S 2347 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH.DING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICA 11ON/PERMIT PLUMBING.MECHANICAL S 2347
' BUILDING,PROJECT IDENTIFICATION
BUILDING ADDRPSS: SANITARY ND. APPLICATION SUBMITAI.DAIS
11FW�NY,.l1I'S NAMI' ( - . f�- r, I'll(INE:.l�.g� GONTRACIt Hf6 NAME: hIC N(L
NIC CONTRO L0
UiJN� u 11
ARCIIITGCI'/IiNGINIiERWEER.: LIC ND: AIIIlRC55: ❑
CON'LAC'I". P11nNB: -1 IIUILDING PERMIT INFO
L ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED NSFU CONTRACTOR❑TCI ARAI'ION QTY ELECTRIC PERMIT ', FCB
Oaz, n by,u . to Iz F :d t ( ft1ta >( , .,.I TOB DESCRIPTION
Iu�]] suisv i 7(BfNn m vim3onne.Bu ns.n,eP..fes: s0se. doyhoree,i. RESIDENTIAL:
cee p in 1 11 f ore and ellen PERIOD ISSUANCI:
Iy— ❑$FOWL El KITCHEN RIiMODEI.
.tUzU License Class Lica APPLIANCES-RESIDENT]AL ❑ADDITION [I PLUMBING RE-PIPE
y 6 Phi Dom Como(...
ARC'1RIEC'1':SDFCLARATION ❑MIj1,T1-UNIT' ❑NfRUC'I'URAL
'Dv, PANELS
ZOfinZ Iudabrdandmy plans shall be used us public records MODIFICATION
OZ4- IIP TO 200 AMPS ❑INTERIOR ❑CIHNINEYREPAIR
F�F'ul Licensed Professional 201-IBRAMPS IMPROVEMENT SWIMMING POOLS
OWNFR-11UILDHR Diz'LARM ION
Hwy OVBI31000AMPS ❑BATH REMODEL/REPAIR ❑DEMOLrrION
d hereby on I tun xcnlpk Ilam Inc Cnnlnx9+rV leAnyc Last,for the
E�iV fe+uawm Section 7031.5.nn�mhs Intl rmreah,ns ode:Any I n ❑fn'H1?a
X 3 g fires. (:ec inny ci y or eoan y SIGNS IHJ?CTRICAI, r�
WLLto w4 h 4 - e, II s k B P J IrM1 p S.tmnure
F�y�' pen k ( - ItermitesIn ppav,un suchpermit issigned.k kemen( SPECIAL CBCU[TIM ISC_
99 y (hall licensedI . t 17 [he � Ill Centocor 1 1' IChaptuJ B /tai
W Ba ' g 'ES ( uand Ill . 1 all ase x JI " Code))I ThMI'.MI:'I'1'R OR I'(11.8INS'I', COMMERCIA
L:
a D.a ttru c n exempt thvelinm and(h hoes f r(he,alleged ex peon.Any violation nn nl ❑NEW BLDG/ADDITION ❑DF:A101,1'I'ION
Section 703L5 by any applicant for.pecsubja,,,,ba aamm
pplicac mi penalty of POWER DE VICES
uxl�y (i( ❑IMPROV El TOO[)SERVICE
~�dlithium than live hundred dollars($SW).
Las owneroRhc IMPROVEMENT
uu,newhouck,ununy],,I with los(devrole en4, fieien, SWIMMING POOL.HLI!CTRIC
D will Ju the work,and thaamdufe is nal lnlrnJul nr nl'fereJ hasnlc(SecJ1144,1{usinnax ❑GrI]FR
III so and Prnfossions Core.The Cmnnmtor's License Law does not apply to on owner of OU'li.I?'I'S-SWfIC11135-FIX'fURIlS
palmy who builds or irritates thereon and who does such work himself IN brought
his own employees,provided that such improvements um not intended or Warned for NEW RESIDENTIAL ELF,CIR SQ IT.
Ie.11,however.the building or lmprovemom is sold within lnon,year ofcontpktinn,the SQ.P' ARBA $/SQ.FI',
or-budder will Iutvn(heburden of paving dal he did no(boll or intpruvc Iia par-
'eI of rnle.7,
XTOTAas ow r of the pmped,am exclusively contracting with licensed contractors to
L:
tict the project(Sec 7144,Business and Professions Coda)The Cmnrnnnr's Li- - -
ceraLaw due s..... QT-y. ,PLUMBING PERMIT' tFEE-
won....ase(,for such pr fans wish n convncmrtsl licensed pm want a+We Co..manors
License Law. FERMI F ISSUANCE
❑I our esempt under Sec. .11&P C for this rcaam r
dL'IEH-DRAIN&VIiN'f-K'A'1'IiR(IA) VALUATION
Owner ale
D tKF.R'S C(1 I'ENSA''ION UE .AI 'ION BACK FLOW PRUI FCI'.DEVICE
hereby aliirm under penalty of perjury nne'nf( allowing dcelarvtiane
❑I have and wintitainmin a Cenificam of Consent tosdf-insure,her Workers Camper DRAINS-FLOOR,ROOF,AREA,COND' S"IONIIS TYPE CONSTRUCTION
sat provided t by Section 17M f theLabor Code.1 thepert ce of the
wok which Ili,"cuit., I, FIX TURES PUR ORAP
❑ I have anti wtll alantain Work Compeasoloon Imurance,as required by Section
3700ofthe Labor Code.for performance offlo,work for which this Frank's issued. CAS IiA.SYSTI:M-I NCAOUTLEIS OCC.GROUP APN
My Worker's Contpcm lion Insurance carrier and Policy numh,r are:
Currier: Policy bi: GAS-lin.SYSTEM OVER 4 0710
Of Ill PICA1'll OIk 1XiiMIT ION FROM WORKERS'
-
COMI'd.N SADON INSIIRANC7 GRIASHANDUS'I'III,WASIIi IN'I lzRCEPIOR
(Thiesec(ionneed not becnmpla(W i[(Lep,nm(is forma hunJrnWullars(51 W) BUILDING DIVISION FRES
GREASE'FRA
or less.) I' PIANCIIECK FHH
Is<nify(hm in the perinnnonee of the work for which this pctmit iv i.vsuW.I shall SF.WER-SANITARY-STORM EA.2010 Pit.
nor employ any Peron in any nmn..,rxo ax to hecan..subject to the Worker,'Cnmpeo- 7NIiIlGY FEE
,z -Dalin..Laws of CAN...tia Data /V
e WAI FR HEATER WHNT/ELEC'I'It
z Applicant 1 GRADING FEE
NOTICETO APPLICANT,117,atter making Ibis Cedifieam of Bxemptian,you should WRIER SYSTEMeIREATING
(~ boon subject to the Worker's Cntnpensntinn provisions aide Labor Cale,you most SOILS FEE
r�
Wloohwirh coolly with such proviours or this permit shall he docnmJ rcvukeJ. W6fIJ1 SI?RVICH
a �
CONS]RUCCION ENDlNGAGENCY NEN'RESIDENI'IA1.I'Lh1B. $Q,Fr. PAID
U QThereby,,III,hxuherc is..Construction(Seelending agency for p,dnnnance of Uwe c p(p
(M work Iia xhich phis pennik is issued(Sec,lfy>J.Civ.CJ
(A (~. hcnJcr',v Name _ TOTAL
U I,und,o,Addmxs -I
Lu 1 erff, ] tlh Irl', dividuct and.(t that base infinnarrumn is - D BUILDINGFEE
UJ consist I.,me( Illy a II cit, ad county ordinances and state hit nalating n+ QTY MECHANICAL.PERMIT Fl,li
U Z haildogeorsolution,andhereby cathedra mpmoontativesof this city t n rupon the SEISMIC FTI:
rho"TcnOnned pmpcay u+r Int+en'torx. -
(We)agree e+save,•indetnnifyand keep or
hnless the City of Cup,Oino again.] PEItNI'I'ISSUANCII - I:LECI RIC F1:17
Iiabilhies,judgmenu.costs and expenses which nmy in any way accmc again.said City ALTER OR ADD TO MECH.
in cnrcyuence oath,gntain,of this peork. PLUMBING FEE r
APPLICANT UNDERSTANDS AND W1 COMPLY WITH AL1.NON-POINT AIR IIANDLIN tlIst's QT. 'F D
SIB EREGULATIONS. M-CHANICAI,F71:
/ r _ AIR IIANDLIN 'I'(OV' FMB CONS'I'RUCTION'I'A
gn «o pL eel/ Brach" Data EXHAUST[A \'DUCT) HOUSING MITIGATION FEE
IIAZARDOUS MATP,k ,CLOSURE
Will the i",ocont of ful a ldingeccapamsme or oralle hamnlons inaturial IIIAI'ING UNIT 1001 1'IB -
as defined by rhe Cuperuoo Municipal Code,Chaplet 1,11,and the Heahh i I lately
Cebe.Section 25532(x)" HEATING UNIT ER 100,000 BTU)
El Yet, No PAID
VEMI'IhATIONIs 'NGLE RES IDI
Will the tt1q,1'team nr fit nodding neenpam n.e eyttiptnem ar nedte11 wmdt Data keoe•Ip(a
emit hazardous air contaminants as defined by the Buy Arco Nr Quality Management BOILER-COMP . R 10B ABB If I'U)
Ilisrin, 'IYITA
❑Yes 0N BOILER-COh1P(OVER 100,000 l{TUI
AIR CONDITIONER
I have raid rhe naode.Se tions i55 5.2i 533 an wnd,55 4.1 understand
d than
eCuhe UANCI3 DATI?
!antis Hmlth&Solely Code.Sections 25505,2553]and 255x4.I understand Char if the NEW ItESI1lBNTIAI,MECH. SQ.171'.
of berg Jaesno(cuacmly most he
ciliBmnmifDec.,cupant '� U
of(he reyuimrtmnN which mus M met prior n+izsuance ofa Cmifcwe of Occupancy.
Owner nr dour..."dase'n t Dale 'f0'rnl.: ISFlllill BY: �9
OFFICE