S 2876APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIUII.DINf: - ELECTRICAL PERMITNO,
BUIIAING DIVISION APPLICATION/PERMIT PI,UMR N MECHANICAC q A !�
,also. mgSbIq-
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:HITECT/ENGINEERvV _ LICNO`
ADDRF_SS:
❑
CONTACT: PHONE;
UU IIA) I NG PERMIT INF0
BLDG IE.EC'I' PI-U-MMK MECH
21) L:J Ip.Y
❑ Consultant Fees Paid by Applicant (Initial)
IJCL'NSED CONTRACT'OR'S DECI.ARATION
1 hereby admit ina,1 am licensed under provision, of Chapter 9 (commencing
wim Sc,ti ]IXXnofl)ivislon3ofthc Be,ine—to Profea.inn. Cuda and my hee,neix
allv<t.
is full a Class
[)air Class Liap
Umc Coa,aactar
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
KFSIDENTIAI:
❑SFDWI. ❑ KITCHEN REMODEI.
❑ AUDI 'I']ON ❑1'LUMIi1NG RE-I'll'IE
❑MULTI -UNIT STRUCTURAC
MODIFICATION
❑INTERIOk El IININEY REPAIR
IMPROV EM IENT SWTMMING POOLS
fe;4MH REMODEURIEPAIR ElDIEMOUTION
❑OTHER
4100
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AI'I'LIAM1'CIiS-R6SIDIEN'1'IAI.
ARCHIIECPS UEC publicrecords
1 undersand my plans shall M uttJ us public records
PANT] \
UP10200AhIPS
I.Icensed Pmlessimal
OWNER.HIIILDER DECLARATION
1 hcrcby nl'lima In., 1 um oxaupf trent the Cnnuuemr's Jem,se Luw 1br da
following reason. (Section 91131 5, Ilusine, and Pmfucinne GMc: Any city or county
Which W nircs a rcrmh ,a enn.wrl. age, impm.n, demohsb. or ar,ur am stmcmrc
prinrmiu issuance. also rtquireslhe upplieant fnnuch p[mtil n, fileasigttedmmmtmm
,hat he is licemed Pursuant to the provision of the Comecon's License Use (Chapter Y
(commencing with Section ]Wo)of Division t of,he Business and Profession% Code) or
he is exempt barroom and the basis I'or the alleged esemplion. Any vinlution of
Section 7031.9h,ary npplicxnl font penalsuhjeclslha npplinmra u civil penaltyaf
not alone that Eve at drtJ dollars I$500),
Lasowaernfthc no,cri, army employees will, as thei,ole compcnalinn,
St.
I dohcwod„ andthe,movamenma intended mattered forsalc(Sec.70,W.Bnsincss
and Professions Code: The Contractor's Liceme few Jens no, apply ,o an Oencr of
property who builds or improve, thereon, and who does such work himself or throng
his own employers.provided that such inproverariv an, ran intended or offered for
le It, h Ib h IJ g p t i Id in y f pl i on the
h '11 111' Ih h d I'I 61rt1 11 hall p fminr
201-BXPAMPS
OVER loOf)AMVS
SIGNS 17.1.1; RICA],
SPIECIAI,CIRCUIT/MISC.
TEMP. ME i PIER OR WLIi (NST.
COMMERCIAL:
❑NEW BLDG/ADDITION ❑DEMOLITION
❑I'FNANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHEk
POWER DEVICES
SWIMMING POOL EULTIiIC
OVI'I.ITS- SWITCHES -FIXTURES r d
NEW RESIDENTIAL IELECIR SQ FT.
� SQ. ,'FL )�) AREA
SQ. FT.
'C''
p`° "
1 I the p pen v ly contracting t g v. tl licensed c t mac m
instruct the project (Sec. 70f4. Business and Profess ons Codkq The Cantreunr s ]-I-
i axe law Ana% not apply to an owner of pmpeny•'ho builds in improves thereon, and
cense
Who contrean for Web pmleCN with a conuacar(s) licensed pursuant o the Contractor's
I.iceme Law.
Inn asctna mal See ,11&P C for this reason
APP, 1 2 1999
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QTY PLUMBING PERMIT FEE
PERMIT ISSUANCE.
�VAI.UA'I
ION
ACI 1714 - DRAIN & V FN'1' - WA'I 1ER (EA)
Datc
#'.lIevjeandTwi
/
WO i'S COMPENSATION DECLARAf1ON
Etm under penally of perjury one of the billowing declarations:
maintainaCcnificatcofComentto.,elf-inmm NoWorkersCottpen-
of the fabor Cod, tthe performance ofthe
Work for whidt11 : pets I I,
❑Ihave J II aiam W ka, ( Iscr,ala,y d m, Section
3710 l he l,eh,'Ctul 0be part!,, af the vook bar vvlo,htli par Tit n,,,uad.
BACK PLOW PROTECT. IJIIVIC17
DRAINS- FLOOR. ROOF, ARP.A. CONE.
ST OR ILS
OCC GROUP 32
IYPIE CONSTRUCTIONt](X)
)
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FIXTURES PER I RAI' G
GAS I:A SYSTEM -I INC. 4 OUI'LIETS
GAS - IEA. SYSTEM OVIiRJ(1EA)
My Wnrkers Compen,alann lnsursrac command Policy umber arc:
Caner: Pon, No.:
CERTIFICATE OF EXEM1BTION FROM WORKERS'
COMP1ENSA1'ION INSURANCE
V
O
GREASEYINDUSTRL WAS' DE INTERCEPTER
BUILDING DIVISION FEES
GREASE (RAP
PLANCHECK lyili
(Thissection aecdue,be,non,le¢J if the permit is fur one hundred dallma is 11X))
nlms)I... fly fall In aha pert tnmanacol'thework lbr wbl"It...Enna. ise aid, l shall
nal employ any persnn m any natmer sa as to become subject to the Workca'i Copan-
SEWER - SANITARY -S'TORM EA 2110 Pf.
ENERGY hili
WAITR H EATER W/VEN1-Ad.l!CfR
WATER SYSTEMG-RLAT ING
GRADING FEE
Z.talion
z0
F =
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L Gi
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(•'
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F' VI
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lrw. of California. Date
Applicenl
NOTICE TO APPLICANT: If. after naking this Cenifeme of IEumption, you should
leans subject h) the Workers Companmtion provisions of the I.abar Cade, you must
forthwith comply with such provisions or this permit Shull he deemed revoked.
GONSTRUCIION LANDING AGENCY
Iheren I'lirm that is a cons,mclion lending agency for the performance of
the work lin which this permit is issued l Sec. 3119], Co, CJ
Lcndcrs Name
Lender's A'Wm,
1 scurfy m t 1 have read this applicmion and cele that the above information is
correct. l agree m comply w ith all shy and county aohma¢es and "air laws mluting o,
buil Jing consuuctinn, and hereby authofire tepresenmli vas Of his city,, cater ulnen the
aMrveanen..... d no,ciy forimPecf ran...now.
I We) agree In save, indemnify and keep haundevs the City of CupOlmo again%
Iiabili,ien,ludgmenn, costs andexp:nses which may in any way aceme agaim,,nd City
SOILS FEE
WATER S17RVICE
PAID
Dam R ciptM
NEW RESIDENTIAL PLMB. SQ. 171',
IOTA(,
'1 -AI x
BUIL ) G rEl!
QTY. MECHANICAL PERMIT FEE
SIDS. ICFP. Q d
PERMIT ISSUANCE
1!LIECT CFlil! (�
ALTFR OR ADDTO MECH. 4
PI, HUNG LEI! - a
(62
in onset' 'race of ,he granting of his permit.
.\PPLICANI'U'OIERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR DANDLING UNIT LTO Il1.fXq CFM)
MK IANICALPIiIi 0
SOURCE H
AIH IIANDhING USE '1'(OVIIk IILIXq CEM)
CON. TRUCTION'ITX
Signmuren APP(" t/Commc,ar Dom
HAZARDOUS MAT' RIA DISCLOSURE
Rill capplicatn orlmprebuildin6occupant lure nr handle haeallous tnalerial
as dcfnN 1, the Cupertino Municipal Case. Chapter v.CE and he Heald and Safay
Code, Section 25532(x)"
EXHAUST'HOOD(W/DUCE)
I IOUSINGMITI(IAHONIEF,
HEAI'INGUNIT(TE IIXI,IXXI If'IU)
1117ATING UNIT (OVER I4)(k000 BE U)
VEN'I'ILAI]ON IAN(SINGIJ! RP_SID)
Ej Ye. ❑No
PAIR)
O:nc Rccciptp
Will the ay,Pli,matar Italian,huilding'Wan pmuse cyuipnutnt In 'faller' which
mi, hamNom, air conmminanls as defined by the Bay Area Air Quality Management
IIOILIER-COM11P (JHP OR I(X),lNXl RTU)
TOTAL:
ROILER- COMP (OVER 10X,00(1 BTU(
ostrici� yes❑Nn
CONDITIONCR
ISSUANCE; DATE
I have rend hamNnusmmcriuls requirements under Chapter 6,95 of the Call.AIR
N EW R LSI DENT[A], MSCI I. SQFI',
li nII Ill&SatCd Section, 25511525533and 25534 d.t dIra it he
h Id' y l t moll f pct enifi lythe tF.mf
of lit"'an(1 Ish'fuC ni t flkcnp' cy.//-
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ISSUED BY: • _
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