S 2817 —APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - - . RUILIIING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBIrvr.-MECHANICAL /] O C
-BUILDING PROJECT IDENTIFICATION S L O
17
BUI LDING ADDRESS: SA N I'I ARY NO. A PPLICATION SUBM1I U7AL DATE
0 Q I� L. /✓
OWNER9 NAVE PHONIiILDRitl A.,' �^��� CO!TV�SAN����` NIC CO I.of
ARCHIT DENGINEER. LIC NO A, gEss,ra �.1(J�� !- ❑
CONTACU PHONE: - VI (VC BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MUCH
LICENSED CONRAC FOR S DECLARATION ❑ ❑ ❑
QTY. ELEQTRIC PERMIT , FEE
i ny the I r d p - rI . 9 t ,mice g __ _ - JOB DESCRIPTION
�p2 with S I "111Ud1p [D 3.4 be Bus JP f,.'n,C 1 I ylicensCs RESIDENTIAL:
F1_ in fell l d effect PERMIT ISSUANCH
FS^X' ]SFDWL ❑KI'T'CHENRHMODEI.
�UyU
--c—Ches. e-36 Lic# �-g APPLIANCES-RF.SIUF:NTIAI. ADDITION ❑1'LUMNING RE-PIPE
yd i Dee Coruna L
ARCHITPAT'S D9CL '1'101 PANELS
El MULTI-UNIT ❑STRUCTURAL.
j ObF y Z 1 onderswod my plaas,hall beorde ds Vu w ce ds MODIFICATION
E2-C UPT0200AMPS Ll INTERIOR ❑CHIMNEY REPAIR
Q4t:Wt Licensed Pm tuitional 2nd-IOW AMPR IMPROVEMENT SWIMMING POOLS
Oat Ia.earned Imbibe
DECLARATION OVER IN00 AMPS ❑BATH REMODEL/RFyAIR ❑Eli
1 Q I hereby affirm that I 1 exempt from tha Coatrns Cas :Airy..Law far the Atl..�..
3 Murcwmlanuala.(slanony no Business and rmrrdemaili..,Airy nay or ennrcny ❑(YTHBR QQA e✓A.nn
SIGNS Fl.EC['k ICAh )�
y suit q ' . Island r 't t pp , mIr... de dol i, p- any n mere 1 1
¢ prat t .. I. y ' ,Ih PPI n.nlbrsuoM1 poria fit, 'y I,f mme,t
G�
^ mitSPP LCIItC 'RSC. rZI
Eh� cell 1 dp 111 provisions fthContractors L I (Chapter9 �
g (w g 'hS t 700(4 tTu ' 3 fid B ! . IP-f ' :C I)or 'I'I� B'fLl OR POLE INS'I COMMERCIAL
Ont h exempt Ih f d theb 1 thealleged pl .Any t ,of ❑NEW BLDG/ADDITION ❑DEMOLITION
❑• Secl ]0315 by yapplicantt a p rot subjects the applicant to a civil ponity of P ;I DI,' 1 Es F []TENANT ❑FOODSERVICE.'
ESQ� nen,a than five hundred dollars($500).
I,as owner of the n,.,a IMPROVEMENT
❑ peps y ym armyeecwithwageo ax (Sc aanpe' ,in, S I MING POO;,ELECT RIC E
a^rowill do thework,and tho nrrcmreanm intended nrnffered horseshit,(See,'J044.Brainess
and Pndessiorvc Code:The Coanrocwrx Licence law diem not apply w ua owner of OLE'rs-SWITCHES-FIXTURES
propcity who builds orim.rovc.threats,nal who docs.such wank himself or through
his own employees,provide)thin such improvanoms arc not intended or offered for NE
sole.If,however,the building orimpm,comot bond wahmone ye:rofeoaidenin,her S EFL. 3A $/SQ.PC
b Id l;l' elheb 1 fp yd tl d'd rh 'ld p epee
pne oI ). PUPAL
co f thep .�04 o I .' IY t t y with l 1 doctors m
construct project t(S n44 Business IP Professions )Tit c t t roc
a Law dow nut apply to an owner of property who baildc or impose,Omrum and QTY PLUMBING PERMIT FEE
who routines for such Futures with v conurenr(.,)Ircerwd preauonwo the Cenemnr s
of ,
License Lew. ( PHRME ISSUANCE
El am uxem.r under Sec. ,B&PCLrthio reason
rs
Owner [)aidAUDER-DRAIN&VENT-NATER FA) VALUATION
WORKER'S COMPENSATION DECLARATION HACK FLOW PROF ECT.DEVICE
_ I hereby affirm aodurpenmty aperjar,ore of nu fokowingdeclamoons
� I] I haveandwill mainland aCenilicaeof Conoemunsoll-insure for Worker's Comped- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sadon,as provided for by Section 3]W of the Labor Code,for the performance or the
work for which this pcnmit is issued. FIXTURES-PER TRAP
] I leave and will mairld.Workers Compan,ati Insurance,as repaired by Saturn -
3700.1Omlahar Code,far performance of the work for which 11111 permit is icsucd, GAS-EA.SYSTEM-I INC.40UTLBTS
M Worker's OCC.CROUP APN
My o pcnsonon l cudmce caries and Policy number t c
Carrier: Puliay No.:y_CSeflr+� L GAS-EA SYSTEM-0OVER
CERTIFIC E OF EXHMPTION FROM WORKI,I
COMPENSATION INSURANCE GRIzASOINDUSTRL WASTF TNTIi;tCEP'I OR g1IB,llINCI DNISION FFER_'
(This section nein not be aaupleted ifthepennl is foam hundred dol lns($;U0 GREASFIRAP
or tenni PLANCH9CK NPX.
Loy any shotinthe any harborer of s o work far which thio permitixes'Coapeall
not employ any penin in any mvmnr aceta become suhjcd to tM1a Workars'Connpeo- SHWLIt-SANITARY-STORM F.A.200 FI'. ENERGY FP.P. '
O z ratios Laws or California.Done WATER HEATER W/VIN'I'NLECTR
O Applicant GRADING FFP.
► NOTICE.TO APPLICAN9:'If,after snaking this Certificate of Exnnp a n,you should WATER SYSTEM/TREATING
become subiatlo the Wnrkefs Compcm.fid.ormi otrofihe Labor Code.you oust SOILS FEE
W fonhwinheomply with each.......too,m'W;s permit,hall bedeemedrevaked. WATER SERVICE
z CONSTRUCHON LENDING AGENCY NEW RESIDENTIAL PhMN. 'SQ.GE PAID
U O l hereby ral than them dsamnstruanon lending agency to, pnaornanmaf Dee ceipt#
w the work for which this perno r is issued(Sec.3097,Civ.CJ
C U Lender's Name TOTAL:
Lender.Address - )TAI:
0. 1 certify that 1 have read this dpp;iwtion and state that the obnvo Infnnnmlon Ix _ BUILDING FEE
m correct.[.agree to coop;y with all city and aunty amine.:,god awn law.odai ago, ,QTY. 'MECHANICAL PERMIT FEE t
U Z M1ai;aing eoanraceon,add hereby arnbodm mpre.ecvml.e,,or ods d4,d, .Is,tran,the - EI
SSM nae
above-mentioned pmpany Gar Impenic n purposes. PERMIT ISSUANCE(We)agree a save,in lmoni;y and mic
kec.hae .the City of Cupcnine ogvnis ELECTRIC FEE
lishi;itics,judgment.,eosl,andexpenxecwlJeM1may in any way aecme ega.ne,hid City pCPBk OR AtID TO MECH PLUMBING FEE
in mrsequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(,fo H dflon mm)
SOURCERLG LA'FIONS. MECHANICAL FEE
L AIR HANDLING UNIT(OVER QOWCFM) CONSTRUCTION TAX
ipIffitulaalbt Applicadtlw,ntector I IDat6HXHAUSTHOOU(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occapant snore or handle hazardous material HEATING UNIT(TO 100,000 B'IL)
as defined by the Cupertino Mouth tal Code.Chapter 9.12,and the Health and Safety
Calc,Section 25532(a):' HEATING UNIT(OVER 100,000 BTU)
Yes PAID
VENTILATION FAN(SINGLE RESIUJ Date Becei.n#
Will the aPPevm or Gen aubuilding occupant nae equipment or device.,which
anis hmons m
urdair manlinunrt no defined by Om Bay Area An Qnaliry Manogmnent BOILER-COMP(3HP OR 100,000 BTU)
DisOidP IOTA 1,:
El Yes rFYyo BOILER-CONE(OVIiR 100,001 BTU)
I have read the hesitations materials reuimoside under Chapter 6.95 of the Call- AIR CONDITIONER
I p ISSUANCE DATE
tomia Huhh&Svfcty COJe,Sedinre 255115.25539 aW 25534-1 undeI f In that if rhe NEW ItBSIDEN'DAh MECH. SQ.FI'.
building row nal curendy hvvavnnnunh rbnl it is my rraponsibilitymnnlify the oo rpnnt �I Y
of lie requimnenr hichnur urn 's cmdt=BeanZ ir, cy.
em zeml ngedt D e TOTAL ISSUED BY.
OFFICE