S 2643 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT IMPLUMBING-MECHANICAL. S 2643
RIl I1, NG PRO.)EM'IDEN'1'IEICA'1'10N
BUILDING ADDRESS. SANITARY NO. APPLICATION Sl1UMIT1'AI.Un'I'L
Oza
J NAMEPHONE C044JRAACIIVIOSNAME NIC `
CONI ROLp
L�LO/ / / /l �Ko 13
.I ARCHITECr/ENGINEI3R: LIC NO: DRESS (l ❑
CON'EACr: PHONE'. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial)
BLDG ELECT PI limit hlliCH
❑ ❑ ❑
LICENSED CONTRACIOR S DECLARATION QTY FLECTRICPERMIT FEE
PCZ
1 nerdy mfino hum 1 am licensed model Emviaona of Chapmr 9 kmm
oeneiny JOB DESCRIPTION
with Scaion]111HDo1 Division 3 ofthe Business and Profession,GNe,and my licema is
m p RESIDENTIAL:
F in full lirttt unU dldcd p PURMI'r ISSUANCE
a V U License Class `3 l is a 7_? �:3/ ❑SFDWI. ❑KI"I'CHIiN REMODEL
yah Dale '- — Comms QA/f APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE PIPE
F..ON ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT [I STRUCTURAL
Z pHZ Imaer,anJ rn%,damshall lw umd as publkrccoNs MODIFICATION
OZ�M UP'10200Ah1P5 ❑IW17RIOR ❑CHIMNE REPAIR
F4t:W Licenced Portr sional 201-Iqq AMPS IMPROVEMENT
aY�� OWNER BUILDER DECLARATION [D SWIMMING POOLS
SCK Ibcmb OVER IWUAMPS ❑BATHREMODEL/BEPAIR El DEMOLITION
a y serf lens dwct I um exempt from the Cnntratnr's Licetm law forma
k 3 a U following rcl.na ISe"inn 9031 s, amines and Prafccsionx Code Any oily m eoumy SIGNS ELECTRICAL ❑OTHER
ty a y which minim,a fr nnil m Conor altar,improve Ucnxrl ish,m repay nny xlrvemrc
FLLp prior to its i..uancoalco myuireslbeappli...I forwch smanit In flennigned.ma¢mca SPECIAL CIRCUI UMISC.
E yg thin he 1s licensed pursuant o the know dom,ofthe Contractors License Law(Chapter 9
ku (cwnmenciny will,Suction pinABol Dlvlsion Sol he Buionas—red Profuaintts CWe)or, TEMP.METER OR POLE INST, COMMERCIAL:
6 that be is exempt therefrom and the halls for me all,ed c.cn�ption_Any viola, nl'
o� [I NEW BLDG/ADDITION ❑DIiM01.1'HON
I+l' Section 7U31.5 by any applicant for a permit subjects the applicant me civil penalty of POWER DEVICES
tn ❑TI-,NA NT ❑FOODSFRVICI:
1„Z} sol 1,as
tan five hundreddollar[SSW).
�=0 ❑Las he oaof ails,re d<•ny,nr my d knot nloy .....iwages..Ifra lhei(Sri. chi, fievi or . SWIMMING M)OL ELECTRIC IMPROOTHER
F- will Jai the work,mails, knot imm�dul lir ulicrcd Gn:JetSec.]IU4,Ifusinu. OTHER
Wc.3 m send Pr..frosi...Cale:Th,Commodes License Law des not apply loved owner of OUI'LEI'S-SWIICI117S-PIXI URES
property who builds or Improves domain,and who does such work himself or through
his own cmployme,provided tha such adinoveracri s are not intended or offered for NEW RESIDENTIAL ELEC.'R SQ IT.
.Nc.ILhowevcn lhebuildingnri......omen,iawdd wilhinorc,cao.1 mo plvim,Am C SQ.IT.FLOOR AREA $ISQ,PI'r
ownerrhuilder will have the burden aifproving that he did not build or improve for par- ` /1
pose of sale.). �Yf
❑ L an owner of rbc pmlven..nal cOda,,cl,contracting wit Iwrowd contract..to TOTAL:
onamn the projet(Sec.90.14,B,now,and P.Ufcsoon,Coda:)Shu Commcud.U-
cemeLaw does not apply to an owner offowl who hailds or improve%dhercen,and QTy.. PI,UMBING P17RMIT FEE:
whanc,ontransl'orsuch projects wllnau+mracmg:)licensed fammanno the Commanr'%
License L.rwPERMIT ISSUANCE v
❑I inn exempt ander See. .It&to C ben his masa
ACTT?k-DRAIN&VENT-WATER(EA) VALUn'I'ION
Owner Date
• WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby vlBnn under pennhy of porjury one of fire following Jeclwaunm
❑I have and will maintain uCenificamof Cnmenuoself-Insure for Wmker'e Cramped- DRAINS-FLOOR.ROORAREA,COND. SgOBIES l'YPU CONS'rRUC'1'10?
..action,as provided I'or by Section 3700 of to labor Cale,for the performance of the
work for wnidf tis permit is issued. FIXTURES-PER TRAP
❑I have rind will mailenin Worli ComPenmction Imumni as required by Seediun
3](X1 of the Labor Car.for performance of the work for which this lmrnti(is issued GAS-IiA.SYB'1"EM-I INC.40U'I'LEI'S
.GI20 APN
M Work(. nsatinnlns cryry Policy
y No Mr
am Crtier:/' CERTIFICATE
I .L�MPTIONy FROM
(A/'KERS' y5 GAS-EA.SYS'fF_N-OVERJIEA)
CERTIIICATIIOFEXEMPTION RAN WfIRKEkS'
COMPENSATION INSIIHANCI', GHEASIIINDUSTHLWAS]F,INrIFHCEI'TUH I^(\ ad .) DI , IEI!S
or less.)('Ihi.a section need not becampleteJ if the Krait isfonme hundred Jallam(bllq) CREASE TRAP - --
I nTytu tin ll, pert (ftl Af 1''I di1 l:'' J (shall PLANCHhCKILIi
ant ply ypenon Y 'f hoc �w 'hut h W A C SI WIH-SANITARY STORMEA.2Ml1'C
z xma I tc Df 3 Q Z nlxn ENI:RGVIEC
0 � G �� NATER HEALER W/VI:N'1/11EC1'R
z Apll t 4 -_ GRADING FEE
y ryOTICE T(I�AI�LrCAM:If al r n. r y u YI c.nc(I L npfn4 you shoulU WATER SY$'fEM?HEATING
a , become subject to the Workers Contpmration Provisions of the Labor Codd,you mord SOILS IEE
W forloodb comply with such pmvr,..as or this permit shall be dttmcdrevokcJ. WATER SERVICE
Q+
rU. z CONS'ra is arctr LENDING AGENCY NIFN'RFSIUENTIA1,PLh1H. $Q.FT. PAID
U � Ihcevoldr,Eattert isocal(Sor.30ldndingogamyhufhc Krformunccair Ivte RcaeipctN
� F' the work lair which This Knnict is issuW IStt.3103],Ci,C.)
U Lenore Name
O {EI Lenders AJdmes TOT TOfAI.:
fQ. 1 cddify tin I have mod this application and.sate ihvt to shove infnrnfadion Is BUILDIN(
Z) correct.I agreed comply with all city and county ordinances and state laws relnfngm QTY. MECHANICALPERMIT FEE
U Z, hnilJing cnnsctrudion.and hemby authorise repreumatives of tis city mentor upon to S19SMI'IgzP
ahovo-mcnfionnl papery fnrinspecfion purp(.cs.
(We)agod,In.avd.indenmilyaod keep b.undresuhe Cifyof Cupcuino again4 PERMIT ISSUANCE IFL[CfRI Eli
liabilities,judgments,rose and expenses which may many way.,mrounairs,and Cr,Ill .it. PLU
,\Lq'Ek OR ADD TO l,1 F:CH. c
onseyucncuof the grunirr of tis pdMBINa 'FIr
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING I1NI'r(TO Wil CEM)S(IUNC' GULATIONS. MECfIANICA FTI$
AIR HANDLING UNIT IGYER IO.IXp CFM( CONSTRUCII(l TAX
use dnppl,c I/G n Dine EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEB
11A%AR OOPS RIALS DISCLOSURE
Will theapplicam or future building(occupant store nrbandle Nvandommalcri;d 1 FAJ ING[IN]I(OO IWh)(00 H'1'U)
as defined by rhe Cupertino Municipal Code,Chapter 9.12,and the Health and Safe,,
Code,Si inn 25532UU" HEATING ONE I(OVER I E0.000 BTU)
❑Yes
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or humid(wilding occupant use equip ram or devices which Dare R"im"a
cold hunrJnns air eninm nd.lars as Uefi nd by lire Holy Area Air Quality Munugement BOILER-COME 3HP OR 10k010 BTU)
O
L1 Yes No BOILER-COMPIOVIiR I[NI.INMI BE GO
I have rend the hadardous malcriakc reyuimmenu under Chapter 6.95 of the Cali- AIR CONDI❑LINEN ISSU�CE DATE
farm Ilevhh&Safely C ah..Serm ns 25505.25533 and o--5534.1 undersand tut it he NEW RESIDE.NTIA L M ECH. SQ.I+P. ^'J A
building Jo meurtently ha.cmm�vnL fM1m it is my resprmsibili,,mnotify rbc occupum ��
ul'them "watswhiehmuBMmmprion10;4v,
is a ofv Cenifieamof0ecupunc ddd
441AIII? e _�_ fi
(lw n ndyea Dine TfPrA 1.: ISSUED BY: •C[/
OFFICE