S 2178 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HIRLDmING-ELECTRICAL PEkpMI'1'NO
BUILDING DIVISION APPIACATION/PERMIT PLUSIRG-MECHANICAL J 2178
BUILDRR;PROJECT IDF.NTIF'ICA'1'ION
BUIhDING ADDRESS - SANITARY N API'LICA'I'ION SUBMII'IAI.DATE
�3S r he
O NERT NAMIi: ,PIH^ONE: CONTRACTOR'S NA LIC NO:
N" NIC T❑/ CONTROL peer
ARCHITF.CI E )NEER: LIC N): ADDRFSS: ❑ Q �/' lU
1 ( /
CONT el': IBJ/' r1/ `rte pilo E: BUILDING PERMITINFO
I ^✓ SS
7,9 ❑ Consultant Fees Paid by Applicant(Initial) Bh1)(y EL[ 11 Mlicll
U WJy
LICENSED CONTRACTOR'S UECLARA'f10N QTY. ELECTRIC PERMIT FEE
I hereby affirm that Iran liceeed under pnrvirinns of Chapter 9lcnninu:nem, - ( JOB DESCRIPTION
wintseminn 0sBal ivisinnlnrnm l{a'loe's and Pndcs.J..n,code.tmAtny license lx Y RESIDENTIAL:
�O 1'I71lMI'I'ISSUANCIi
F-W rstrofall nrlass Uffeel. - DSFDWI. DKI'fCHBN RIiMODEI.
Rub License Class Licp
Rub APPLIANCES-RILSIDEN'I'IAI. []ADDITION [:I PLUMBING klidPIPE
�Q u] Dom
F Oy nr
ARCIITIiCT*S )UC
ION El MULTI-UNIT ❑ URA
I udered my plassal husedsm 'ANIIC
ZOwZ blic vdMODIFICATION
O Z.N-p - IIP 1020(IAMPS DIMERIOR ❑CHIMNEY REPAIR
FSI_ Li,,cmd Prufsssional 201.101NIAMP$ . IMI'ROVpMF:NT []SWIMMING POOLS
q iv OWNER-BUILIDEk DECLARA'I'ION _ OVER IIN10AMI'S UBATII kI7MODEURITAIR DDEMOLf1TON
�j d I hereby mprm that 1.,it exempt I,,. be Cnnlro cum's License Low lur the
6 3 a.U following mount.(Section 7031.5,Business and Pmfesuists Code:Any city ry county SIGNS ELECTRICAL D OTHER
W
U.y which requires a permit to construct,dreq improve,demnlish,or repair any structure
,Ff,LLO� primpoiui...mr 'ook.mciireslheapplicam f,,,such permit to fileasigneJsmmmenr SPECIAL CIRCUITIMISC. _
f�} Ihmhe i,sceved,wes..mrn the pmvisinmuf the Commelor's License Law(Channel 9
y�j lyQ� (commencing with Sedion]IXN11 ul DivisinnJof the Businasund Prnfessimw Goshore, 'I'EMP.METERORPOLE INST. COMMERCIAL
W q o a that he is esunipl 11"mfirnm andihu bmis for the alleged exemption.Any v6latio n of D NEW BLDCUADDITION D DEMOLITION
I Y. Section 7031.5 by any applicmu for a pemnl subjects the apphea t m a civil lam Y of � IN{W TIN DEVICES ❑TENANT' ❑FOOD SERVICE
�..w
.,it are than five hundred Offer,($500).�=apl.as nwncndthc pmpeny,nrmyemployecs wiNwugcsnslheirmle anttpanwtion, SN'IM1IMING POOL F.LLCfRIC IMPROVEMENT
G will do the work.and lee mrmmrc is nm inmate)or..Oered hersale lSmJ(HJ,Rusines ❑OTHER
~w
3^
and Pndessionr,CoJu The Colonialist's Licemm Law Anes not apply to an owner of OIITLIITS-SW' -PIX'I'URES
property who Im I&or improves thane,and who does such work himself or through
he awn en,suyle,pervlded that such improvements are nm intended or ot'fcred fill NEW RESIDENT !CFR SQ Irl'.
aft.If,hnwcver,the building or lntpmvmncut issnld viddenone yearofaomplclin i, he SQ FT FLOOR ARIA SISQ.IN'.
nwrier-hadder will have the burden(if proving(hal Ire did not build or improve far par-
L]L m owner of the property,am exclusively contracting with IicenseJ commemrs to
construct the project(Sec.7010,Rusines,and profexsions Crde:)The Cnmmaoh Li.
crew Law Jocs ren apply to an owncrof properly who huilds or improves themnn,and QTY. PLUME G A FEET
whocninructf..rmdtpmjeclxwitbu.nnoucions)licensed pnmmntlothe Cisma 0 - -
Liceme Law. I'ERMI'f ISSUANc1I
❑Iain curio., drSew. .B&P C for mi,reamn
_ AL9'ER-DRAIN&VENT-WATER(EA) VALUATION
Ox Dote ��J)
WORKER'S COM1tI'ENSA'I'10 ECLARATION / I� TOO
I hereby affirm under pemdtyuf pe,in,one.film l"ullnwing&'Iantinm: nn ( v V
D I have mit will maintain aCertificnm of Cnnsentin,cl6i0sute for Workers Conloce- D AINS- IVIF ROOF, R:A,COfz
STORIES TYPE CONS'1'ILL1CfION
,alirn,m tion Pe or by Sec37k) or the Lubar Code,for the pcdn reeve of the 1.
work for which this permit is iswal, ' 'PURLS-PER7RAP
D 1 have and will maintain Weaker,Cmn,mouninn Insurance,es require)by Section t-
3](q of the LnMrt Cele.for performance of the work for which this permit is icweJ, - 5-014_SY_ST -1 N . LI: ti (CC ApN
My Workers Compensalnn Insurance comer and Policy number are: JIM
Carrier: Policy No: 3A5-EA.SYSTBM(IVER J IFA) WY
CERTIpicATE OF EXEMPTION FROM WORKERS' hASP/INDUS'1'RL WASTH INTERCElyI' R
COMI'I7NSAI ION 1NSUItANCIi BALDING DIVISION PEES
0'hi,weli..n need not be eon,feled ifthe permit is fm nuc hundred dnlhax(51(X))
ur less.) PLAPT iC IFP. Q
I certify that in the performance of the workforwhich lhispemtit isk%ued,I shall SEWER-SANI'T'ARY-STORM EA.20M PI'.
not employ any person in any mnnnenn e m twernm,heel m the Wodit Conflict- ENERGY E:E
O Z ,.lion Laws of Calibomia.Da¢ WATER HEATER WNENT/F:LEC R GRADIN ItiE
y Applicant
G (n NOTICE'1'O APPLICANT 11;after eaking this Cerlifie4le A li,emption,ynu'InsZ W"ba s"'RM"REA'IING SOILS Plil7 hunmeeul7wun tlm Workcr'.v Contlxnsmirn provlsinnxnl'Ihc Labor Codc,yo.tnust
forthwith emnply willi uclt pmvi,inns minis pc.it it:Jl be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW N161DENTIAI.('LMH. SQ.PE PAID
U ❑ lherenyaflirmlhauherei......amnion lending agency for the perhsmmncc of Date Ip
� � the weak far which mi.a prnnil is issue)(Sec.3097,Civ.CI
❑ ULender's Nanta _
W Lrnders Adders, k)I' L'
I coolly that I have read I n'application and,lam thal the alcove infnrm:uinn i, BUILDING FIFE GO
fA correct.I agree to comply with all city and county ndinaneos and state laws relating to QTY. - MECHANICA1,PERM17 FTSE
UZ entities analcoun,and hereby authndac mpresenmtives of this city m enter upon the �• Sf PER
above-meminned property for ingws inn purytrses. PERMIT ISSUANCE if U Q RIC IT-E
(We)agree to save,indcnmify and keep hvnnles the City of Cupertim against
liuhilitiea,judgtncnlu,costs and expenses which cony in any wnya<crueagaimund Clly ArnriRORADDTOMLCH. -
men
vvcynsmeutthe 'act oft his pct tai U ❑IN(l hili
APPLICANT'UNDERSTANDS AND L COMPLY WITH ALL NON-POINT Apt IIANDLING DN1'P(TQ IU,OIXI CFM)
5 1RCP.RyffDl.AgIONS. � F..HANICAL Fl T
//l l( (// AIR HANDLING ON]T(OVER IQfNq CFM) STRUCTION'I'A%
Signa,. - A,hcont/Cmaoneas Dae IXI IAUST HOOD(W)DUCTI USING MI"fIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will thenppllcant nr berm Ithd'utgoccupant smrc(irhandle IutmNou..wmrial HEA'1'INC,UNIT(10100,01N)BTU)
as defined by the Cupertino Municipal Craft,Chapter 9.12,and the HnJth and Safety
Curb.Section 25532(0)? IEAg7NG UNIT(OVER 100,000 RTU)
C3 Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Dam RariplM
Will the applicant or Terre building occupant use equipment for slevim,which
emit hazardousair contaminant as Jefred by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100,000 BTU] L.
D"hid?
Y" 0 No, It(ILI7R-COMP(UVI71t IfX1,fNN)H'I'll)
I have mad the haatWous naterials tegomment under Chapter 6,95 n1 the Ceti- AIR CONDITIONER ISSUANCE DATE
fomla Health&Safety Cade.Sections 25505,25533 and 25533.I understand Ilia if the NEW RESIDENTIAL.MECIL SQ. 21-n
w / / /
building dors not culremly have a motion.that it is my resperr ubil' m ay notify the eccupanl /'
of the mqulrcmem,which must be me prior to issuance afa Cemitirnte of Occupancy. 1�
Owneranmlhuriml..gem Due ISSUED BY:
OFFICE