S 2261--- APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
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CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENHEIF'ICATIObC.'i'
PE 11TNO
, 2261
BUILDING ADDRESS
SANITARY NO.
APPhICA'I'IONSl1BM1"COAL UA'I'9
OWNER'S NAME: -PHONE: O
L NEL PkEAL7oA5 e,L
CONTRACTOR'S NAME: LIC NO:
3,r3Tw,4T6� 6�-7eks 5"1 2 1
we
ElCONTACT:
�i
CONTROL#
yRCHiTECTILNGIN1AiR: LIC NO:
ADDRESS 4- IJ AT10A A-- F
.- PHONE:
'. 13UILDING PERMIT INFO
BLDG ELECT PLU�MI R MECH
❑ Consultant Fees Paid by Applicant (Initial)
(
cz.
13 do
El
LICENSED CONTRACTOR S DECLARATION
Ili - l y B fair 1 r d J v of Cl I I 1) (,("1 - g
wins 7000 fO".on 3of1he BUS,csand Prr:' s Code. ana ry license's
inf Ilfnaeand fa SC x320'
Hacnec Clan Lm.N
Done eon
QTY "" ELECTRIC P,ERMPTI IPEIi i
-
"JOB DESCRIPTION
RESIDENTIAL: ,
❑SPDWL ❑ KITCHEN REMODEL.
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT' ❑STRUCTURE.
MODIFICATION
❑ CHIMNEY
INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECT'S DECLARATION FjIfF%
All
understood my pains shrll he used as puhl'm rcuxJs
PANELS
11P T021111AMPS
Licensed Pm raincoat
201-1000AMPS
OWNER-HUILDER DECLARATION
I hereby a l tit I I pt t n Contractors L Law fat the
roll of '. (Section 7031.5. Business ll f scion Code. Any aily .1 eon nY
wit eh repr'rc a uaur I roannstrum, alter.' np- , J h p'' any structs re
El BATH REMODEVREPAIR E:1 DEMOLITION
_
[_1 OTHER
q 6Lf
Q 144, 'rem
OVER IOuOAMPS
SIGNS ELECTRICAL
pr t t. '". 1", without, tire Ipl' Ir recruit blue eignadnacmenl
' . Law (Chapter -1)
es recanted puumm Contractors melm5"s,tr ftheC mo 'I' '
that hm
(c gwithSection 9000) lDiion 3 ofl Bone" and Profachom,Code)o,
0r t he ', catnnpl mansfuch antimans[ the ba.: for 1 a II 6 J esvirrion n Y Omlancer ,f
SPECIAL CIRCGI'1'IMISC.
/ 4CFM �'�
�^•
1EMP METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDGIADDFHON ❑ DEMOLITION
POWER DEVICES
Stance,9031.5 by any elplaont for a permit subjects the applicant too civil Penalty of
not more than tive hundred dll ($50)
❑ I fib p I ny ) ply II 'g: Ili' f
❑ k a t t' t ti ff fulf I (S .7044 B
[-]TENANT ❑ FOOD SERVICE
IMPROVEMENT
OTHER _
SWIMMING POOL LLECfRIC
Professions Gde:Th Contractors Ie L ti t apply der of
and x
OU'1'LE'fS-S WITCHF_S-SWITCHES
Off
'
property who builds or pr ves thercon, and h, does sada wok h' nself fi rough
nit intended or for
his own employees, provided that such improvements am offered
sale JLbowever,the buif,ingorimpmvennent is sold within one yearefeempletion, the
er-builder will M1nve the harden of proving tlmt he diA not hrIIJ of improve for pro-
NEW RP.SIOENTIAL ELECfR -1'.
S .00R AREA
$/SQ. E.
y
pose of sale ).
"
❑ ],.is owner of the property, an exclusively contracting with licensed contractors in
construct lie project (See. 9144, Bnsimess anti Prof aunts Code) The Cord mcore, Li -
cents, LowJ t pey t f property n builds V m I
w1 lads forvuel hurlers wthae 1 l (s) license(] pct :and more Contractors
_
-
O
'`LicenxeLew.
QTY 'PTRAP
❑Iamexmalaredwyne, ,H&PCfmtm'oaOwner
PE
tT A (FA)
DmcWORKER'S
VALUATION
COMPENSATION DECLARATION
herebynl0mi undm' cnuhyof penury ono of me following declaations:,OQ
13 . DEVICI,I
I have and will maintain a CerNicate ofConsent td self-inmre forWorker's Comp
eamr, asprovide,] for by Smtion 3100of me Labm' Code, forme pirfour an e, of Iwork
U F ARBA. GOND.
STORIES
TYPE CONSTRUCTION
for which this prod le issued.
X'I'UI�I
have and will maintain Workers Cotnpclu Insurance, as rmired by Smtion 3)00ofthcLuhnrG,de,mnhcperfrm mafinework for which this permit isiseuW.
�n'r
GAS -INC 40UTLETS -
OCC GROUP
APE
CAS-P.A. SYSTEM-OVER4(F.A)
My Work�ornysenfiu,LNstvunce nd Policy n �r '
KK ����{{-- a
Cour at ITC)APnlicy No.
GREASUINDIIS'fRI. WASTE INIIiRCEPTOR
CERTIEICATEOFEXEMPTION FROMWORKERS'
COMPENSATION INSURANCE
BUILDING OIVISION P585_
'hission decd not heu,mplemd if rho permit ie fnronedmndmddollara(SOO)
ml... ) (Ien
GREASETRAP
PLANCIIECK FEB w
SEWER -SANITARY- S'IORM F.A. 200 FT.
ENERGY FEE
I earthy mut in the perfoninncenflhe work horseman tutpromas issued, ]shall
not employ any Person in any con erxb asrobe55(( pp��uhject mthc Waken Cmnpmn-
satins laws, Cal�forniv D:nc �J—J 4—`1nY.
Applicant � J 1l
WATER HEATER WNENTIELIR TR (�
GRADING InEE
.NOfICR TO APPLICANT: IR after ma Ing chic CenlOmtc of F.xmnption. you should
thu
become xnhject,othe Worker's Cmnpml5mion provisions of the LahnrCode, yon nn't
WAI BE SYSTEMRREAADO
SOILS FP.P. '
-
WATER SERVICE
forthwithcomplywim.meh provisions or this permit shall he deemed ,evoked.
NEW RESIDENTIAL PLMB. SQ. EL
CONSIRITT[ON LENDING AGENCY
Ihmeby aflim, mauhmcisae(ma¢omion lending agency for ilia perlormnmce of
PAID
Date Receipt#
_
TOTAL'.
I the work fair which this permit is issued (Sec 9097, Cie C)
t L le Na
'
TOT
- -, .-
Under', Add , t5
ify[hill Ih 'd0: application and stale lb ill hinformationt
rwt l arnica t Imply wan all dty and e(4 my olid ,:mc and stem law: I ing to
building construction, and hereby authorize reptesetnnlives of this city center .pan me
BUILDING
QTV. MECHANICAL PERMIT ` I; 1. PPE
SEISMIC EEE .
PERMIT ISSUANCE
ELECTRIC I .5
abovemrntionul property for inspection purposes.
(We) agree to save, Indmirfl y and keep harmlctis the City of Cupertino against
AECH
Z OR DD'Y
PLUMBING P..
Iiabilities,judgmmnls, uslsandexlrcnsos which mayln any way ncemeagaim"am CityACF
in n"Faces of gr of this permit
APPLICANT 1' Df A lS AN .h PLY WITH ALP. NON -POINT'
q
NULL U I0.44'PM)
MGCHANICAhF
SOURCE R' L, INS Q_
HOLING UNIT (O DR Itl,llfq
CONSTRUCTION'!
B 1
UST I( I (W iJ I)
alum ofA,haml/C Data
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
LIVING UNIT GO 100,000 B'I'U)
Will theapplicamor future buildtngocmtpanl store or handle hazardous material
as dcfinul by the Cupertino Municipal Code, Chapter 9.12, and ll a Thoth and Safety
Code, Smtion 25532(a)P
H A UNIT (OVER 100 ,000 IF (I
,
Ycs El No
PAID Oat, Receipt #
VENTILATION --FAN HBSID)
"
BOILER -COMP QHP OR 100.1100 PTU)
Will the applicant or holow building mrLiand use cyuipment or devices which
sair hazardous air cnnwminnnl, as thh ned by the Bay Arco Air Quality Management-
(�
V
District?f
Cl Yes E] No
BOILER -COMP (OVER 100,000 BTU)
AIR CONDITIONER
-
I havenradth under Ch,har 695orthe Call
Rama North & Safety Colle, Serious 25505 25539 i d 25534 I tordinsurad thet'f the
ISSUANCE DATE
NEW RESIDHNTIAL MECH. SQ. Cr
b 'IJ' 6J tem tlyl t dent tk ft'. Y pan ably ..lythe occupant
_
H the cararcruch" which ain't ho Tame issoarea of a Crtellho al'0mupancy.
ISSUED BY:
TOTAL:
Owner m' mttborizedagent - Data
OFFICE