S 2448APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO
S 2448 .
BUILDING ADDRESS:
ES 6,6< /,/j
SANITARY NO
APPLICATION SUBMITTAL DATE
tWNE NAME: C
� -r.C✓J C. /T/
CO 'If1R'S NAME :� LICNI�
NOT
❑
CONTROL #
IBUL /ENGINEER: LIC NO:
ADDRESS:
CON'TAC'T: PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT kUMB MF.CH
❑ ❑ ❑
LICENSED CONTRAC FOR 'S DECLARATION
I hnGny affirm mat 1 are Featured under prodt.Ionx ofChil9 (p omen ng
L with Section 90001ynfN Division 3ofthe Businessand Professions Code. and my license is
in lull fnnl`va c �������
LiI I.I Cl ss [ic.#
L are Ccmrac .i�C�
QTY
. ELECTRIC PERMIT
'
FEE
JOB DBSCR PTION
ESIDENTIJO
FOWL El KITCHEN REMODEL
[]ADDITION ❑PLUMBING RE -PIPE'
❑MUCI'FUNIT ❑STRUCTURAL.
MODIFICATION
❑ INTERIOR El CHIMNEY REPAIR
IMPROVI ?MF:NT E] SWIMMING POOLS
❑ BATH REMOUFUREPAW El DEMOLITION
❑OTHER
- Gym
PERMIT ISSUANCE
APPLIANCES - BESIDES I']AL
ARCHITEC'T'S DECLARATION
4 1 understand ity plans sholl be used as public records
PANELS
UPT0200AMPS
11 licensed Prof sional
J OWNER- I3UILDE Rd, the Carl( 1'I ON
J
-y 1 hereby affirm That am exempt from the factors rs Co e: Aire y d fnr'he
which ing reason, (Section 903L5, Business and Professions Cade Any ray nr wuure
which it, cultures a perms nc 'urea el, alter. improv., h pard eb, or repair any .amnnre
psnunsieeuanoe,alooll toihrionlillaounlfn r Court Law
his he ideing cdpustion tothcpmvlslom aloft eBusin Business Leense LOw (Cbuph
(ammatencing with Senion]000)of Divi.inn3 nfthe En'inox'and Prof
4 that he is exempt therefrom and the IF ... fnr the alleged ate ,I
I See'ion 90J1.5byanyapplicantfora Pl'I Ranhjeet lica 'Ipena of
not more than five hundred dollars ($5011).
❑bliss owner °fill' property, army employ an wages n. code le,
wJl do the work, and theotnmutrc is nNimmn rnBereal fit sit 'cat Busmen.
and Prolmyhms Gale: 'Ile Cotnme suss Ucm not a .a r of
properly who builds or improves thereon, and h . ovh b i If hough
Ito own entpmyee., favora'hat such if, ,,, tax a not n over d crud for
sale. If. howevcq lire building or ,m cut is, l at urof compldian, the
eolludder will have (lie burden of proving the wild or ingrove fnr par -
po a of xme.),
❑ I, us'caner of the prnpedr. itm exclusively counselors with lice nsed conaonors to
construct the lthen Sec. 90wa, Business tied Professions Cnde:) The Continuator, la'-
se Law does notapply it) an owner ofprophnywhobuild sor improves dtem,,n, and
who contracts for each projects with a Cor emge) licensed Pursuant to We Conlroemre
license Lnw. 9
❑fouroetdptunderSea ,B &P C of this reason
20I -I W0AMP5
OV Fit 000AMPS
SIGN i
1 IRCIJf17 'C.
INST.
COMMERCIAL-
❑ NEW BLDG /ADDITION ❑ DEMOLITION
El TENANT [I FOOD SERVICE
IMPROVEMENT
[I OTHER _
p ICES
WIM .HLECTRIC -
UFLETS SWITCHES _ FIXTURES
NEW RESIDENTIAL. ELEC'IR SQ FI'.
SQ. FT. FLOOR AREA
t
S/SApL
'IDEAL:
QTY. PLUMBING PERMIT -
.-
FEE
I PERM L'r ISSUANCE
-
ALL ER -DRAIN A, VEN'1 "- WATER (EA)
Owner Date
VALUATION
WORKER'S COMPENSATION DF.CLARA'L'ION
1 hereby anion under penalty of perjury sae of the fidlowing du:lnmtinnei
I have and will maintains Certificate of Courant to vein houre for Workers Compel-
orlon, as provided for by Section 3900 of the Labor Curb, for the perldradeco of the
fnr which'his pemtil is iavted.
w I have and will maintion Worker's Compensation Insurance, as requirnl by Station
3]11(1 al the Luber Code, of the performtinee of one work for which this rental is issed.
My Work pf'. i �alin Ins pneS randPalle, hrnrc' n
Curies. /c TAW /NUIJ1 c Policy No.: �_���- �9���a %�
CERTIFICATE OIr EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(T his , dot newlnm bee tmpldal't ❑epum't's lorotch'ndmd JolUn e$ Its))
or lev,I
orkcn Gmpcm
salon Laws of Cvlifornia Dam
APP' veers,
BACK PLOW PROTECT. DEVICE
DRAINS - FLOOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
FIXTURES - PER TRAP
GAS - EA. SYSTEM- I INC .40UT
-
PN
r�
Q
CAS - EA.SYSTEM) IEA) 0
ORBASEIINUUSTRL W N'TIiRCEPTDR
I ODIVISION FF,E,B
1
GItEASH'I'RAP '
31AN501ECKFEE
EBWER- SANITARV -S l<M EA.2t111 Ff.
WATER HEATER WNEN'�'IBLECTR
NOTICE'ro APPLICANT If, after fall Ill, Certificate of Eseduaion, you should
become object ,, the Work... G.mpre,o ion adroitonx of the tabor Cale, Italians'
fanhwi'h comply with well personal dr, pennit'hall be deemed revoked.
CONSI RUC ION LENDING AGENCY
Ihcrehy aUmtthat them i.uwn.wdion lending nsency for d,e performance of
the work far whleh this permit ie i ... ed(Sec. 3097, Civ. C.) -
Leeders Nome
WATER SVSTP.M'UFAG
SOILS FEE
WATERSERVICE
PAID
Ie
I
NEW RESIDENTIAL PLMB. SQ. FI
Date Reeipt#
-
TOTAL
Leaders Address
1 evalify (hill I have read d applu,stone add done Bar, b above als,onerion. is
Coolest. I agree in ly will, all city ' I county shadindaresund , stale laws relating to
h'i'd g sstiucton. and heab)awhormapresunativcs of'hi.city t,, enmrupovhe
above- mentioned properly for inspccfmn purposes.
(We) agree lit Indmnnify and keep harmless the City of Culwnlno against
Ilubili'illjudgtnem.,costs mdexpenos which zany in tiny wvy meme against m'iA COy
ta'equenec of the granting of this permit.
APPLICANT Il IERSLANDS AND WILL COMPLY WITH ALL NON -POINT
UL IZNS.
'TOTAL
BUII INDG
'
QTY ' MECHANICAL. PERMIT
FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC PEE
ALTERORAUDTOMECH.
PLUMBING FEE
AIR HANDLING UNIT fI'o 10,OIM)CFM)
MECHANICAL PEE
AIRHANDLINGUNG'(OVER 10,000CFM)
CONSTRUCTION TAX
plicanUC rrnchn Date
HAZARDOUS MATERIALS DISCLOSURE
applicant or future building°ccupun' emm or handle hazardous matcrinI
he Criterion,, Municipal Code, Chapter 9.12, and the I Oul'h and Safety
70,dc,S�cfiou 5532bo?
❑No
III 'Will the applicant or future building overhaul nee Nuipment ordv,x,, which l
'omit Locations air cnmanneras as defined by the Bay Area Air Quality Management
Dntricl'1
NYC. F1 No
I have read the hazardous mur requirements under Chapter 6.95 of the Cali-
Pamir, Hcahh & Safety Code, Seniors 25505, 25533 and 25534.1 understand that If the
I ]it ngI� nlyh veam vn4thaliti.myr n.ihili'y tnrvtif the occ, pool
et'he�hmo.them'pdorm1.w.nse ofa C���hem, prior m 1.w.nce ofa C Gee
EXHAUST HOOD (W /UUC'T)
HOUSING MITIOAfION PEE
HEATING UNIT (T0100,1100BTU)
HEATING UNIT' (OVER I Og000If Go
PAID
..
VENT ILAI'[ON FAN (SINGLE RESI D)
Dole Receipt#
BOILER -COMP f3HP OR 100,000 BTU)
-
'TOTAL:
BOILER - COMP (OVER I00,000 NTU)
AIR CON UI HONER
ISSUANCE DATE
ISSUED BY:
NEW RESIDHN'1'[Al. MECH. SQ. FP.
wneror'uthonz Ou�Dme�
OFFICE