S 2117APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. -ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING- MECHANICAL
BUILDING PROJECT IDEN'1'IF'ICATIUN
Pr: IT NO
2117
BUILDING ADDRESS:
/d 16t -/i' /3u 4 a-
SANITARY N(I.
APPLICATION SUBMI'ITAI, DAPI
Ll
pWONII:
C4siZ u00�
CONTI2gCTON NAME: LICNO:
NIC
ElCOMI'A
CON TOL
., AItCII1TE /EN GINEfiR:� �l.11 N
1,`/'_
ADURystifS/•A/ Idvr #V�
Y `
: PHH.ONE
IUILDING PERMIT INFO
6 /q q w t „ C^ Sl��,n'O i/ T
❑ Consultant FeeS Paid by Applicant (Initial)
Bfh�II�G/ ELECT PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION
1 herehy aimed that I .,it licensed ummr provisions ar Cimino, 9 (cmanum e
QTY. ELFCrRICPERMITI FEE
JOB DESCRIPTION
II"Rh1IP ISSUANCE-
wiln Scolks.7XXBof Dlv' m3nfthe Bisincesandlbeficsioa. Clvle,andmylicensel.
in full torte :mJ ellen. /z6f"
LicenncC�Lle.p 4 6.14 TV
pale Co tar Q
RESIDENTIAL:
CSFDWI" ❑ KITCHEN REMODEL.
❑ADDITION PLUMBING RR -PIPIT
❑MULTI-UNrr [I STRUCTURAL
MODIPICATIl3N
APPLIANCES - RESIDENTIAL
A ITEC DECLARAGOry
ssla revspublicrecnNs
�
AMPS
❑INTERIOR ❑CHIMNEY REPAILrenscd
IMPROVEMIiNT SWIMMINGPO 'OotI
Prnfessior
MPS
in (exempt frm the CmaRXI'ION
hereby. (See Nal 11. eBosni from the Coacwoa License Law far Om,had, OR maron. (Section ]OILS,
nJ Pmfderi is Cale: Any cityar coumY
❑BATHREMODEUREPAIR ❑DEMOLITION1
(IAMPS
NI'ANIII.SIunJersmnJmyp
CTRICALwhich
1. aftxs
a perms m unrsmm6 alcor. ntfarin demolish, nr any
ret,
i,sa o.,alair
mearrimemprior er its iemm�ce, also rtquirtxNe npplicam for suehpermiuoworce
I Ull'/MISE.
ow(Chaintent
untruetor's Lilznnc Lnw IChapmr 9TER
POLE INS'1Thal
he inmcmpl therurmm and the bunis for the alleged exemption. Any violation of
❑ N BLDG/ADIIITION ❑ DEMOL ONSection
EVICES
]031.5 by any applicam fora permit wbjecas the upplicam m a civil,smalty of
not than five hundred dollars($510).
u
I, as owner ofidepmpmy, or my employees with wages as lllciranle compensation,
will Jo the work, and the structure is not intended or offered Battle (Sec. 7014. Business
❑TENANT SERVICE
IMPROVERNl'
❑ OTHER
SWIMMINGYOOLELE'rTRIC
OUTLETS -SWITCHES- TURES
land Pnbfessiom CodeI he Cno,tw, r, Lkenne Lnw does not apply to an owner of
property who builds or improves Ihetcon, and who docs such work himself or through
his own emlJoyrox provided Incl smh impmveramm are not imendnl or officmd for
NEW RESIDENTIAL ELEC"R SQ FT.
SQ. lel. FLOUR AREA
5/SQ. Fr.
sale. IL however. the building or improvement is sold within one year M ctrmplaion, Ise
crhuilAcr will have the hunkr of proving that he did nm huild nr impedes for pur-
c of talc).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors toTOTAL:
Ia l:
nna tin p l t(s ]EwaB' eP r: Code) The red ,r
weLa e t apply to fp pony h builds o p thereon. and
t onus forsuehp rjeels wed rum tons) Interval parsuent to the Clnracnas
,,„•e
y
QTY'TP PLUMBING PI RMITI lY
L I
PERMITISSOANCEE�
-
License Law.
Fl tum esomPunde, See. , 13 A, PC for lhivunnn
�s _
A TEIt Il IYt dr vBNT=W�s'(Hk1EA);'_f'1
Owner Elate
VALUATION
BArK WRIlCIEC, DEVICE t.. ''
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of Perjury one of the following declaratlons:
-
Dk INS- MOOR, It001;'AItRA, SOND,(�', �.,{r
IhaveandwillmainminaCunihcuronrCnnsenttusell'-avamrar Worker's Cmopcn-
satins, as pmvideJ for by Section 3]Iq of the LaMrz Qele, for the perfonn:mre ollhea
k or which this permit is issuae,
STOItILS
TYI'ECONSTRUCHON
pI XT REST PRR TRAP' 1'T o V+!. Lj "J
Ve Lubar Coda, furvhv performanw nftho work for which this pomaia is issued.
X00and will maintain Workers Compensation Insurance, as required by Section
3
GAS - A..YSTE-1JJ4C:40 .HTS
OCC GROUT'
APN
Myier:,'r�Un�lun. •ranJly'oliaY nu9�g�ry_ /k{r
Carrier: policy
01ic No.: vT$ �`e
CFRTIFICA'I'Ei (IF EXEMPTION FROM Wf1RKER5'
COMPS 9ATION NSURANCH
(Thsnacdon neral Boa Neu aPletuH' epennil'rs lisonu hundred dolWrs (S IOU]
or less)
'
'�'�
-
GAS -A.SYSTTiM-OVF.R4(GA)"''-
GRIiAS 1 L 'L IN'1`RRCEPTOR
lg,- I
BUILDING DIVISION FEES
-•.-
GREASE TRAP
I.ANCII
nn,,""
SEWER-. pnVt(S'IY111M 5A.2(10 PI'.
I conifylhal in the peel' t ework l'or which this permit it.meed, l doll
not employ any Person i i sed i become subject to the Worker: Compen-
E -.ROY LER
Xt"ArVIA TL[CTk
satins Lnws of Gllifamia. u
Applicata r
GRA INC. FEE
NOTICE TO APPLICANT: If, after making this Ccrtlbca e . mphnn, 3oa shot
become subject in the Worker's Compensalinn pmvisimc nrlhe labor Code, you matt
fanhwiN comply with each pmvisium nr this pennil shall MAcemed mvOkeJ. '
��PYff
WATIik SYti' Ci0111p
♦
Ue VplinI iR ,' aceep
SOILS AH
CONSTRUCTION LENDING AGENCY
I lwmhy ufOrm thin Num l.v ncnmwation lending ugenry for l hepedmmanan
Ne work for which this permit is issued (Sec. 3097. Cis. C.)
Lmalm`s Name
l WS IAL I'LMEt,.r n¢i;1 s7. I 1
PAID
Receipt
a
nsI II J
a 'TOTAL:
TOTAL:
Lenders Address
i sions
1 certify that l have read this application and state that the above information is
nanc
emova. ugme ur comply wish all city and enemy ordies and slum laws relming m
building construction, and hereby authorize representatives of this city to enter upon the
1 N Pmt 1 �a fl EE
p1en♦Le{A�
BUILDING FI- i
-
1 'MIC FE
above-mentionedpmpertyf nspeuaion purposes.
(We) agree b.",me ndemnify and keep harmless the City of Cupeninn against
eabilitics. judgrmms, -And exprnses which tiny inuny wayncvion., ad said City
in,consequent oflh ming of this period.
e� SS NGF.
ELIICI'ItIC I§:'
/,/
ALTER OR DTOM
PLUM HI NO FI
A ULINC UNIT .WU CFMI
-HANICALPEE
APPLICAN 1 - 5'TANDS AND WILL COMPLY WI f{ qLl NON POINT
SOl1RC13 Ef ,A ONS. ^ /{�y
Y LI�((J(
v HAUSTIIOOD(W/DUCT)
CONSTRUCT[ON TAX
Sign u-Applie lto, Dole
HAZARDOUS MATERIALS DISCLOSURE
{pUSING MITIGATION FEF
Will the applieum Ur fuutre IwiNing cecupam store ar handle hazvdnus material
lNG ll
us dufinod Fy No Cupadlnn MameJ�nl Cmle' Chapter 9.12, and the Health and Safuy
Code. Seclinn 25532BC
HEATING UNI '1'(OVER IOU,IX1011'fll)
Yes
❑/Vr/I�rc\.`
Will the appliant or ban huikling rxcupata ora equipment or devices which
emil hazardous Bir comenumm is as defined by the Bay Area Air Quality Maragmucen
Uisain't
E] Ven 11
PAID
Date Neeeipl it
VEN'IIL A'I'ION I -AN (SINGLE RIISIU)
pOI1,ER-COMI'(JIIP OR I00,01X1 BTU)
'fOl h
BOILER- COMP (OVER 1(X),00k) {TG)
AIR CONDITIONER
s under Chapter 6.95 or the Cali-
1 bout tar o iaemdaan a nct4B&533
ISSUANCE DATE
NEW RESIDENTIAL MECII. SQ. lel'.ne
,..is Health A u ty CNe. Sections nd 25534. I murr mnJ m itNe
docs IC enllyh: .leanslxm0ditytone yIh ca,mamq''
IUi%meaof a Ceti I I
ISSUED BY:
Ovnermauffinsuried eat Dan
'TOl'AL:
OFFICE