31009 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. - PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 31009
BUILDING PROJECT IDEN1'IFICA'fIOS
BUILDING ADDRESS: SANITARY NO. APPLICATION SUUBBjMII TTAL DATI
l 0 1 �i _�e2
OWNERS FAME: PHONE: C.NTRAC0NAME: LIC NO
S iA :IND Lr�COMEOI.«�f�g
.\RCHI C ;S UENGINEER: LIC NO: ADDRESS ❑ (�(, 2 ['rr
�
ao Sri , LLL/// '7lWVT
CONTACT: PHONE: BUILDING PERMIT INFO
IM-247
f� /_ / O ❑ Consultant Fees Paid by Applicant(Initial) III DO ELECT' Pf- n MEC
L
LICENSED CONTRACTOR'S DECLARATION �D QTY ELECFRIC PERMIT FEE LTJ! LrIW/ L^J/
I hereby aifinn that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WIZ with Section 7(XX))of Div ision 3 at the B-im,,wd Profession,Co Ii,an&ny1mero,is
F�� in roll Tome wJ d(ca. [[ rn�' PERMIT'ISSUANCE
=UI- License Class Lit,N FDwL ❑KITCHEN RF'_NODEI.
E-Z ul Dne�I'S UI7wr ��. APPLIANCES-RCSIUEM'1A1. []ADDITION ❑PLUMBING RGPII'E
..My AR il'TF.CT:S UIiCLARRUO PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z p y Z I understand i y pluns,hall be used as public records �y MODIFICATION
O ff.4-a UP TO 200 AMPS ❑INTHRIOR PAI
rD CHIMNEYREPAIR
F.H.F 42 Licensed Pmfbsalmn.1 - 2111-IIXNIAMPS IMPROVEMENT �J
Oat I am BUILDER DECLARATION
OVER i0 AMPS ❑BATH EL/REPAIR ❑DEMOLITION
C Q I hereby,Toted that 1 em cacmp(from the Conlra<tor.License law for the
3 LLU following mason.(Section)UJ L5.Business and ProRsians Carle Any city or county SIGNS ELECTRICAL ❑OTHE
H wmm�rcgnha a n<rna(m<aneweL alto,in,parvq aetmlinn,��r repnh say xtramam
prior to its issuance,also requires the upplicmt for such Permit to rile v signed statement SPECIAL-CIRCUIT/MISC.
f Y that be is liceoeed lam rad,to the provisions of the Cammmares tacmne taw(Chapter 9
0a Icnmmencing with Section IOW)of Division J of the Bmincuand PmPoe,ions Codt)or 'r EMP.MIT ER OR POLE INST COMMERCIAL: s f(��!sJ',G
L E m C Nm he is exnnp((humGnin and(he bootee Rrt the alleged excntptinn.Any vlala(ion of ❑NEW BLDG/ADDITION LJ DEMOLITION
u' Section]031.5 by any applicant for a permit subjects the applicant to acivil penalty of POWER DEVICES
H not more Nan fire hundred dollan(S5W). []TENANT ❑FOOD SERVICE
F.
�I,at owner f the property,or my employees with wage,as(heir sole unnpemation. SWIMMING POOL ELECTRIC IMPROVEMENT
p. will do the wart,end the x(mclace is nal cleared.,.hired for sale(So,.9M4,liasiness [:1 OTHER
W —3 m and limitations Cote:The Conductor's License law does not apply to as owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves Ihemon,and who does such work himself or through
his own amployces,provided that such imico vemam are nor indented nr otYcred t'or NEW RESIDENTIAL.ELELTR SQ FI'.
sale.If,however,rhe holdiegof improvementis.vold within one yenrol ttnnpletinn.the issO i � SQ.IT.FLOOR AREA VSQ.Pf.
tambu
er-builder will have the rden of proving that he did not build or improve for put-
pncofxolcJ. �o1
72 40
O I,m owner of be Pmpcny,um eselusivcly ren nc,no,wilt licensed omeach-ter `
ctM1 projectp ( Business and ProfcoComnaas Li-
aems,Law does
m,raply,.an c- cimpose,
nn.and QlY. PLUMBING PERMIT PEE
woocomunn foraucn pmjccu with ucantrvaortp licensed parnam tothe Cenvvctr
License Law. PERMIT ISSUANCE
❑Iamtaemptander Sec. ,B&PCronhlsrc ,m
Owner Deem ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DF,CL.ARATION 13ACK FLOW PROTEC'E DEVICE ^( h
I hereby afoot under penalty of perjury one of the following dectisfuni 2 1 �A
�U l have and will maintain a Certificate of Consent to ocif-nsam for Workers Compen- DRAINS—FLOOR.8008 AREA.COND' STO .S 'TYI'Ii CONSTRUCTION
cion,ns pro.not for by Suction 370)oI the Lahnr Cada f r the perfomunce of(he
work for which this permit is issued. FIXTURES—PER TRAP
O 1 have not will maintain Workers Compereation Insurance,a,required by Section
TIW ofthe labor Cita for the p<rformance of work for which this permit is issued. GAS-EA.SVSTEM-I IN UT.1rTS OCC GROUT' Ali
My Wnrkm'.Cninpcnsation Immhmco curia and Policy numhvare:
Carrier Policy No.: GAS-EA.SYSTEM-OVER,( )
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GR6kSFJINDUSTRI.WASTi' ERCEI HU ,DING DIV SIGN PEES
(This wiionameal of hecu optimal il'Ihe Nish,1,bate hardredinllus Pi Ddi GREASP,TRAP
or leas.) PIANCHECK FEE ,i
I rectify that trim,leeformence of(he work for which this permit is issued.l shall MME
nm employ or so as to hre Moe sub'ccuo the Workers'Com SEWER-SAN19'ARY-$TORME .Z( V
p y nny lermn in any m ) peed ENERGY
Z sa(ion laws of California.Date WATER HGTER W/VENT/ELF.CTR
Z O Applicant NOTICEubj APPLICANT:IL after making thin Crninca t th Gabor o d you should WATER SYS'I'EMGREATIG �\become womply the Wonkus Comtism this i mvislnns nfthe LuMrr Cole,you ecus funhwith comply with such provisionwrthis pcminhall be deemed revoked. WATER SERVICE
CON$TRUGTIGNLIiNDlNGngageCY NIiW NESIDIiNT1A1.('LMB. SQ.FT.VQ I thereby kFar.1aflirrtthelthemmiti iv(ctd(Secti3097.Cing agencyint the perlrmanccof ReceipU� � F' the work Por whichthis permit is ivuul(SaJ119].Civ.CJO ULcndds Name TOTAL:Leaders Address TOTAL1 certify(hat 1 nave read this application and sum that(he axwe information is Vi cannot.l agree m comply with all city and county ordinances and pate laws mithingto QTY. MECHANICAL PERMIT FEEZbuilding mmuorion.nnd hembynuthance representatives ofthiscily to toleration the
aMrvammn(ioncd property for ingectian purpasree. PERMIT ISSUANCE(WO agree to save,indemnify and keep b rmlos the City of Cupcnino against ELECTRIC FEE
Liabilities.judgments.Costs and expenses which may in any way ammeagainsl said City Af]ER OR ADD TO MECH' PLUMBING RiB
in ueyucnce of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL.COMPLY WITH ALL NON-POINT AIR HANDLING UNU'(TO 10.(MCFM) _
SOURCE REGULATIONS. MECHANICAL FEL
LIZ AIR HANDLING UNIT(OVER IO.000CIIM)
6� CONSTRUCTIONI'AX
Signummaf Applican/Contractor Due EXHAUST HOOD IW/DUCT) HOUSING MITIGATION G
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant mre or handle hvmrdrus material HEATING UNIT(TO I W,M)BTU)
as oil tied by the CuEenlno MmomEul Cade.Chapmr 9.12,and the Health trod Safety
Code,Section 255]]1.1! HEA'TLNG UNIT GVER 100.000 BTU)
❑Yet ❑No
VIiMILATIOE FAN(SINGLE RI3SID) PAID '
Uau Rcc IM
Will the air contaminants
aminfntorc building occupant use ea Air u or devices which
^ithavrdnm air con(amiwmx as Defined by the Bay Arca Air Quality Management BOILER—COME(JI{YOR IW,IW BTU)
Ui,llt<(^
TOTAL,:
❑Ycx E]No BOILER—COME(OVER Ig1,tXX1 BTU)
I hove read her haurdous mwerials AIR CONDITIONER
t5,2553 ,minder Chapter Carie ISSUANCE,DATE
hsmiu gdoesHealth&Safety try hale.ve
e a Sections 155115,is toy and 155Ja.I I understand(ho(if the NEW RESIDENTIAL MECH. SQ.FT
bathe re Jaen not currently Luse he me,p th:m 1(is my responsibility hftcla a idf(the tsccupam
of the rtquimmcnu which matt be tact prior m iuuance o!a Ccnincau of Occupancy.
Owncne aatbnrimd agem Dale TOTAL: ISSUED BY;
OFFICE