S 2511-APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOBITLIANG - ELECT RICA I. vrRMrr NO.
BUILDING DIVISION APPLICATION/PERMIT rLDM1B,INI MECIIANIOA1, S 2 511
INIL1)1S.1'NOJF,C'1I IIENORF 'AOON I
_
OFFICE
FEE
❑ 1 971sm
.JOB DESCRIPTION
❑SFOW
CION LAI;: ...y.. ..... CC
%L,le-s )�" s 25-7 7��Q
" f
❑ CnnsultantEyes Paid byApplicant (initial)
000wits
Fqc
U F
Q U
b. Z W
TT
LICENSED CON'RACTOR'S DECLARAION
1 hereby ut'frm Ihm 1 am Ilccnsed under Fovisinn%nI Ch"ver 9 (cunm.co'ing
Section 7000) of Divi,lon 3 afthe Bovine" and Vmfrainnx Code.aml my license is
in full lame and effect.
."case Cln.s, Lic, n
Dale Cnnmtemr
Q'rY. ELECTRIC PERMIT
PERMITISSUANCE
APPLIANCES - RESIDIiN'I AL
Fly
O-Z —Q
RA
ARCH1'ITCTS DECLATION
InndemlunJ ntyplun., Shull be mol as pth1w...... ds
PAN171S
UP'IU 21111AMI'ti
F14L,
Licensed Vogw,innm
201-1000AMPS
Q�yd�,
C
X 3 d U
W It. h
c.'
OWNER-HUHLDER DECLARATION
I nerehy alfnm that I at ,xerapl tram me Cumm"o" Utsen.0 Law k" the
fu14n'ing reawm. ISminn ]11319. Huxinex and Pmfe%,ions Code: AnY city urcoutttY
which require%a permit m comtmel. alter, improve, demolish, or repair any nmeure
prinnu its.svalevud4ornluirrelhca"I", nI lo"t"h senninu file a,ignN smtcntem
that he is licensed pursuant the provision%nfthe Conmenter's l.icen" Law hephr
I?R I(kM1AMPS
SIGN. LIiCTRICAL
'PECIALC 'UITIMLSC.
aCpO
d p. o C
WMm
cg E.
W 3 m
A.pmryrty
Icmnnencing wimSection]IlWlaf Uivision3oDhc Bu%inu, mA Prokssinm Igor
phut he is exempt tlan foon and the basis fur the alleged exenplam. Any violati of
Section70n5 by any applicant for a permit s.bja,, the upplinml In u civil 1mbY
not more than rive hundred dollars (5510).
Lusow nerof the propcnyoany, cmploytt% with wvge,mlheir soleamtpen%miom
will Jn the work, unci thesvncmrc is not imcnAW nuJlimxl for "IeNce 7044,Itueinc.v�
and Ploc,sion, Cash : The Collator's Licence Law docs nm apply to an nwner of
who hands a improves thereon, and who docs Such work himself or through
rix mployc:,, provided Thad such lo.pm ensu not intended n offered lit'
sale. If, however, the building or improvement is sold within one year ofaomplcmon, the
.N ,TGR OR LE INST,
1"Ay R vl P.S
S 1 ft�'G PO LIi1.li,T RIC
O LF.. -S I'1"CUES-1'1X'1l1RES
NEW RE, )EN'I'IAI. Ei=R SQ F ..
WNT SIil2VICE
=
NEW RP.SIUHNTIAIrVI:MR.-SQ.PI".
builder will have the burden of proving mut he did not build or intpmsc for put -
.os
nacw
caclvely isnuaeting with Gecn,ed am
of the aloin ny, am u%i
'TOTAL:
Lender's AJJrc.w
QTy.. PLUMBING PERMIT
QTY MECHANICAL- PERMIT
onstructtthe project (See. 7044. Busine„ and profession, Cn,h:) The Contractor '% I.i-
a Low docs not apply to an.wnerof property who builds or improves thereon. and
r
wN, c.ntrucs or such pniect%with it contract..(,) Iittn,ed pasnnu m the Cnnatmmr',
amt,.I me nanlinp t - hi, I¢nnil.
AI'V'twA f 1' iST SAND N' .Y N'1'rH AL1. NON -POINT
License Irw.
PERMIT ISSUANCE
112CE . T 1'I
E]Iamcjlnit,B&PC Rv�im%
EXHAUST 11001)(W))UC)
I IOUS G MITIGATION FEE
f �n
AhI'HR-DRAIN&VENT-WA'1'ERIEAI
OFFICE
FEE
❑ 1 971sm
.JOB DESCRIPTION
❑SFOW
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROl'IiCI'. DEVICE
El PLUMBING RF -PIPE
I hereby tiff rte under penally of perjury one of the fnllow'mg declandom,:
❑Ihio,amd will maiamin aCenilicme of Con,cnnn se...... baWorkci,Copgaa-
DIIAINS-ITLUOR.RDOI?Al2]iAC NO
Sauna, as provided for by Section 3](0 of the Labor Code, for the performance of the
work tiro which bS permit i, i .... d.
FIX'ITRES -1'17R TRAP
GAS -IiA. SYSTEM -I INCA OU I LE I'S
IMPROVENIENT
I have Slid will muinmin W ..kur's Congmn"uoa hwumnce, its required by Section
371100 the LNu Code,fnr the performance of 'he walk bit which this are, i, iswcd.
GAS -IiA. SYSTEM -OVER 4 (IiA)
C3 DEMOLITION
My Worker's Compenmtinn ars ranee carrier and Polity number tire:
Carries'; Policy No..
GR1fA. TJINDUS'LRL.WASTIJtlT1RCLElOR�
-
CI!RTB'ICATE 01' FXEMI'I ION 17XOM WORKERS'
COMPENSATION INSURANCE
I�
GRIiA. E"I P
—'
(This .....n need oat be co iftwdct he permit k fn nn, hundred dollars IS 100)
ser le%sJ
Icertifythat,. he ped nmm.re of the work for whichthis pemtit is is"ed. 1,hall
-
SEWER RS;INITARY-STORM EA. 210 FE
Z
Z O
s
:DzCONSI'RI1C1'[ON
U O
O U
tLLI'
A.
f^ to
U z
not employ any person in any menace so an to become Subject to the Worker; C.mpen-
"tionI.;,—of Califnmla Dam
Applicant
NGHCI' TO APPLICANT'. If, after making this CertiBcam of Exemption, you should
nxunte eah,ccl w the Wnrkcr, Con:pcn"dun proskie., afthe labor Ct.la Ynn mu%t
fonhwhh annply with such powision% or permit Shall be deemed rcvaked.
LIiNDINGAGF:NCV
IhenbyalflmUhaWmrci,ua.:utmetion lemdingagency for the pe't'oonanec of
the work for which this permit is ix"ed (See. 3097. Cie C.)
1 -coder', Na c
WA'I'Ej LII!A'1'E5tWNBNUF.I.IC-1
WATIid N.,l'STIiM/1'RIiATING
WNT SIil2VICE
=
NEW RP.SIUHNTIAIrVI:MR.-SQ.PI".
'TOTAL:
Lender's AJJrc.w
I cethat 1 hms read tri, application and viide thin the above iaraniotlon is
nily
emercl.l agree, comply with all city and county ordinances and state law% Mkidng to
cnSlc:ion. and herchynuthorlrc represcmuffvc, of Ibis city teener upon the
builJingnm
QTY MECHANICAL- PERMIT
PERMITISSUANCE
AI:rER OR A DD TO MI!CH,
r
raswe-mentioned pmpemy for inspection purpose,,
(We) agree to save, imicnmily and keep hamdes%me City of Cupertino against
I'mbil hics, judgtncnt,. OoN and c panes which may i n any way accent, against said City
amt,.I me nanlinp t - hi, I¢nnil.
AI'V'twA f 1' iST SAND N' .Y N'1'rH AL1. NON -POINT
AIR HANDLING UNIT(TO 11,000 CFM)
CONS' IUC'IIONTAX
112CE . T 1'I
AIR 1IAN D1.1N(i IINI'I' (OV HR 111.000 CPM)
EXHAUST 11001)(W))UC)
I IOUS G MITIGATION FEE
ign:sure of ApplieundCantme.tr ale
HAZARDOUS MAI 'ERIAI ti DISCLOSURE
Will me applicant or future bailding trcupunl ,ore or handle bloc duos ntu en,il
a, defined by the Cup me. Municilwl Calc, Chapter 9.12, and the H.1th and Safely
Cock,S-lit 25532(a)?
II I!A'IING ON IT TO I1idolo IIT U)
HEATING UNIT (OVER 11%1,11 RTD)
VI?N I'[LAI 'ION FAN (SINGLE RESID)
C] Yc., F-1 No
BOILER-C'OMP(311P OR 11%I,OW 11'Tll)
PAID
Hare Receipt p
Will the applicant nq tltturc huildingoccepunl use cyuipntemur device,which
mil hn'rvNnm ;illi cnnumin .am us defined by the Buy A.Air Quality Management
HOLLER -COMP (OVER 1110,100 BTU)
Di, hict]
❑Ycs ❑No
AIR CONUI'I'IUNEIt
Ihale rcad theh:tranl us '¢dols rcyuircnunts under Chapter h95 of the Cali-
famt. hh & fey , Scc.on, I and 25 . 1 mukohnd fund the
NEW RESIDENTIAL MECIL SQ. IT.
nt nors Ynuveu ,tu - pp ,ihlllylon.arymencapent
tr_hich mu et nyRrcIct,nirnfya9'puy%vv
OFFICE
FEE
❑ 1 971sm
.JOB DESCRIPTION
❑SFOW
❑ KITCHEN REMODEL
DITION
El PLUMBING RF -PIPE
IULTI-UNIT'
C3 STRUCTURAL
MODIFICATION
❑IN'I'CRIOR
❑CHIMNEY REPAIR
IMPROVENIENT
C]SWIMMING FUOIS
BATCH REMODEI/REPAIR
C3 DEMOLITION
,❑
U+fr l R
COMMERCIAL,
❑ NIiW BLDGIADDITION [I DEMOLITION
0'117.NANT ❑ FOOD SERVICE.
IMPROVEMENT
❑ OTHER
saQ, FE
S
PLANCHECK FEE
- T`
ENERGY FEE
LD
GRADING FILE
SOILS,FSEE
'` n
FAIR'/�((j�
w rr)ale Receipt x
TOl'AI.:
BUILDING FH'
Or92
FEE
SEISMIC flit
0
E1,1iC P.
P1 lID BIN( THE
MECHA GLFEE
CONS' IUC'IIONTAX
I IOUS G MITIGATION FEE
PAID
Hare Receipt p
1'AI
ISSUANCE DA'I'S
7,`
Isg1n:D BY.
^
7
•/1
7