S 2297 -APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL /� ^^
BUILDING PROJF.CIADF.NTIFIcsirION J L L
BOBBING AODRI3S$:
rl/zrb L�NpPr v��m DF?, SANITARY NO. APPLICATION SUIiMITIAI.DAT13
- /o -G-yam
OWNER'SNAM�E[�,�' PATINE: CONTRACTOR:S NAME JLIC��O.
I IM N�-+a EAS DRa JC U �' T NIC CONTROL
CHITECUUNGINHER: LIC NO ADDRESS'. EJ
E c
CON9'AC`U ^ PHONE' BUILDING PERMITINFO
Pat ,/ �1 1A I m f 3?/-t(.co
❑ Consultant Fees Paid by Applicant(Initial) BLDG i El E i PLUMB MECI1
1 r„/I••WLICCENSEDCCONTNTRRACfOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hatch,affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
hwpO with Section 700(d.f Diviona 3of@c)Wain...and Pmfessiams Codgatdmy license is RESIDENTIAL:
H full force and ellen C�a. A PERMITISSUANCF.
�UU License a l.ic# JJ rt O C `r 5 V ❑SFDWL ❑KITCHEN REMODEL
h<i Date Cmdracmr 5 APPLIANCES-RESIDI3MI'IAL Z-Z`VO [:1 ADDITION El PLUMBING RE-PIPE
F,ptn ARCHITECTS DECLA ATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
OZ--v17.J- landyytmnd my plans shell 6c useA ux puhGc..curds
OJ UPT0200AMPS 22 Z MODIFICATION
F•,.I'.W LmensnVPrnfesvonal ❑INTI!RIOk ❑CHIMNI3Y REPAIR
..l 201-1000AMPS IMPROVEMENT
SG 7,..1 OWNER-BUILDER DECLARATION [I SWIMMING POOLS
y C W 6 I herchy affirm that I am nore exnnpt from the CannaLicense law far the OVER 1000 AMPS 11 BATH RISA ODEUREPAIR ❑DEA PYLON
xx0MU following reason.(Section W3 7031.5,Business and Professions Gale:Any city or actuary ❑OTHER F SIGNS[LEC'1'RICAI. }�
F O which requires a pert..)[to atmxlrucl,ober,inmrov0.Jamnlinh,or repmlr uny almcmre /Ge�/79C�1�xv L,_,,q4L`
DIN primo sl atm q rc lh ppficaml hpermin fl 'g Matmemenn SPECIAL CIRCUITIMISC. T
Qtom h .licensed P-11 I Ih P .inn f ra c t coral 1 (Chapter 9 # OL.4?! i
1 ❑C (wt g 'll Ser 7000) rid ism 1 tin B ' eas dP f:.' ..Cn Is)or TEMR METER OR POLE INS'1'. COMMERCIAL'
a.6 C K that he is exempt Iherefmta and the basis.for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ,❑DEMOLITION
W' Section 7011.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES
>. manarc than live hundred dollars($500). ❑TENANT ❑FOOD SERVICE
�=a0 ❑I,av owner of the pmpeny,or my employees with wagevm lheiraolccompcn,micn. SWIN)MING POOL ELECTRIC IMPROVEMENT
F will do the work,and the amoure is not untended or offered Porsale(Sec.7541,Business - ❑OTHER
and Prolessious Coda.The Contractor's License Law dress not apply or an owner of OUTI.1 1'S-SWITCHES-FIXTURES ,
progeny who builda or improves thereon,and who docs such work himself or through TL
his own employees,provided that with improvements am not intended or offered for NEW RESIDENTIAL IiLEC R SQ FI'.
sale.IL however,the building or improvement is.cold within one year ofcompledon.the SQ.FII FLOOR AREA VSQ.IT.
ctwne-builder will have me human of pmving that he did not build or improve for pun
pose of Salm).
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:136-.
O ,
construct the project(See.ANA,Business and Pmfessions Code:)The Committees)hoes Li
(
canew Low docs not apply to at,owner of Out who builds or improves lhemnq and QTY PLUMBING IT' FEE
mmmcts for such projects with a contractors)licensed punuanl to the Contmdory
LII``�, ll
❑�nafir{�— ,13&sClirz Nit mason PERMIT ISSUANCE a
OwZBe, Dae ALTER-DRAIN&VENT-WA15R(t ) VALUATION
WORKER'S COM 1117NSNI[ON DECLARATI ON HACK FLOW PROTECT.DI3 Q (,y
1 hereby affirm under Penalty of Perjury one of the following declarations: o O
(haroq
ve and will maintain aCerifcam of Consent to self-insure for Workers Campion- DRAINS-FLOOR,R(A)F,AREA,CON S'TOR S TYPE CONSTRUCTION
satin,us provider)Iia by Station]70(1 of the lather Code,for the performance of he /a
forwhichlhis,enernki.sued. FIXTURES-PERTRAP
wa 1 have and will maintain Worker's Compensation Insurance,as requited by Section f.� 4Pag.r.� sro -
it the Labor Code.far the perfannanecal the work
{fmor w�lhiicchht this,permit n issued. GAS-EA.SYSPEM-I INC.4UUTLI.TI:S V py OCC GROUP MIN
MYia xr�+l1ct xmgfMrB' n safety Nn;{1 GAS-EA.SYS'IEM-OVLRJ(EA1 �y
CEkfIFIC MPENi ATION ONFRAN WORKERS'
COMPENSATION INSURANCE GRFASF/INUUSTRL WASTE INTERCEPTOR
IThiv.emion need not he completed ifthe permit is for hundred dollars($LULL BUILDING Il1VISION IEF_S _
or less) GREASE TRAP
Icenif Ohm in the perfonnance aDhe work for which this YLANCHECK 113E
Y fficWnwcd.Ishall 2/` b
nolemLaw any penon loony manner.vn ns to become suh em et the Wnrkers'Cum em SEWER-SANITARY-STORM EA.2UI FT.
z swimm laws of California.Data l p ENERGY PP.E /g” nzo
O WATER HEATER WNF.Nt/ELI3CTR -I
O Applicata
zy
GRADING LLE
NOTICE To APPLICANT':It,after n along thin Cenipcateof Excmglnn,you should
WATER SYS'1'IiM/fR13AfINC,a SOILS PEE; become subject toat
the Worker's Compensation ps smnr of the r Code,you most
{✓a forthwith comply with such provisions or this Permit revoked. WATER SERVICE y
� Q CONS'TRUCT'ION LENDING AGENCY NEW RESIDENTIAL PI.MB. SQ.FT. ZL
U I hereby anion thin is a nematedon lending agency for the Performance of Ila pip 7o6t/rn
U L6 § a wok Ourwhich nhix peroul is issued(Sec,Mai.Cie C.) / V
O U Lender's Name
U Levdcts Address TOTAL: O1LV6 1098 TOTAL:
Fp,t I eerily than I have read this application and slate that the above infornatien i. l BUILUING Elel3 G�(If
V) etntectlegree lm comply with all ally andcoumy ominances and sure laws relalingm QTY, MECHANICAL PERMIT HE
U , building construction.and herchy authorize representatives of this city to enter upon the SEISMIC FEE 7f �
above-menlumad property for imsNoina purposes. PERMIT ISSUANCE
(We)agree m mm,indemnify and keep hemdes me City of Cupeninn again.l .-
lubiditiea,judgmono,wctxand es,roes which may in umy wayaccnm.,rm,i,aid City ALTER OR ADU TO MECH. 6
quer thegmatingofihis pertain. PLUMBINGFEE y
APPLICANT UM1 ER$TAND$AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 11111(10 LEND O, O
'GURCE REGUL H NS. o MECHANICAL FEE 70
to 6-5Y3 AIR HANDLING ON['I'(OVER IO.000CFMI CONSTRUCTION TAX
Still
wore ofApplichnBComtnnorIF Data EXHAUST HOOD(W/DUCT) r�V HOUSING MITIGATION FAP,
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant note or handle hazardous material HEATING UNIT(TO IW,000 BTU)
as defined by the Culetino Municipal Code,Claptur,9.12,and the Ilealth and Safely —1
Code,Section 25532mo? HEATING UNIT(OVER IWAX)BTU) r Y
❑Yea QS11 ! �+>>
VENT �y'ILATION PAN(SINGLE RE$IDI PA1D� � Q/J`•p.� .�
v
Will Inc applicant or furore building occupant use equipment ordevices which BOILER-COhIP(3HP OR 100,000hate Receipt#
p BTU) V
it hazardous air contaminants as defined by the Bay Area Air Quality Management
..sola^ TOTAL: iq
EI Yes BOILER-COMP(OVER 101,010 B'I'U)ko No
I have read the huandous materials Pantomimed,under Utopierfi950 the Call- AIR CONDITIONER 1�' s ISSUANCE DATE �\
fon da &Safely Code.Sxtena 255015.is my and 7553].I unalcistand th nom if Inc NEW RESIDENTIAL MECH. SQ.EE
uilJing chew Code,have it that is my rcnda 53ility unorify thud if ordthe
c t rs oetact mulls,uance of/-eylificylc ol'pcypyncy. .•� y�
Ownerctrauthonzedugentt leatoo TOTAL: e t) _/JC-
b` 70 ISSUIiD RY:
OFFICE