S 0651APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING . ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT rINGP PROJECT ]DENT [FICA]
BUILDING PR(1JECT IDf:YI'IF1CAl'ION
PHRMI INO,
S 0651
I{UILDINGADDRESS:
q v flrr'
SANITARY NO.
APPLIGTION SUtlMI'ITAL DAI'li
2 �� 4 y
.Wr 'S NAM: 1'f{ NE: jo
r `r' LkO S
Y
LIC NO:
L
NIC
❑
COM'ROLN
ARCH[ 'I ECHENGINEER: LIC NO:
n1DDRI S: �11
f
CON'1'nC'I` 1'HUNfi:
❑ ConMllfenl F.s Paid by Applicant (initial)
I3111LDING PERMIT INFO
BLDG ELFC'I' PLUMB MECH
,� c r
❑ ❑ ❑ ❑
MXZ
'00
�Wf
aUW
f. Z W
rn6a
Dy
ZO Z_Z
LICENSED CONTRACTORS DECLARA1lON
I hereby affirm that I xm licensed under pcoiaia.. nr Chapter 9 (commencing
with Section of Division 3 of Ne Business and Prnfcssion., Code. and my license is
in full forte and c t.
Lice Ia..L1Bg
Ume Co., a '
ARCHITECTS DECLARA (
Iundcmmndmyplan,shalt FcusedaspuMilm ds
Q'CY. ELECTRIC PERMIT FEE
Jp(j DESCRIPTION
RE I;
SFDWI. ❑KITCHEN REMODF
❑ADDITION C] PLUMBING RE-PIPE
❑A1UI.TI-UNIT [I STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWI1h1INGPODLS
❑BATH RE DEIJR PAIR �DF:h LITTON
[_1 OTHER
PERMIT ISSUANCE'
APPLIANCES- RESIDENTIAL
PANELS
UP T02W AMES
W
C C Q
5�' 0 a U
1+13 W lFwhich
�L0as
LicensedProfcs,ional
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt Gom the Contractor's License Law for the
following reason. (Section 7031 5, Business and Professions Code: Any city or county
requires a permit o, construct, alma improve. detiolsh, of repair any swetnre
pro t t •cls yaim, 'he applicantf permit i.b d 4ab,oacra
201.1000AMPS
OVER l0X)AMPS
SIGNS (ELECTRICAL
SPECIAL CIRCUIDMISC.
E y
u�
W Cep
d a etL
7.=G
F
Wa�a
6 3
That 1 I pun n top "m : t th C 1 an I L (Chapter9
leo rumoring Tl Section7(X1)) fD i,7. J fth lbo es dPmessmns Cade)nr
Nat he is exempt Iherefom and be basis for Nc :dlcged cacmpmon. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
net more than five hundred doll... ($500).
1. as owner of the property, or my employees with wages as their sole compensation,
will dothe work. and the structure is not intended or offered for vale(See7] ,Business
and Profes)iom Code: The Cummcmis License Law does not apply it) an owner of
property who builds or improves thereon• and who docs such aork himself or through
his own employem, provided that such impmvemenn ala not intended or offend for
%ale. If. mwcvcr. the building or improvement w sold within one year .f roo plearm. the
TIiMI' MCTI'R UN (•OLE (NST.
COMMERCIAL:
❑ NEW BLDG/ADDI'T'ION ❑ DEMOLITION
❑TENANT ❑FOOD SERVICE
IMPROVEMENT'
El OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHES-FIXTURES
NEW RESIDENTIAL ELECTR SQ PR
SQ, 14. FLOOR AREA
$/$Q. I-C
ovourbuilder will have the burden of proving that he did not build or improve for pur-
j DOTAL:
q,scofsale.).
1, its owner of the property, am exclusively ennlracling with licensed contractors m
convoultl project (S70W R:' s, are1 I:: ,C ) The C tractors L
ss tapply to an owner ,t property 1 h ail i I :thereon. and
who l ts for suchp j t: Th a cfinal OIlenledpul-cto 'he Contractor
Ei�r
QTY PLU ING PERMIT
License Lave
❑ I ren excmpl under See. . B m P C far Nis rearm
PERIOD ISS
L
ACIER-D IN -WATERIER)
VAI ANON
Dam
Owner
WORKER'S COMPENSATION DECLARATION
BACK PLOY E VICE
I hcmhy affrm under penal, of perjury cine of the following declarations:
❑ I have and will maintain a Certificate of Consennn wlf-insum for Workers Compen-
RBS TYPECONSTRUCTION
DRAINS-FL EA OAU.
. tion, as provided for by Section 37M of he Li Cldc. far he performance of the
j� r which Nis permit is issued.
b]/I have nnJ will maintain Worker's Compensation Inwnncc, as required by Section
]00ofthe LaborCode,for the sofimmicacofthe work f.. wPermit is nmcld.
FIXTURES -ITER TR
GAS -IiA. SYSTEM-) INC O .Els
OCC. (iR(]Ill'
APN
GAS -IiA.SVSTF.M-OVERi(EA)
Pillbhaiicchtha,
CamMy wrr .a sat Pol ay No. A_ Ilk(ela`toVOl
CI7. RTIFICATP,O XIIMPI'ION DRUM WORKERS'
COMPENSATION INSURANCE?
GREASHANDUSTRL WASTE INT ERCEMOR
RUII.DING DIVISION FEES
GREASETRAP
PhANCIIECK hili
("is smliunnecdrot becompimed iflhepennu is foams M1undmildollors($B)r)
or Ica.)
iwhich ths,crmil oissved, l shall
Icv'difythal inthe performance of Rework ln
not employ any person in any manners an an lection subject it) the Workers' Cooper-
S17.WIiR_SANITARY -STORM IiA. 20C, FE
ENERGY 19717.
WATER HEATER WNEM1T/EUCfR
WAFER SYSTEM/IREATING
GRADING ITC
SOILS FEF.FTOIAI.:
Z
ZO
F .N.
0
VC)
its
L.)
rat
F y
U z
anion Laws of California. Date
AppBeanl
Nr 11CH TO APPLICANT: If. after making this Certificate of Exemption, you should
leconm anblen m the Workers Compensation provisions of Ne LOMr Code. You must
runM1wiNcnmplywiNsuch pmviniomamispermit shulMdechredre„.ked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that is a construction lending agency for the performance of
the work for which this permit is issued (Ser. 1097. Civ. C.)
Lender'., Name
WATER SERVICE
PAID
[)ate
NEW RESIDCN'TIAL PLMB. SQ. 1T'
TQIAL:
Lender's Address
BUILDING I,lil?
1 certify that 1 have rend this application and stale Ihm he uhove iamrmm on. Is
cored. ngrccocomply with all city unit county mdirnnc.,and Ilam law, relmirg d,
building umsmstion, snit hereby authorise repteacmmivcs ofNll city menteu upon Nc
Q'CY. MECHANICAL PERMIT FEF,
SEISMIC IPh
aMomonenlirredpropemy foraspeninn purposes.
(We) egret m save, indemnify and keep harmless the City of Cupertino against
liabilities.judgmmnls. costs and asperses which may in any way accrue against said City
I'IiRMI'I'ISSUANCE
ALTER OR ADD TO MECH.
F,LECHH 197E
PLUMBING FEE
in consequence of Ne granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
AIR HANDLING UNIT(TO 10,800 CFhH
MECHANICAL IB7.1:
D
SOURCE RF �UL,,rttteRION . .gyp
/ fN __- ^ (�/ �J y
`/ U
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION L$.
Sign a Appll nttazor r--1. Date
HAZARDOUS MATERIALS DISCLOSURE
ous merial
d1 the applicant or future building occupant sore or handle haVaNm
as deli ed by he Culcnin. Municipal Code, Chapter 9.12, and the Health and Safety
Coxlc, Section 25532(4'!
/�
EXHAUST HOOD (W/DUC) Z-V
HOUSING MITIGATION ITE
1117.ATING UNIT (TO 100.000 BTU)
IIEn'1'INC, UNIT (OVER 100.000 BTU)
V liN'I ILAA ION FAN(S INGLE RLS( D)
❑Yes ❑N.
PAID
Dun R"eipt R
-
Wi111hc applicant or future buildirg anmpum use cyalpmcan or devices which
t hmmdou., air contaminants as delimN by the Bay Arca Air Quality Management
'10'1'AI_
t
1{OII,HR-COMP (3RP OR IIXI,IHM) BTU)
BOII.ER -COMP (OVER I00.ff) I BTU)
Olein vY
❑Yes E] No
AIR CONDITIONER
ISSUANCE DATE
O✓
Z. 2 G I
I have read the Eazvd.v, materod, U under Chasse, 6.95 of the Cali-
4,miu Health & Safety Code, $rctions 25N1.S, 25533 and 25531. I undersand Na if the
building N,a, on¢crrently have a tenant that it is my respomibilily m notify Ne occafrom
NEW RESIDENTIAL MECH. SQ, F1'.
BY: