S 2485 - APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERM[r No
UILDING DIVISION APPLICATION/PERMIT PLUNIRING-MECHANICAL
a ` BUILDING PROJECT IDENTIFICATION J n 4 o
ASANITARY NOILICAI'I( SUIMIDATE
ILDING ADDRESS:
IiRT AyM@ t I' (INE. - CF)N' AaQ10H'S NAME: i o NIC CONTROL
RCIII'rEC'UENGINEER. hIC N(1: UI 4 a S J ❑
CONTACT: .t rPHONEBU
: ILDING PERMIT'INFO
��d f A a. `5 2--11
--I 1-7 [:3ConsuDunl Fees Paid by Applicant(Initial) HL❑Dc RL1❑!T PLUMB MEGA
LIC17NSED CON'TRACTOR'S DECLARATION `f QTY I:LBCTRICPERMIT 1'EE Lr/Uy
I hereby affirm on 7000)of that I am lieeni comer provisions of Chapter 9(commencing JOU DESCRIPTION
NUS Lila rcemm cBte - -L ss cal rrofeaalnna ode,and cony l'tacrosu is RESIDENTIAL
with Sect
w O O PERMIT ISSUANCE
CIF in fb111'o s / ElSIT)WE ❑KITCHEN REMODEL
N
6zU APPLIANCES-ItESIDIiNT1At. ❑ADDITION [I PLUMBING RI PIPE
6 aor
FOy ARCHITECT'S UCChAN ION PANELS CMULTh UNIT ❑STRUCTURAL
zQrnz lundersmnd my plans abaft be usul us public rccnNx MODIFICATION
Ozr-`, UPTO200ANUPS I CINTERIOR ❑CHIMNEY REPAIR
P�.t: I Licensed Pmn,,mieal 2014INNIAMPS IMPROVEMENT CSWIMMING POOLS
d WF,; OWNER-I{UII-DER DECLARATION OVER 1000AMPS ❑BATH REMODHIJREFAIR ElDI',h10L1'1'ION
K w'd 1 hereby affirm that 1 an,as,.Pt from the Contnalor's Licence Low fur the El
a6yx5�O y U following reason.(Stalin 1 7031.5,Business and and P nfessione Code:Any city or.arty SIGNS ELECTRICAL OTHER
t++31y H which requires a permit to construct,alcor,improve,demolish,or repair any swemm
E. prion,its ismance,alum rcyoitee the applicant for arch permit In fileseigneduatemenl SPECIALCIRCUIT/MISC.
Y thtyy y..1 that he ie lwensnlp...ionl In the pr0vlmnm oft he Contractnt's License Law(Chapter 9
I No (comnaneing with Section]0kayof Division l of the Hui and Professions Cade)ur TEMP.MINER OR PULP INST. COMMERCIAL'
IVthat he is exempt merefann and the basis for the alleged exemption.Any violation of El NEW BLUG/ADDITION ElDEMOLI]ION
.m. Section 7031,5 by any applicant on a permit subjects the applicant for civilpcnulty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
f-Z
not more than five hundred dollar (D.(550> IMPROVEMENT
d wi Lo the windthe peony,or myemplended.,cimagcstssthein,le rnmpenwtion, SWIMMING PHIL ELECTRIC
FD will Jmhuwmk,ands: swrnurmicons Lici se Law does
e(Scy to a n,Iimainesx 00'THEIt
IY w and Professions Code:The Gemmae.''License Law saes not apply m if owner of OUTLErS-SW'ITCIII!5-FIX'IVRFS
6 3 at.out y who build,or o id,mvth thereon,and who does such work dee o f it through
for
baa own employeese provider that.pooh nuva,is....old t m nal intruded m ol)2ru1 for NEW It I1SIDEN'rIAL 1?LECT SQ PI'.
sale.If,huwever.the building orimprovunem is sold within nnuywr Mcompinion,the SQ 17.FLUOR AREA LSQ.PI'.
cr-builder will have the burden of proving that he did not builds improve for par 1
Ease of soled.'
0 1,as owner of the pmpeay,am exclusively contracting with Iicemed comment,to "rOTA h:
construct he project(Sec.7N .Business and Profovsioms Cmme: fair Conwaors Li. -,enne cot applyu or ProPcny who build.or lmmprove,Putman,an I QTY, PLUMHING PER NEE
who enntaces lir such projects wi@ a contrationd licensed pursuant m the Commalurv.
Licenx lam. PERMIT I'ISSUANCE
0 I can exempt under See .B&1'C far th is maann
ALTER-DRAIN&VGNI'- A'r: VALUATION
Date
Ir WOR K 1:R'S COMPENSATION UfiCLA RA'T'ION BACK II.OW PROl'HC'll DEVX'1i
1 heuhy o0irm undo penalty of perjury Ina nl the following dedmationc
❑I have and will maintain a Certificate of Concent In self-insue for Workers Courtier- DRAINS-FLOOR,ROOF,AREA,C�riiiit, STORIES TYIECONSTRUCIION
tritium as pmvidrd fnr by Section 3700ol'the Labor Code,rnr da inimi ma ire of N,
r wTrchina permit,i,sncd. FIXTUHIS-PIiR T(?\A'
w01 have and will maintain Workers Compensation bromine,a required by Section
3]00,fthe LahorCode,fonheperfommnce of0tu work for which ilia permit l'issued, GAS-!
SYS'I'P,M-I IN AOU"L,TS OCC.GROUP AIN
My Work pp1F Com gqntinnI r cearrierand Polacy ryrt AA3fDS cns-
Caoraer:;�Fd�` -F mak^ @ Pjgwy Na..411 EA.. (.TF -Q IiR4(EA7fl
y
TRTIFICAIEOFEXEMITION PROM WORKERS'COMPENSATION INSURANCE GRFASI91NDUSI RL WASTE 1 H'I
BUILDING DIVISION FEES
(This unonnuJ not be mmpleteJ if lM1e permit ashmme hundred dollars(51tN)1 GRF.ASIi TRAP
orinvJ PLANCHIiCK FF.F.
Ioyancertify that
romarithe
arymmanceol,toliework
afte,ochlhm duciiilisissued,Ishn- SRW'EH::"$�FTARY- 'TORMEA.200 FE
nm employ any person in any Intoner so as m become subjm to me Workcri Compcn- ENERGY Flili
O ,� 'mint Laws of California.Dutc WA'I'lilt I IF,A'flili WNIiNT/F,I,IiCTR GRADING I'IiG
rA NOTICE TO APPLICANT,IL after making this Certificate of Exemption,you should WATER SYSTENUTREATING
E" I+vrrmc,rbF,O m the Workers Com 'tion I the Lebo Code. most SOILS FEE
) pens, provisions o you
a'�.t fimhwith comply with svch provisions or this pcnnit Ilett be JeemeA revnkui WATER SERVICE
Q
CONhe.no ni'moNDING AGENCY NEW RIiSIDIiNTIAf.PLMB. SQ.PI'. PAID
U O Dm Ra'uipl#
herebyallion that Them issue (Sec.0n lording agency for the performance of
the work fnr which This pennil is issued(Sec.3097.Civ.CJ
OU Lender's Name TOTAL
1 :
W Leerdreas nd 's An 'TOTAL:
1 certify That 1 have read this applacmann and elate that the above information is BUILDING PIE
.F.th correct.l agtne In comply with all city and county oNimni and state lawn mining nm QTY, MECHANICALl'i PEE
G Z hnildingconsrum ft.and hereby authentic representatives of this city um enter upon the SEISMIC I'
r above-mentioned property for inspection prpuas. r
(We)agrecor mc.indemnil ad hari the City of Cupertino 'rte I'F.RMI'1'ISSIIANCF ELECTRIC PE'
y an p > pe gam
1'abiiio,,jOhnnit..coacand expmaea which mmyln any vayac,maa,mm,aid City ALTER OR ADD'I'0 MECH.
in rvequence of the gmmirri this penult. PLUMBING 1: E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIN'P AIR HANDLING UNIT(TO FLOOD CFM) MECHANIC PEE
SOURCE REGULATIONS /� r
d/ _ _ - 11 —43 AIR HANDLING ON['1'(OVER 10,000 CPM7 CONSTRUCTION AX
Sigmal ofApplictiiift/Conttrruuclorr IST al) e EXHAUSTH00D(W/DUC1) -
HOUSING MITIGATION FF,Ii
HALARDOU9 MATERIALS
rVOTr DISCLOSURE
W'lllt Ili,,Cicamor fuarebuildingk.Chaptr9.12,handle HeamOund Safety HEATING UNI'I'1'TO 100.000 B1 ff
ae deli Sed by 25 32(a)!no Municipal Cnde,Chapter 9.12,unA the Health cool Snfay
Coda,Section 25532(.)'! // HEATING UNIT(OVER IINI,(1fN)II'1'U)
E]Ycs fjj No PAID
VHNTILA'IION PAN(SINGLE ItESi D) Dote Receipt#
Will Ire appliavm or fuwrc building occupant y A equipment or Management
which
emit hauNnus air cnntaminann s dehndJ by the Ray Area Air Quality Management BOILER-COMP(3HP(1R 100(Np RTU)
Piano? TOTAL:
❑Yes Nn BOILER-COM 11(OVER 100,000 B'PUT
1 have mail the hamrdom materials requimments under Chapter 495 of the Cal- AIR CONDITIONER ISSUANCE DATH
I'main fleallh&Safety Cale,Sections 255115,25533 ant 25534.1 undi that if Nc NEW RISIDRNTIALMECH. SQ.FT. [Y
bfdoengJcesnms,v chummutefti, ,titasmymarymsihiliry mnotify the uccupam ( r
of them moots which tnapl he nretp m mi,uunm ofa Cetf mens f tp:msy.
9
Owner mthorired agenta� GTA^ ISSUED BY.
OFFICE