S 2936APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII.IIING - ELE(TRICAL
BUILDING DIVISION API'LICA'I'ION/PERMIT PLUM uurvr,. no-:cxnrvlcnl,
PERMIT' NO.
BW )ING PROJEET' [DESE BgCXUUN
BUILDING ADDRESS: /
2-2-2-4-qHAMMOks1.b WAY y 6APE.I2_T"I;sl 9SDI+ 6-r
SANI'T'ARY NO.
APPLICA'LIONSUBMI'ITAL DN' F.
L9 1cr
1
OWNERS NAME:
JHr[I_NIi: �•'�
�'THE0821Er� G2ou �so'-3'1 (-�i3
CONIRIR�ACIOR'. NAME: /, % LIC NO
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E:1CoBSBltan[FecS Pal[by APPIICBN (Initial)
t BUILDING PERMIT INFO
BUILDING
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LICENSED CONTRACTOR DECLARATION
-
IhIYdl-n ILII Idd, ov, ICla, mr9 ("nourano,in,QI'Y
wdhSection 7000doCDim,ion 3oOh, Business and Prof...an
ons Code d nY I'celse is
infullf dclfea. Ggls
IJen+,e Class Go. V
)ale 4 Contrudnr
ARCHII'IiCTS Dr:C1A PION
Iundcninnd my plunr,M1all he used us public records
1.¢enseA &ofnbna3l
OWNERl'sIouDER OFCLARAI'ION
hor... melon for I ml uBaoi. man the Clonsto o License Luw for the
muowing teams. (Section .ul.s, na,men<:md I'rae.,ia.. c.da: any city or ea+my
which re 4uirta a Tu,.1- t. tors, he I'lleq impose", denlalisq ni repair anY struclum
p,lot hal,fir,urdpt..6nrequi,m.... n.... nl li+r such penniuol'ilrw,,u eA aalenmm
t inn r. d I .tat n d p r'I c t r nd 1 (Cn pm 9
6 n,hem 91101qof ,b e 1{,- JPrf' :Cdc)rt
that M1 pt 1 of d o , in, th II k l pl An, (a of
tied 911.i19hy my stalwartfnrn perm I+Julr tlw applrunloaavlpewlly of
not more than five hands,,( radius ($500),
01. as owner of the property,(it mycmployecc with wages as their. colo contpensulion,
will do the work,und the "nature isnot immodcdoroftmd hasn't, Sec. 91144,Pusincu
and Profession., Code : The Contractor, License Law does mol apply to an owner of
property who build, or improves bell and who docs such work himself or through
Ills own cmployw.r, pawalcd that such Io") ctuar" a a oat inmaticd nr aB J Ibr
vale. IL however, the building or improvement i.c .cold within one year of completion, the
ee-hudder will have the burden of proving that he did net build or improve for par
pose of nuleJ.
ELECTRICEMIt FEE
1
JOB DESCRIPTION
RESIDENTIAL
❑SPDWL ❑ KU CHEN RFMODFI.
❑AUDITION ❑ PLUMRING RE -PIPE
❑MULTI -UNIT El S1 RUCTURAI,
MODIFICATION
❑INTERIOR ❑ CHIA1NIiY REPAIR
IMPROVEMENT EI SWIMMING POOLS
❑ I1ATH kHMODFWIt HPAIR (]DEMOLIT'ION
❑OTHER
m
PERMIT ISSUANCE
AI'I'LIANCI!S-RESIUIiN'1'IAI'
PANELS.
UI"I'G2RBAMPS
3111-IIkIBAMI•S
OVlilt IBOnAMPS
SIGNS ELFCI'RICAI.
SPECIAL( Ilt('lll'1'/MISC.
TEMI'METER OR POLr:INS"r. S4
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT'
❑U'I'IHR
#OWI?RDI?VICES
SWIMMING POOL ELECTRIC
DO I'LETS-SWITCHES- FIXTURES'
NEW NISI ULN'f1A1, ILFCTR SQ FI'.
-
SQ. IT. FLOOR ARF,(
g/SQ. ler
TOTAL. u'
❑ 1, as owner of the property. are exclusively contracting with licensed rua ratlor, to
msvu l the project (Sec. ]TIN, Business and Profe,aion, code:) The Comruc"ry Li-
Q'pY. PLUMRING PERMIT pgg
seLa, Acesran apply roanown..ofprnpany who hold, er mpincn lbcreemand
111. con lacca ha such pmjea l with romtt..etnr(s) I.....cd pnr,tunl loth, Contactor,
Llaen.m law.
PERMITISSUANCE
❑I-ine.emyt under Syc�B do P C tin thkarason
/`
Owner,
ACI'I:It-UItAIN &VIiN'I'-WAI'FR IEA)
/
WORKER'S COMPENSATION DECLARATION
I heaby affirm und,,vmmy of praury nneeftho follnwmg deelaati'va,
❑ I huvamnd will raiations Cenificacof Carlen In sell' -insure lin Werker',Con,a-
lunar, as provided far by Section 370I of the labor Cale, for the ped-arr a me of Ibc
work for which this penal, is issued
❑ 1 have and oil maintain Workers Cempcn.rminn Insurance, as required by Section
J7 of the Ldar Code. for the performance of the work forxhich this profit is issued.
My Worker's Compomenion Insurance carrier xnd Policy number are
Cornet: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
BACK FLAW PROTECT, DEVICE
VALUATION
DRAINS-l+l_OOR,R(N)l',ARI?A,COND.
FIXTURES - PER TRAP
GAS- EA. SYSTEM I INC. 4 OUTLET
STORIES
OCG GkOUP
TYPE CONSTRUCTION
APN
GAS - EA. SYS 'I'F,M-OV HR 4 (FA)
GRLASETNDUSDIE WASTE INTERCEI'L'OR
COMPENSATION INSURANCE
(1'hls section ncal not he unnplae l d the'conic in nature hood"[ dollars IS I Ont
nr les,.)
GRI3A51? TRAP
B11I1.U1NG DIV1910N PI?Ii5
PLANCHECK FEE
O ,'� .Mian
(7
Icenify that itnhery:rfarmann'ofthe work forwhich this -tis ism ed l shall
our con le vn permi
p y ypcmnn in uDo mannerwas to hanmc xuhfed In thu Wnrkari Cam p'�°-
Law" of Cullbimia. Umc
Applicant
SEWI?N-SANITARY-STORM IEA. 20fllN'.
LNIil10V PI31i
WATER HEAl HR W/VpNT/ELEC'IR
GRADING FEE
z
ar- lonhwilh
Q
N(YUCI? TO APPLICANT W..J t, ager making his Cenilicae of Ear pit,,., ioc , y( sbn°hl
beoonm nevi "I 'he Wader's Gmglorsco,athis prod, hell of the Lahnr Cale, You nnt,t
comply with such pravieions onhis lMmnil shall he deemed revoked.
WAIT int SYS'I'I SIGKTAI'INC,
SOILtlFEE
WATI2R SERVICE
NEW RESIDENT IAL PLMB. SQ FT,
5 z
U O
y
O U
CONS TRIICI ION LENDING AGHNCY
I herebYamnn that there i,. consul IloininGagency far the perourancrol
mawa,I farsemen mL, mdl r, i�r..al (stc.3Wl, cis. c.)
Lender',
PAID
Date Race t
Nmnc
cnAddress
oral.:
TAI.:
U Leader's
E 0. W
W co111fir
U z buildingconnmct
above-mentiuned
Ilubilltics,jndgmcnt.,w.(,and
'n
APPLICA
SOIJRC'I
Sts..al..,+nrgpphe..+n/ca..vuaor
a.
Co
Icenify thin I have mad This application and nate that the Naos, intimation is
Toodullcoanply with ulldyconecaloryanlinunwI floul ar,imluone,u ngte
logand for hosamhorizerposes. tntives of dniv city menmr upon the
property for inspn�tion pugxsm,.
(We)agree to save indemnify and keep Ifroadea the Cityof Cupenine agaimt
Oxpascs which only nany way accmcagtlnst.said City
c ......Once of the gaming of this permit
T UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTqIR
EGUI Ip
BUILDING M.
QTY. - MECHANICAL PERMIT PEf:
SEISMIC FP.H
PERMIT ISSUANCE
ELECTRIC FEF
ALTER OR ADD 10 MliCll.
1'WMBING FI3E
HANDLING UNIT (IG IO,INIO CPM)
MECHANICAL I:IIE
AIR HANDLING UNIT (OVER ItLINMI CFAB
CONSTRUCTION TAX
Tac
I IAZARDOUS MAI'FRIALS DISCLOSURE
Will the applicam er future building maupam stun or hanAtO hnaaNnus mamrinl
delincd by the Cupertino Mune tl Code, Chapter q. 12, and the Ilealth:mJ Salcey
Section 255.Ln(al?
I] Yea
ExTAUS'r DOOD(W/DUCT1
IIENI ING UNIT (TO 11,009 BTU)
HEATING UNIT' (OVER 100,000 If IU)
HOUSING MITIGATION PEE
VENTILATION FAN(SINGI.B RFSID)
BOILHR-COMPCUPOR IOB.000 RTU)
Ilan"?
-
WIII the applkunl ar nature building o[eupant uxe cyuipnmal or davicev whidl
mit haardnus air cnnmminank, as fired by the Bay Area Air Qua01y Managemea
0Yc, n
PAID
Ikea Receipt k
IO _ 0 0
ROILCN-COMI'(OVFIt I mooddl1'rU)
ATRCONDRIONER
f
+nncn
Ihave mail he lusIondar, ou sal, requirementsChapl 695 (of the Cali.
mnaH III &Yftry Cod S f ttf15, 25fl3 1 tti4.l i ltml it the
I m n t I than y ryn'bilityl (fyth cupanl
Im,'m the Ip nor. f Ger fit cl�, j��'
ISSUANCE; DATE
` �% ,S
(' r ?
NF.W I<ESIDIiN PIAL MIiCH. SQ. Irl'.
Owner
f---il-]
or uuthonwd ngenl Dam
TOTAL:T�
ISSUEDBY,
OFFICE