cenificam of IixemP'ien, y.a should
become subject,, the Worker's Compensation provisions of the IaMm Code, you mus'
forthwith comply with such provisions or this permit shall be deemed revoked.
CONS'I'RUC'I'IUN I,IiNDING AOI:NCV
Iherebyaffmn'hanhere is a conaure;mn lending agency for the performance of
the work for which this permit is issued(Sec. 3097. Co. Cr
Lenders Name
Lendda Address
SOILS FEE
WATER SERVICE,
PAID Date Receipt
NEW RIiSIUEN'flAh PhMB, SQ. 171
TOTAL
TOTAL:
BUILDING FEF,
1 renify'hot 1 have mad this application and state that he above information is
s ret. l agree to cmtply with all city and county ordinances and slam law—chningm
hrildingeoustruainn, and hereby a...it ivn representatives of this city to note, upon live
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
I PERMIT ISSUANCE
ELECTRIC FEE
nhovctnemamod propedy III, inspection Purposes.
(We) agree 1. save, indemnify and kee, harmless he City of Cupertino agaimt
Iiubili'ies,judgmnas, costs and expenses which may in any way accedeagelnaudd Coy
I ALTER OR ADD TOMECH.
PLUMBING FEE
I. c.nscgoerce of 'he granting of (his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT RO 10.000 CFM)
MECHANICAL FEE
SOURCE RB�R1TTfO
`La,
vv-- SII�I{pp
AIR IIANUhIRGUNrI'(OVF:H W,00() CFM)
CONS'TRULTION TAX
Signature of Appli ndContmctor Date
EXHA US'I11100E IW/DUCIO
HOUSING MITIGATION FEE
HAZARDOUS MAI FRIAL.S DISCI OSUkH
Will the applicant., future lmilding occromm,mre nr handle hxrarduos mmerml
ax defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
rode. Section 25532(al.
❑ Yes Nn
HEAT( NO UNIT ITO ioo.000 H' N)
HEATING UNIT (OVER 101.0X0 BTU)
PAID
Date Reccim#
q
L VI1N'I'ILAUON FAN(SINGLCRESID)
Will the applicant or future huilding occupant use equipment or devices which
I, hircoh as air ammminants as defined by the Bay Arca Air Quality Management
I{OIL L'H -COMP (3HP OR IIX1IXq RTU)
BOILER
TOTAL:
BOILER-COMP(OVER I00.001BTU/
'
UismeC
y
C Yet XNo
1 have read the h aa'd.us materials requirements under Chapter 695 mooCuli-
Boma Health & Safety Code, Sectimu 25505, 25533 and 255341 understand that ifarm
AIR CONDITIONER
ISSUANCE DATE
�)
NEW RESIDENTIAL. MECH SQ, FI'.
'sonobilhy to...ifydtecnp I
odyhave unanh Xtxthisroy re.ie
mildi nulcnrrcw
uvmemv
7
which mu act prim t. ivsaarceafa Ccnifill" r �cupuncy.
5 l oo
ISSUED BY: �O
TOTAL :
owner ora horimo agent Date
OFFICE