S 2116 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO nun.uwC-ECKCrRICAI, PEStI No 2116
Bt,HI.DIN;DIVISION APPLICATION/PERMIT rhumnmc.nu[rlmmcnl. \V
RUICDING PROJEC'F IDEN'I'IF'ICA'1'[ON -
BUILUING pDDRFSS: �` ' S SANITARY NO. APPIACATION SUBMITTAL DA'L'E
(1WNIiR'Si Mh:: PHONE'.', CONTRACTORS NAME. IACNQ
f N/❑C CON'fROl.p
ARC111'1'IiC1'/ N'ER; LIC NO: ADDRESS
CONTACT: PHONE BUILDING PERMIT INFO
?Lfo L O E] Consultant Fees Paid by Applicant(Initial) BLDG ELECT N.UMH MECH
D ❑ ❑ ❑
LICENSED CON'FRACH)R'S DECLARATION Q'TY ELECTRIC PERMIT FEE
1 hereby off.,hal I ala teemed under provisions of Chapmr n lumananeing JOB DESCRIPTION
MaZ with Seanon 70W)o[Uivisinn Aoftheµusiness vnd Professions Gwlc.and myliccmeis RESIDENTIAL
W O p 1'1311 MIT ISSUANCE, ❑SFUWL ❑KITCHEN RF,MODI3I.
��G RtBfarmvnde 33�rz3C
Nu Licc1 (Ins c I.h'1 A'1'LIANC ITS-RHS1DFWIAI. ❑AUDITION ❑PLUMBING RE-PIPIT
y'z wj Du,e Common
0<aa ARCIII'I'IiCT'S DECLARATION PANELS ❑MUI.TI-UNIT ❑STRUCTURAL.
Z b,�z. I understand my pbms shall be nieces public record. MODIFICATION
UP TO 200 AMPS.
OZ-�� ❑INTERIOR ❑CHIMNEY REPAIR
F7NF-Id Ur,med Professional - 2061000AMPS IMPROVEMENT C]SWIMMING POOLS
6 I heresy atffirm mm NlumlexelnN tromElhc ComrelON
c uric Licca.+c law for the OVIiR IIXXI AMP'
❑RATH REMODEUREPAIR O DEMOLITION
3 following mason.(Section]0J L5,Business and Rnfessinns Code:Any city or counmY SIGNS E1.13CfR1CAL ❑OTfiER t
y which oraims a pemot m cannna6 alter,improve,temnlish,m repair any+wrnme
prinnn l,.v kwance.also rayuircs theupplicant for.+uchp"mi,m Ncnsignedewmmem SPECIAL.CIRCUIT/MISC.
Lou lwiflicen,rdph....hoI t focC dracon,Urcroc I.a.(CaItr9RoQ /P
w�QQ (ca ,.ilh Se,onon 701oxh t 11j,kii i ofthc lothine,intoIT:' 'CJprz 'I'HMi'MI3'I'FR OR POLE INS r COMMERCIAL'
6goC That he is cenum therctrnnand the b.Tsh-the alleged cx It on.Any hdmitonpi ❑NIiW BLDG/ADDI'TION ❑DEMOLITION
grown]IU1.5Sym,applicator fora rpnnitsuhjvo,beupplicam to a civil peneftynf 1'0W17µDEVICES El THNANT FOOD SERVICE
N t ar
FZa Ome than five hundred doll.($51X1).
has owner of the prupcny,or my employees with wage,as their sole cnmpensarion. SWIMMINGPOOLELECrOUC IMPROVEMENT
F=.,C will Ja the xnrk.and rhe srmcmmia nal imm�detl aroRereJ for
sale(See.]IH4,Basin,, ❑OTHER
a w ea and Professions Code:The Contmmors License law does nom apply to an owner of OUFI.ET —SWITCHES—FIXTURE
properly who builds or ilii Hereon,and who dues such wad himself or through
his own employees,provided dun such improvements are.,it"mended or offered far NEW RESIDENT1AC F.I.ECfR SQ F r.
sole If,however,the huildingor lnprovenwin issuld within one ye,trot cnnmplmion,the �SQ.FT.FLOOµAREA LSQ.FT.
er,hudder will have Lha louden of I mving than ha and nm build on improve for par- �J
pascal sale.). " CXR
1,us owner of the po"i'l,i L exclusivity conlraning wish I'mcnsed alarm"n,to OIAI..
mmmu"the pmject(Sm.70.14.Rminess and Pr..f,,ions Cn le:)the Conaucmr.v G-
cerise[.aw does not apply to an owner of pmpcoy who builds or lmpmte,ammon,and QTY. PLUMBINGPEItMIT, FEE
who contracts for such projects with a ennvunm(s)licensed pursuant to the Contractors
I.icentt law. PERMIT ISSUANCE
1 not exempt under Sec. .It&PC for this reason
ALTER-DRAIN&VENT-WATER LEA) VALUATION
Owner Dam �0
WORKI3N:5 COMI'13NSA'I'ION DECLAIFATole BACK MOW PR(JT[CT.DEVICEIImrchy imum under penult,of perjury one g I
ne of the followincclmoniom:
I hove and will mninmin a Ceoi reamul Consent to self-Insure,liar Workers Camper- DItAINS-I'LOOIt,R0017.AREA,COND. STORIES TYI'13 CONSTRUCTION
satior,os plrw.ded fnr by Scc,lol3]]1111 of the LaborCoLl,far my pcifniounce of the
wank for which this perm",is i"t"ll, FI%'I'IJRES-PUR TRAP
C] I hone are will maintain Worker',Compensation Imumncc,as Left lired by german
l]IXlnl,he Lathan a de,fnr the performane dthework fnr which o,tworit is issued GAS—ITA SYSTEM-I INC.4 OU'IT.Ei S OCC.GROU T' APN
My Worker's s' ,yn, cc emr and Pohv,num `
Carrier: e.n Policy No.: AS `( YY� GAS—PA.SYSTEM OVER 4(HA)
CERDPICA'f 3017 EXEMPTION FROM WORKERS' GRL'ASI%INOUSTRL WASTE IN'I ERCEPTOR
COMPENSA'ION INSURANCE RU1I.DING DIVISION I IiE.S
iswcoon need not lc completed date is furore hundred dollars 11100) GRB%SIT TRAP
nr Icvv)DhI'hANCHF.CK FBB
I scally lhmmrhe i imumeaBh cMhis penal,is is.wn hull SI3WIik—SANITARY—STORMI?A.21X)izf.
nnI tea"r"y n person inn noon"en n+ be bort to nmpen- HNHRGY PEE
O ,7. sminn Lnw.v CUBLnni' Ot od WA'r1?R 1117NI IIR W/VEN'I'RLI?GI'It GItAU1N0 EEE
z Appl"cunt _
y NtYI'I an' P ICgqI1 :f n"c ix Cenificnm o axon shunld Wp'TER SYSTEM/fREA'1'INO
a ; becnn bjem to ife J1'lnker'x CoJ xmsetion provisions of the labor Code, ust SOILS PEE
pooh i comply with such provisions nrthis permit shall be deemed revoked. WATEiR SERVICE
'M1 CONSTRIICI'ION LENDING AGENCI' NEW RESIDENTIAL PLMIi. tip.FC PAID
U0 I hereby affirm that them is a eomauetion lending agency for the erformarme of. r Rncmpt4
F-, 'hework far which this permit is issued(Sec.RoO.Civ.CJ
W 6cndcr's Name, TOTAL:
0 CUA ,ndeds Addmuv 'IU'1'Ah: IIIIILDIN l'
cenily.thnt l hrec rend tris:mpliention and ,at,That Ere.above inlormrtion is .. )
ra ,ormo.I agree I"o ugly with all city and county odirance oud sane haws relating to QT'Y. MI?CIIANICAI.PEItMI'I' + FET?
UG huilding commudnst and herchy motan,ch,lresentmwev nl'trn
his rim otcmmon'hc SEISMIC FP.
7id
above-memianed properly for inspection purposes. VHRMH ISSUANCE
(We)agree to save,indemnify and keep harmless rhe City of Cupertino against Fd.ECI'RIC FE
liabilities.judgments,costs and expenses which may in any way accme against raid City AC,ER OR ADD TO MECH.
I'LIIMPING FEE
in consequence of the planning of this permit.
APPIACANT UNDERSTANDS AND WILL COMPLY WITH AIA.NON-POINT AIR HANDLING UNIT(TO 10.00 CPhf)
MT:CIIANICAL FEE
SOURCE N[GULATI0N5.
AIR HANDLING UNIT(OVER IRKS CPM) CONSTRUCTION TAX
Siglunum of Applicam/Conlmdor Dom HxHAIJS'T I IOOD(W/DUCT) IOUSINGMEIGATION PEI"
HAZARDOUS MAI FRIALS DISCLOSRH
WIIIthevpplicenm nr Iluure huilAing nc"lpvm slam nr handle lizard.....immrial HHA'1'ING UNI T'(TO 100,0011 If lUI
,is Coil,
Sci
by the Cupertino Minnwipal Code,Chapter 9.12 and,he Heohh..it Sultry
Gdo,Suvdnn 25532(u)7 DEAL INC UNIT(OVER 100,000 II'I'U)
❑Yes WN" VEM1TILAfION PAN(SINGLE RESIDE PAID
L
Will the applicant or fume,building occupant use equipment Aar devices which Date RccciptN
hazaNm contaminants coil nair conminonts AefinN by the Bay AreaaAir Natality Management BOILER-COMP(JHP OR I00,0X1 PTLD
DisOict]
❑Yes yell 11011.ER-COMP(OVER 100,000 BTU)
Alit CONDITIONER
I lams mad me hazardous maml.al,mi uiremem,unit,,Chapter 695 of the Call- ISSUANCX§
Beata Iludm&SI ty Culp,Sc,licL,25505.;,9533.025534.1,mulets 'i I in ache NEWRESP)EN'PIAI.MECH. S 4 4 ^[(TJ a[J
huddi,mij no unently lmavuamnum,ihv, 1 revpmsibililym ythp
aeceunt Q. T.
aft in nCenif enf( ch m.
( euthnnzeda me TOTAL: ISSUED BY: A To
OFFICE