S 2877 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PIiRMI'I N(l.
BUILDING DIVISION APPIACATION/PERMIT PLUhuuNc.MECHANICAL
BUILDING,PROJECT IDEM I'IFICATIOY 2877
BUILDINGADDRESS. SANDARYNO. APPI.ICAI'ION SUBMI'1'1AL MATE
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OWNER'S NAME. PHONE CONTRAC7ZFAML NAC CONI'ROLM
LIC NO:
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ARCHITIiCT/ENGINEER: LIC NO. ADDHIiS.: [+ C/ b __1
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CONTAC'P. PHONE: HIJ ILDING PEIdMI'1INFO
�j ^ Gam, X96 L6 Q ❑ Consultant Fees Paid by Applicant(Initial) BLDGELECT PLUMB MECH
C, E]_
LICENSED CON'IKAU]UK S UECLARA'1'ION QTY ELECTRIC PERMING - FEE
I hereby affirm marl am ham.ed ander plavidnn,nr chager 9(commencing JOB DESCRIPTION
�
Z mSeelioo 7s000)o(N W o Salthe lhsincss and Poole,
� � nylicenselx OOIEtMI'1'ISSUANCLIi
'DWI. ❑KITCHEN 11MODELWullu ]fed'
ensCUzWLLo, A) 'LIANCFS—RISIDIENTAL []ADDITION [I PLUMBING RE-PIPEek. DECAR
F 7koo
PANES ❑MULTI-UNIT C3 STRUCTURAL
Z O y unds shall Z I ersand my planhe and as pubic retards MODIFICATION
OL—.W UP 1021X1 AhIpS I El INTERIOR ❑CHIMNEY REPAIR
F run F"W I.IccnsW Professional 2111-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNFILBUILIIER DIECI.AItAI'ION
OVER tg10 AMPS ❑BAI'llOTHER RIiMOUELR2EPAlµ C:1 DEMOLITION
C 6 1 hereby.(firm mm I ren exempt Iro1n the Cnnmadoo :License Low fnr the
O d U which it urns a Permit
t ](131 s,Business and Pmfdemolsnn.or An it t ❑OTIiIiR
X3 6 Yc Yor nm^Y SIGNS EiLECDtI AI.
W LL in x'111[11 its requires a permit to ea..he alter,imptave,h per..... file
repository atmcturc
f"LLOg
Prior miu issuance.also reyvirns the applicam for such permiuo EleasignoJ smmmcrt SPECIAL CIRCUITIA/ISC.
,E mat he is licenscApursuum to the pme,nonsof the Common's License Low(Choper9
W00 (onmmencing wire Section"IOIHIIof Uivision3oflhe llnsinens:mA Prolessinre CuAul ur 'HiMP MIUERUKIna.t)NST.
F esc
I Ih n he is cemnp.Ihetefman and 11th basic f r the nllegal nsmion.Any vine aioll of EW Il1.DG/A11ITION ❑DEMOLITION
..� Section]031.5 by any opplicm t for a pvnni1 subject,mr applicanuo a civil penally of POWER DEVICES
not more lhon live hundred dolbns($Slay [I TENANT El FOOD S17RVIC17
F Z Y IMPROVEMENT
d cep
[:J 1,as owner of the property,army employees with wages as their sole compencation. SWIMMING POOL ELECT RIC El OTHER
will do the work,and tom structure is not intended ornBcred four colo,(Sa._DLI,nosinesssiness
63$ and professions Cale:The Comint License Law doer not apply m un owner of OU'RETS—SWITCHES—FI%TURFS
prnpeny who bull],or improves thereon,and who does such work him,elf ar through
his awn empluyces,provided man such impmvenerb aronut inendeA on nµclrJ our N)EW RESIDEN9'I AL HLECTR SQ PI'.
sale lf.hnwovar,the�uilding«Inlpmvenmm_,sold within nncycarnfmnlplutinn,Ola SQ.Ff.FLOOR ARRA $/SVI°I'.
per-builier will hoe the mull pmving that he did not build or improve file par- �J
o,eof sale.) . 3 Zo I J o '�U
❑1,as owner of the prnpeny,ren endusively commeting wire IicenwJ dlmruamrs m tlE
cumwcl the project(Sec.7044.Ilusiness and Pmfesinm Co1de:)The:em.ra Li-
cnseLaw Anex not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE -7,5
1'� y //'� , �77S
whocormalafnr.....hpmjeeswitlutasm,coebmm)licensed pnsurm in meconn"'cnas , T If
License Luw. I'IiRMI'1'ISSUANCE_
lamexcngeunder Sec. ,B&PCforlhisrenson
Owner Irate AC1ER—.RAN
kiAl VALUA'I ION
WORKER'S COMPHNSATION DECLARATION HACK PLOW PROI'ECI'.DEVICE Q O O
I hereby affirm under Ienully n(Ja,jury one of the fallwing declamtin ek: o
❑ Ihovcund will maintain a CcnihcmmdConsonuo sill'-Insure for Worker's Compen- DRAINS—FLOOR,ROOF,AREA,CONI, ST(IRIES L5?
CONS'(IUCHON
satian,os provided for by Seclion.1"M of dm LA.,Cndo,for ma perfommueo ol'Ihe
work]or Marto us permit is issued, FIX'1'1)RES—PER T RAF'
❑I have and will maintain Worker.,Compensal inn Insurance,as reyu ied by Section 37M of the LvMm Code.fnr the performance of the work for whirlOhn,s p]erremt isissued. GAS—EA.SYSTHM-I INC.G OUTLETS OCC GROUP AI'm,orl011? IiMITION Tk(lM W NKERS'- 1 GAS—IA.SYSTEM-OVERJ(EA, (j 0 `" OBJ
COMPENSATION INSURANCE GIIEASIVINDUSTIt[.WASTE INTER01719OR J
BUILDING DIVISION FEES_
n1ti....llnn need not Wcnnlpicned i f the permi t is Future hundred dol tats($100) QµIIASP.'TRAP 1
m less.) PLANCHECK PER
I certify that in mepensurnmm«ofthe work forwhinlibb,arad i,k,00l.I shbl SEWER—SANITARY—S'1'DRM EA.2(X1 IT.
not employ any person m any mammon,sa m n become subject m the w tiers Cnmpen. ENERGY PER
zsatian Lxs of Cods,ia.Date WATER HEATER W/VFWo%-LECTR
7� 0 Applicant GRADIN PG
q V NONCE10APPI.ICANT:11:of ternmking thio Cenllicma ul lixemptinn,you.,I aid WATER SYSTEM/I'RIEA'fING I
a t) hcdmm sohj,,l ,,the Worker's Compensation plavi,ialls nI the Lahm Cade,yen must SOILS I
LkI 1� fadhwithc ly with such pro,ki...s nr this permathall he deemedoe,cked WATER SERVICE
D z
CONSTRUCTION LENDING AGENCY NIEW RISEDENTIAL.PLMB. SQ.FT PAID
UO I hercbyallirm that the.use o.anannian lendiag ugeney forme verfnmunecof 1 c Receipt#
the work fat which his permit is issued(Sec 309],C!,C.) -32- 0()( o y
C) VLender's Manu '101'AL
xrolees Addrc,.a -2 l
�Ls I ecnlfy the, is a
I have read this and dale mat me shove ianno noon is BUILD 'I 'E
L. fes/) correct.l agree to comply with all city and county ordinances and slate laws relining In QTY. MECHANICAL-PERMIT - FEE
V z building mmwelion,and herchy authame mpmsenntives of this cirymemcrurym the SEI. FE
above-mentioned prnpeny for inspection purine,. PERMIT ISSUANCE
(Won)ogtec m save,indemnify and keep hannlcss @c City of Cupeninn against UC ME
linhil'nies,ju]gnents.costs andexpense,which may in any way acemeagarill said City ALTER ORADD IO MIECH.
wnsc9aenca of the gmming of this le it. PLII ,RING FEE
UNUI:RSTANDS AND WILL COMPLY WITIt ALL NON POIN'P AIR HANDLING UNI'I'('l'O 10,000 CPM)
SOURCERIEGUI.ATIONS. M HANICAI.FEE
/^ '! AIR HANDLINGUNII'(OVER 10.000CF10) CO.STRUC7OON TAX cep
Signamrc of App,11dtj ntmdor Datc EXHAUST HOOU(W/DUCE)
HAZARDOUS MATERIALS DISCLOSURE HOUSE G MITIGATION FEF.
Wi111hcapplicamorfuhaehnllAingoccupant,rent nr hlmJlc hnzardnne nlmuiul HEATING ONE'(1'O 00,1100 HU)
an defined by the Caveman Manic_ual Code,Chapter 9.12,and the I Iazlth and Sudety
Code,Sienna 25532m)? HEATING UNIT'OVER IIXf W BTU)
❑Yes E]No VIEWILATION FAN(SINGLE RESID) PAID -
1 ae RecciptN
Will the applicant or fuse building occupant use equipment or devices which
mi
emit huwnlnus air dmwnant>as JchncJ by the Nnae Air ay Ar Quality Management N(IILER-COMP(3111'OR 100,000 BTlll
Inkiricta. BOILER—COMP(OV1ER I(XfpE0WDJ)
DYr, ❑No,
AIR CONDITIONER I have mad me hmmdous liar,is requirements under .I and rsta of the Cali- A I-DATE
bumia Health&Safety Code,Nations 25505,is my and 8511.1 understand thin if the NP:N'RGNIDRNTIAI,MECf1. SQ.FT. �� 2 N�- /
building flows not cumndy have aewnt mat it is my mxrynnihllitymnmifOccthe pancy. "''/� (((
nl't�kmnena- Ich rpust �mrt prior to iaauuna nfa Crnircme of Ornlraner.
i
Ow auI one age Dune 11517 ISSUED BY:
OFFICE