S 2586 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUanING-ELECT RICAL PERMIT NO.
BI)ILDING DIVISION APPLICRI70NLPERMIT PINGPROJECI RCIb\N IFIC S 2 5 8 6
BUILDISG PNOJEG'T IDF:STIbYCA'1'ION
IlLjSTog NG 4)RBSS: SANITARY NO, APPLICATION SORMITI'AL DATE
nt.- ct-id--t-t 4-I�,a
O)y N�ER'S NAME: VIIONP.: CONTRACTOR'S NAME: LIC NO: NIC CONTROL N
W6--SGI� uJOv O �/d
ARCHI'DiCTIENGINEER; LIC NO ADDRESS: ❑
CON-FACT: PHONE: BUILDING PId12M1TINFO
Z.'7—�}T/_ ❑ Consultant Fees Paid by Applicant(Initial) nIJKi ELECT' PLUMB ME❑CH
��lV ❑
LICENSED CON"TRACTOR'S DF.CLARAI[ON QTY ELECTRIC PERMIT PEE
1 hereby alf...haf 1:Im Erenwd unael I,mvisinn+af Chaprel 9(rnrmncndns JOB DESCRIPTION
CWZ with Section 9nrgB m'Divi_anli3 nnha Businessland Profendans cdcane my license is O RLSIDENTIA I:
WOO PERMIT ISSUANCE
FLL in full forecand effect. ❑ SIDE. F1 KITCHEN RIiMODIiI.
" U Liacnnu Clan. hic.N RESIDENTIAL []ADDITION ❑PLUMPING RI:-PIPIT
Q. U APPLIANCES-
N a d DTIC Gnnlr'FCL
AHCHI'I IiCI'S UE:CIANA'IION ❑MULThUNU' ❑S'I'ItUCIURAI.
F 7 h PANELS
ZOmZ I rmderstunJ my plan.<hall be used a.public maiNs CIUMNICATIOS
OZ�� UPT02110AMPS �� � El INTERIOR ❑GIIIMNIiY REPAIR
W Licensed Prol'ccionul 201-10X0AMPS IMPROVEMENT E]SWIMMING POLLS
't f�
OWNER-BUILDER DECLARATION
K� OVER Ifill AMPS [I BATH RI3M( )EIJREPAIR ❑DEMOLI'I ION
C C hr asetuh,.(Sino on tun cBusin slam fpr Cantons.Co License c ty o fol Inc
whichllow ng.iosa (Section]O3lln Business and op-se,
an o oilmmY SIGNS ELECfRICAI, ❑OI'l1ER
413LLH whichrnp:imanpeas..ne.in,sthe pSheimpnr.,drnnIDnn,ore a signed stmcmec
F'LL'"f pnnrcisl iensedp,rsuant,,rex thenpplloofflir wcnpenni's Url-cll.(Ch.ement SPECIAL CINCUI'I'/MISC.
i- mm tic is pursuant In the pmsisninxnnne eommrrnr.Li<enselaw tchama9
I Waoo (con,m.ncingwithS...lnn]IXX9nfU;vnioril oftheBusincssarid Prolcroseels GJc)to 'TEMP.ME'Fl7k OR POLE INST. COMMERCIAI. AF
a.a C th a he is exempt IM1crefmm and he basis for the alleged esemplion.Any Gulalinn of ❑NEW BLDG/ADDITION ❑DEMOLITION
ac
K m_LL Section 7031 5 by eny epplieml fill u pernil subja6s dee 1pellarf m,a asil"anally of MINER DEVICES
W m not marc lM1uo Evc hmWred dnllun(SStl01. TENANT ❑FOOD SERVICE
I ' ' IMPROVEMENT
_< D 1.asimner al the pmpeny.nrmyempinyecs x'ilM1 wages as(heir sole annpcns;ninn, SWIMMING I"N'FLEM RIC
ta; adl JOthe wol'k,and IM1e structure n riot intendedou,0ened fornalc rSeu.](N4,Btionees OTHER
L m and Professions Cede:'foe Contractors License law Anes not apply m an owner of OUTLETS-SWITCHES-Fl%TURES
prupeny who builds or m,procs Ihenvn,,Iwd who docs such work hunsdf... hrmtgh
his own employees,presided do,such inrpmscn¢ms arc nor .,ended or ollemJ lin NEW RESIDENTIAL ELECfR SV Il'.
eak,.If,hour r.Jhe buildinRor lmpmse col(sola(within oric yeurof compieuoa,the SQ.PI'.FLOOR AREA SISV.Ir[
abwlder will have the harden of poising that lie did not build or improve for pur-
e of sale.).
1,ns construct the project
the Sec.7ty,.Beams exclusively erefe,ing with rte Cmmr lor's fir TO' L:
r,,eIstheproject(Sec.00n Businessandrlywhouns N ei ThoCsthei,or',Li-
scl_.wmre muchPlymnn With
aofpm(cnywhe sed pursuant
CoroiiClor'i QTY- PLUMBING PERMIT FEE
who commas far such pmjeax with a confrwfor(x)IianwJ pursuvm e,the Cnmmnor's
License Law. VERMI'I ISSUANCE
❑lno,ear- Infer Se . .i{A P 4r rVi
ACFFR-DRAIN A VEND-WA'I'IR TCA) VAIAJA'1'ION
O 'I
WORKERS Vpy f NSAGON DECIe following
BACK FLOW PHOOiCI'.DEVICE
1 hereby Illfiml under punulry of penury oar of rbc(nllnwing dcrlumliuns:
"(base rind will mninuin aCvnilicme ill Consenno ndb insuretor Worlar'x Coreper- DRAINS-IT.00R.R( COND' STORIES TYPECONSTRJOCT10N
nasion,as provided far by Section 391111 of Inc labor Code,for the perlommnce of filework Gil which this permit is issued FIX TURES-PER'11B 11 4.2
❑1 have and will moielaot Worker's Compensation imuraoce,as required by Section _
3)0(iM the Labor Code Gallieperhe'ntanm offs,work for which l nk,sc.n,if iv koecd, PIAS-13A.SYS'IE (.4 OU'TL13'LS OCC GROUP APN
My Wolter',Compeosm;on Insurance carrier and Policy number are:
Currier: Policy No.: GAS-ITA.SYSTEM- M41 F
CERT INCAI'1:OFE XEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEYIN'DUST RL NTE INTERCEPTOR
91111,UING DIVISION FEES
('II;sscoiunne.it Ilie catuphold il'the pern;l is fonmr hundred Jullure(Y I kR GREASETRAP
m Ica.) n 1'LANCIIECK PEC
I cmfify thsu In the pcdialnoncu nflhr work lar which this pcnnit is issued.(eM1u11 SEWER-SANITARY-S'IiM
nm employ any person in any manner so us ni brcnmc subject m the Worker:Co npen- - - ENERGY FEE
Z sono Laws of Culifomin.Date WATIiit I IEA I HE WATN'17F.LEC'IR
ZQ Applicant GRADING PHUT
'Z 0 NOTICETO APPIJCANE If,after making this Certificate of Exemption,you should WATER SYSIENY RIIAl"ING
f~ hcs'utnc euhjacl to In.Worker(,Cnmpcnallion is ions 1 lia,Luber Cole.You nnld SOILS PEE
forthwith comply with such pnolmmn,or,his tSnoth shall be deenlnl rr-,.kcd. WATER SERVICE
] Q
L\: CONS'I'RUM]ON LENDING AGENCY NEW RESIDE NITA L PLAIN. SQ,IF. PAID
UO n,cmhyaffirm dial ixacunsimeOon lendinga5ency forthe l'rrfnmlance of Dale cipfN
Thu work tot which this Floral is issued(Nee.30S7.Civ.c.)
E" lenders N.oW 'HlI'AI:
U Lander'v Address TOTAL:
anilY that 1 hour mad This applicmion aml sm¢that rhe uhwr information is If UILDING PI-(
A.
.F.IN crest.(agrecmrnmply with ill dty and cnumyoNlmmrra stmt.are haw.renAngm QTY. MECHANICAL.PERMIT FEE
U Z building cnnswction.amt hereby authorize reprucnmevesofthis city hsenfer upon the SEISMIC FEl
atone-mentioned property for inspection pugnws. O
(We)ui u,sale.indctm,i(y:red keep el less 1n.City of CiT alno to oho( I'IiRMI'iISSUANCI'. ELECT RIC PIlE
SZ 7
Iiabililics.judgmems,costs and espsnwe which may,in any way accrue against said City AITfER OR ADD TO MECH
In
e,,nerceof the giodm,of(his pcnnit. PLUMPING 1: '
PI ICANH
T 'NUCRS'TANDS ANU WILL COMPLY WITfI ALL NON-POINT AIµHANDLING UNIT(TO 10.(XM)CF.MI
IRCERI ' PLAT )'S. MECI3ANIf,AI,F'Ii
AIRANDLINGUNTT(OVER 10,000CFND CONEGRUM[ON'I %
SignalumufAp ;c - nlmclnr Dur li%I{AUS'I'lIU(iD(W/DUCT') DOUSING MI'I IGATION NCE:
HAVARDOUS MATERIALS DISCLOSURE
Will
IM1e IF,pliann orf inure boilding uccupuol su:m ut handle hullo".,mulerinl I IEA'IISO UNIT(TO 100,0110131'Or
¢s defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Sale,
Colic.Section 25532(a)1 IIEATI NO UNIT(OVER 100,000 BTU)
❑Ycs PAID
VENTILATION PAN(SINGLE.HIiSID) Date Receipt p
WIII fire e,,icum or(..tune hn'Jding necupu I use rquipmcm or devices which
emir k3arJam is,rinandiamnzs defined by the Bay Arra At,Quohy Atm,agemeril BLURB-COMP(311P OR 10(1.010 BTU) IO
Digrirl?
El Ycv trill BOILER-COMP(OVER 100.000[11Of
AIH CONDI'1'IONE1l
I blue raul fhc n ode,S s ric.detions 55 5,25533 an udder C 1 arat fL to of Ate Cali- ISSUANCE DAIS
f is Health k Sa(ep Code,Sections 23505,±5531 arid]5311.I ani i1, d fhc,if the NEW HESIDP.N"TAI.M1IECIL SQ IT -2 - 2- 3
-r a 9
u A'mg Jixwu manly havcumnnuf.That It is n ly l cSions ell fly enunify lee iwadnnt G /
d tM 'ah ua he me pdfn m iauancc of a Ccrf sl(kc cY.
z3e.
Owner or auttionz dagistf Date TOTAL: ISSUED 1{Y:
OFFICE