S 2710 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PHRM P NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL (N 2710
BUILDING PROJECT IDENTIFICATION J
BUILDINGADDRESS; SANITARY No. ICATION SUBMI'TIAL DM If
APPL
OWNE 'S NAME: PHONE' C TRAC"HIPS ME: ItilLIC O:
p'- NIC CONTROL#
MUD
ARCHITECT/ENGINEER: LICNO: 7DDRi: ❑
CONTACT: PHONE: ➢U ILDING PERMIT INFO
-11 ,r /� O ❑ Consultant Fees Paid by Applicant(Initial), BLDG ELECT ELECTPLUryMB/ MFAH
r C/N BC ICL I� ❑
LICENSED CONTRACTORS DFCIARATION Oil ELECTRIC PERMIT - FEE
A�'Z
II by ffrcethtl vita 1 p i Iehnpte-9¢mm
nr � g JOB DESCRIPTION
with5 i 9q)0) fD' - n3oflhe Hus tuIV fes nsCA it myfre n RESIDENTIAL:
WOO
F�IyF infillf nd effect PERMIT ISSUANCE � Z l J [_1SFDWL El KITCHEN RF:MODHI.
dUU I,ieense Class LIc.# - APPLIANCES-RESIDENTIAL. ❑AUDIHON ❑PLUMBING RE-PIPE
y�G Data Crnlnml
FW,n ARCIIITEGT'S UECLARATI N PANELS El MULTI-UNIT El STRUCTURAL
ZOyz, I understand my plans shall be used as public recoNs MODIFICA'T'ION
O Z.. UP TO 20M AMPS
�.-j-F,W Licensed Pm@ssionel _ ❑INTEBIOIi El CHIMNEY REPAIR
Q
OWNER-BUILDER DECLARATION 201-1000AMPS 1�' ROVEMENT E]SWIMMING POOLS
0.' C< I hereby affirm tbal)am exempt front the Lommcmr's Lau:me Law for the OVER 11000 AMPS �T3ATH REMODEWREPAIR DEMOLITION
aOWU
3 F whfollowing uirt a,permit
n'1NL5,Businessand improve,
or Any city nrremnrY SIGNS ELECTRICAL ❑OPHI?R
W y which require,n permit us 0orwlruel,alter,improve demolish,or repair any and statement
�G 'III,boslcense reale., ulre'.vlhe r.....amt for ss¢hpadius, fileaeLaw(Chapter9 SPECIAL CIRCUIT/MING.
Thal he is licensed pursuam to We provisionsnhhe Cantrauors License Low(Chupler9
W (emnnted.,will,Scouou700CEefDivi,mn m
roof the Buse,sand PmfesmP.
ua,Cortina TEMP. P INST COMMERCIAL:
a W o C Thal he is exempt thereflnnl routine basis to,,the alleged exemption.Any vielulinn of C:1 NEW BLDGIADDITION El DEMOLITION
it 0. Section 9131,5 by any applicantfn.......Isnojeds the implied.,Io penalty of POWERDBVI
W^'m ❑TENANT ❑FOOD SERVICE
>1 nomum um than Free hundrut dollars($500).
pZI,mnwnerofihe prepeng ormy employerswith wages ae lhei...le compoo,ourm, SWIMMING ,01- .CT IMPROVEMENT
A2 will do the work,and the structure is not intended or offered for sale(Suc.7044,Buxtneax E]OTHER
m and Pmlrssians Coda:The Combcmrs Licence Law docs urn apply m an owner of OIL, .B-FIX 1R ,
0. ti property who builds m'improves thereon,and who duce such work himself or turzmgh
his own employees,provided that such tmprovenmnts aro not intended or offered for NEW RESIDENTIAL' R S
,Arc If,bowevm, hehundingon,improvement in sold within nneyeuroruamplermat lire SQ.FT.FLOOR AREA $/SQ.IT
uwarnJunder will have the burden of proving thin he dad not build or improve for pun
E] 1,ss owner of We propeny,ant udusively cnmracrog with lieeasrd enntuuo..to OTAL:
onvaua Elm price,(Sao.9044,Basion..,and Pmfassiom Code)The Comments Li-
un,Law does nsapply to an owner of properly whit build,or impreves thereon,and QTY, PLUMBING PERMIT ,FEE
who coalraels her such projects with a commnogs)licenced pursuant o the Conuoemrn
License Law. PERMIT ISSUANCE
❑ Ilam exempt under See. ,B A,P C for this reason
Owner Data ALTER-DRAIN A,VENT-WATER(EA) VALUATIONQ�
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(H PC'I'.DIEVICH
I hereby anion under penally of perjury one of the fallowing declaration
❑Ibase and wallmaintain.Cerlifirvtenf Comenl to self-insure for Worker's Q)Inpnm- DRAINS-FLOOR,ROOF,AREA,COND.
scant as provided Section 3]00 of the Code,for the STORIES IYEECONS"IRUCT[ON
pmvi y perNnnance of rile
work for whish this pcnnil is issued. FIXTURES
-PER'TRAP
❑ I have and will mninmin Worku•'s Compmasiame lm,amm,c,as required by Section
3701 of the Labor Cede,for the performance of the work l or which this permit is issued. GAS-EA.S YS'I Esil I INC.40U'TLETS OCC.GROUP APN
My Workers_ ran�tyly g Policy
Policy
Curries: 1(I1 I. I Cl Policy No.: GAS-EA.SYS"C VER 4(E
FROM WOI<KBRt
• CEITIFICA'IE Oh E%EMPTIHN S GRBASFJINDUS L AST 1tETE4 R
COMPENSATION INSURANCE Z " a » kBt1I}, LNG DIVI$IONFEP.S
fIhisseamin need notbeamouoll
.pleted ifhe permit is for r hundred dvrs($IW) GREASETRAP
or less) PLANCIECK FEB
I employ
any Thal in the pelta coverrecomit Ne weak fn,subject
It to goothe W as rsmN,1 shall
not unploY any person in lm SEWER-SANT Y-S .2fN1
any ea as to hewme suhjut to the Workers'Compen- Jul ENERGY PER
Q Z satin.Law,of California.Data WATER HEAHE W/VBNT/ELECfR
z Applimal I GRADING PEE
a h NOTICE TO APPLICAN'D If,after making this Cerlifmbe of Bxelnptiun, no should WATER SYSTEilf4iALING.
(•^ become s.hja,,m the Workers Con,eaemlon provisions of the Labor Code,you must SOILS PLC
isions or
W
forthwith ereby firm CONSTRUCTION
con lm LENDING
shall he dY revnkul. N17WRSIDEN6
Qcomply with is perm
CO,1mm,,C'DON LENDINGAGENCY NEW RESIIIEN'fIAL PLMI1. SQ.FT. PAID
4. 0 ding agency for the lmdnmmnecof I RewiPt#
w u Newark for which this permit is issued(Sea 3097,Civ.C.)
Ucroa Name TOTAL
at, :
lender's Address TOT
I certify that I have read this applicullnn and state that the Move information es BUILDI 31a O
.. ea u,mea I name0 comply with all any sad m,.nty ordinances tied sten laws rmmingm QTY. MECHAMCALPERMI'T FEE
C.J Z building construction,and hereby authorize representatives aflhis city tnend,uponfire SEISM .FE
abuse-mentioned property For inspection pua,o.<n
(We)agree m save,indemnify anti ken nlr,s Nc City of Cuprntno agalmt PERMIT ISSUANCE ELE RI. F.E
Iiahilities,Pnlgmenb.costs and expenses chat troy way accrue vgairad,rid City AL'ITRORADD'I'OMECIL
PLUMBI. �FF.F.
eonvcyuence Mthe gran ting mit.
APDL 'I' INDERT'A S t WTI , PLY WITH ALL NON-POINT AIR HANDLING UNIT(10 10,000 CFM) M[?CH ]CAL PP.F.
S R N
/ AIR HANDLING UNIT(OVER Floras)CPM) CONS UCTION TAX
Signewrc o[ApplicnnVCon¢ r Doc BXIIAUS'f IIOOU(WIDUCI} HOUSIN MITIGATIONFEE
HAZA OUS ATF,RIALS DISCLOSURE
WIIth,der Cupemnr fuutrebnaadlCmdv,Cpamslor12,rad UnHunith anmbnal HP.ATING UNIT(TO 100.000BILE
vs defined by rile Cupcnino Mnnicipvl Code,Chapter Y.12,and rile Hmllh vad Safety
Coda Smlion 25532(a)R � HEATING UNIT(OVER 100,000 BTU)
0Yes VENTILATION FAN(SINGLE RESIII) PAID -
Dau Receipt#
WAI the vppGrem or forum building owupnm ane eyuipmem or devices which
et hmnNoun on rontamanant,a,drimed by the Bay Area Air Qeduy Manvgemem BOILER-COMP pHP OR IfNl,pfq PT'U)
ml
Dnlrictp "AL:
�yaa 4401to BOILER-COMP(OVER 100,000 BTU) ,
I havered e a mberinls me uvderCha Chapter of the Cali- AIR CONDITIONP.R
mgnimmr n ISSUANCE.DATE
fomia Safe ecuona 2SSf1.5,255J3 and 25534.1 understand that it the NEW RESIDENT IAL MECH. SQ,Er
.do art havoamnant,Nart is my resparibilly to notify ln,nc � .--� '�
Ciang must MING prior te ajacififo
O ern prized vgem Doe/1 TOTAL: ISSUED BY.
OFFICE