S 2255APPLICANT TO FILL IN INFORMATION WITHIN ('iED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL)ING-ELEC'I'RICAI. Illi 1'I'No.
IIUILDING DIVISION APPLICATION/PERMIT rl.unwlNG MECHATIS ' 2255
CONTACT:
❑ Consultant Fees Paid by Applicant (Initial)
LICENSE[) COST RACTOR:S DECLARAI ION QTY.
1 hereby affirm that I um licensed under min i.sions or Chapter 9 (atmmencing
HOZ with Section 9 [—(100) of Division 3nf the Business and Pmfessinns Code and my license is
in full rand, andeRea 1 p, 12-9
Z Z W Lice.
+ Lic. p -!
QDan, ContDECL
Dm A, hall Is, use DEEmblic f10N
N Z 1 understand my plain sM1nll he u.wJ us public rtwnb
Vr-
F � Licenurl Pme—a ll
$- OWNER-BUILDLR DECLARATION
Q I hereby affirm that 1 um exempt from the Contmaor's License law fill the
a V following reason, (Section 7031.5. Business and Pmfmsiuns Code: Any city or county
O N which rcgvirth a Permit to construct, alter, improve, demolish. or repair any suvaure
prior to its Issuance, also requires the applicant for such permit In rile a signed smmment
Gf(hat he is iiccnxuron
d pursuant the pvisioof the Commchrz w s Licence lalChaptar9
�C) (commencing with Section 9(X)(puf Division 3ofthe Bunincxund Professions Crd0a,
e that he is ewmpl therefrom and the b:uis for the alleged escmption. Any violation of
m
Section ?031.5 by any applicant for a permit subjects the applicant to a civil vaalyof
not marc than five handled dollars ISSUE).
G ❑ I, as owner of the property, or my employees with waged as their side comPenation,
yin will no the work,and the smeture is a intended ormllered for sale(Sce. 9014. Business
3 _ and Professions Code: The Contractors Llcenx Law docs our apply at an owner mf
propeny who ballIv m improved Ihercon, and who Joos such work hintwlfor Enmgh
his own cmpinyees, provided That such intpmvemcnls arc rat Imnulnl nr offered for
sale, if, hnu a the building o-ntpro est is sold within nneycanf cnoplodon.lhe
er-builder will have Ile btaden o1' Pmvhtg that he did nut build or improve Inr put.
To of salt.)
iM 1, as (owner of Ile property, um eadnsivcly,...... 'noting will licensed "ammomc to
construct the project (Sec 9044. Bus and I'rnfe,xiom Code:)'I he Corr uldn" Li-
cv.
wLin, hall wnoll tit an owner nl'prapeny w"n,oIt,, haddden nq+rt ,s thomenClan'n.uml QTY
who eonnnds Btrsuub pr jcdls whir n annmttlnrG) Ilrellwd pnrxunnl m the Cnntnumr,
Lids c Law.
❑ 1 um " 't, to, Sed. . U Ne P C ka Ods m.ui
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENT IAL
PANELS
UP TO 200 AM1IPS
SIGNS ELECTRICAL
SPECIAL CIRCUHFAHSC.
TEMP. METER OR POLE INS'('.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES - FIXTURES
NEN' RESIDENTIAL EI-ECTR SQ IT.
Owner Dam
. WUIt KI;R'S COST PENS A' I' ION DIPCI.A RAI'If 1N
I h,lO, IfIna aaf,r sonaly II pcl'jmy oro. of lire lbllow mg dellann ton:
❑ I1ho"c ndwilln mwma Ccnifcnm ufConsent et mlh Insertfor WorkerL, Coatpcn
sullon,
nx Pmvidul for by Suction 39111 of the Luhor Cade, for the Pcdnrun ice of the
sen k for which Ihix permit is i ke,
I M1twc nLit awill Call ode,
Wnrkdx Cnngw l III, v nk too w1n 1, rapumn by tic,uod
3 Il of the IaMtr Cddq for lir, perfurntunce ul the wnrA for which Ihix permit is ixened,
My W9rkerxc I Inucma �r�icr and Palmy nynt `�i(26D010 /8
} yutn
Curve I�:%�N Polley No:
CERTIFICAI OP SAID NINSURANCE NPROM EOItKEH5'
GUM.13NSeI,d Hi IN SURANCIi
(This,enlan nualernbccninplend ills, pemtit ix formal hundred Jnllun (511X))
ar less.)
I certify that in the rynormance of the work for which this permit is issued 1 hall
lemploy any rosin in any manner.ad tosm
ld laconic object the Workers' Cumpen-
C) Z 'allium Law, of Callifomu. Dao
Z Applicant
NOTICE TO APPLICANT: If, after making this Cenifie:ne of Escallu nn. You should
become subject to the Worker's C['mPenaaon Provisions of the IaMa Code. You oma
fonhwilhpmtply wilhwch sonm n a lhi, pcnnil,hall the dmmed mooted.
a�
Z CONSTRUCTION IbWlendING AGENCY
agency
U O IMrehY aRnm that is acan.arvdinn lending agency for Krfonnance of
IL f-' the walk far which this Permit ix issued (Sec. 314'7. Civ. C.)
OIcnJer's Naim
U
}U Lender's Address
M. 1 certify that I have read this application and state Lha the aM+vc inh+nnmion is
f' lA correct. I agree to comply with all city and county nfdiwnces and slate laws relating In
U Z building construction. and hereby authorize rcPresemulivcc of this citym enter upon the
above-mentioned progeny for important purpows.
(We) agree to save, indenmify and keep horri the City of Cupenino against
Iiobilitievjudgial c 'to and exl¢nes which may in any way acme againo wid City
in consequence of gm ofthi, permit.
APPLICANT I E 1JAN 5 AND 711.1, C .IDLY WITH ALL NON -POINT
SOURCE LAT S.
Si rcufA,pl admConl Lor Ume
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant 0r furore building tvcupanl acre or handle havallous Ina¢riul
as defined by the Cupertino Municipal Code, Chapter 9.13, and the Mortis and Sentry
Code, Section 2553200!
❑Yes No
Will tba apprcam or turn handing tvent:na use aaluipnmnf on novice, whi,h
mil hunnlous sir conlunumvnu no JetineJ by the tiny Area Air Quality Maltagen,vnt
District?
C] Yo, C] No
I have read the hwamlou, nmmriulx mquinanunls under Cmgner 495 0l Ibc Cali-
train Ifinallh & satny C I S"non,25505 25533; 125534 1 land"'Inuid thad 11 the
haildiii,lov,no,r Ely haso a mina"'. ttl Y pnnmhltry Inow fythe"uppan
oft 1 th wl' h Ih sop 1 nrul'l I�G�d y
Ownerarmal !led al D:nc
/ Z- Z9/
PLUMBING PERMIT FEE
PERMIT ISSUANCE
AU ER - DRAIN k V ENT- WATER IEA)
RACK FLOW PRO I'HCT. DEV ICC
DRAINS— FLOOR. ROOF, ARE A. CONE.
FIXTURES—PER TRAP
GAS—EA. SYS TFEE- I INC. 4 OUTLETS
GAS— EA. SYSTEM -OVER 4IEA)
GREASEANDUSTRE. WASTE IM'ERCEPTOR
CREASE'rRAP
SEWER — SANITARY — STORM EA, 200 FT.
WATER HEATER WIVENTIELECIR
WATER SYSTF.MITREATING
WAFER SERVICE
NEW RFSIDGVr1Al, PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR TO MECH.
AIR (IAN Y UNI IO.fIOD CFM
U-
"r
ItON i I C(W/IDU'COrl Ol.lg10 BTU]OVER I(In.01f)bTl(1AN (SINGLE RESID)' OR 1110.1118) BTI,
BOILER—COMP(OVER BTU(
AIR CONDITIONER
N I.W HIS I DEN'r1A1, MECH,
FIMOR AREA I $ISQ. Pr.
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY hili
GRADING FEIi
SOILS IEE
PAID
Dae Be •Ipt a
TUDM.:
BUILDING 7;E
FEL SEISMIC FEE
ELECTRI 'L i
PLUMBING FEE
MECHANICAL F .E
CONSTRUCTION TAX
HOUSING SEE '1'IGAT ION hili
PAID
Oats K... P, p
SQ. I'LL / /
TOTAL: 1S91FD BY: v/
El
I
BUILDING PERMITINF)
BLDG ELECT PLUMB PLUMB SIECCH
ED
FHL
JOB DESCRIPTION
RESIDENTIAL
❑ SFDW'L ❑ KI ECHER REMODEL
❑ADDITION El PLUMBING RE -PIPIT
❑MULTI UNIT ❑STRUCTURAL.
MODIITCAn'ION
❑INTERIOR Cl CHIMNEY REPAIR
IMPROVEMENT C] SWIMMING IOOIS
❑BATH REMODEURE19MR ❑DFMOLFI'[ON
❑OTHER
FR I I
NE$ LDGIADDI'TION ❑DEMOLITION
❑ TEAQNT ❑POOD SERVICE
IMPROVEMENT
OTHER
PLUMBING PERMIT FEE
PERMIT ISSUANCE
AU ER - DRAIN k V ENT- WATER IEA)
RACK FLOW PRO I'HCT. DEV ICC
DRAINS— FLOOR. ROOF, ARE A. CONE.
FIXTURES—PER TRAP
GAS—EA. SYS TFEE- I INC. 4 OUTLETS
GAS— EA. SYSTEM -OVER 4IEA)
GREASEANDUSTRE. WASTE IM'ERCEPTOR
CREASE'rRAP
SEWER — SANITARY — STORM EA, 200 FT.
WATER HEATER WIVENTIELECIR
WATER SYSTF.MITREATING
WAFER SERVICE
NEW RFSIDGVr1Al, PLMB. SQ. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR TO MECH.
AIR (IAN Y UNI IO.fIOD CFM
U-
"r
ItON i I C(W/IDU'COrl Ol.lg10 BTU]OVER I(In.01f)bTl(1AN (SINGLE RESID)' OR 1110.1118) BTI,
BOILER—COMP(OVER BTU(
AIR CONDITIONER
N I.W HIS I DEN'r1A1, MECH,
FIMOR AREA I $ISQ. Pr.
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY hili
GRADING FEIi
SOILS IEE
PAID
Dae Be •Ipt a
TUDM.:
BUILDING 7;E
FEL SEISMIC FEE
ELECTRI 'L i
PLUMBING FEE
MECHANICAL F .E
CONSTRUCTION TAX
HOUSING SEE '1'IGAT ION hili
PAID
Oats K... P, p
SQ. I'LL / /
TOTAL: 1S91FD BY: v/