S 2592 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO BUILDING-ELECTRICAL PERMIT NO.
xuu,,IS(:DIVISIDN APPIJCA'1'ION/PER1111'1' r1.w1HIN°'ho-cn,5recnl, S 2592
BUILDING PBOJECI'IDE,NIIF'ICATIUN
BUILDING ADDRESS: SANI TARY NO. APPLICATION SUHMII'1'AL )ATE
Eriailu N 200 ��
OWNERS AAMC: / PI10N1!: CUN'IRACI'OR'S NAME; LIC No:
-TAMFS G- 6ALL1 foSO -1VX NIC CONTROL#
two ARCHITECUENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: DU I LDINC PERMIT INFO
❑ Craofit nDl FPCa Paid by Applicant(Initial) i[]
BLOC I31Uici PLUMB Nil: if
!C ❑ ❑
LICENSED CONIRACrOR:S DECLARATION QTY ELECTRIC PERMIT 17E
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
M=Z .,In Section 9(XN)ol I iG,ion 3 fine lrminesa and ProRvxinns CNe.and my license is IDENTIAL:
F,2 in full fire and effect. PERMI'I'ISSUANCE Q
DWI. ❑KI'1'CIIIiN RIiM0Dli1,
4VU Liunuc Cl:nn lisp APPI,IANCIS-RESIDENI'IA, DDITION ❑PLOMBING RI PIPE
F Z•W Ilam Conuuaor
mQa ULTI-UNIT OSTRUCTURAI,
Dy ARCHITIiCI'S DECLARATION PANELS
Z O,A Z 1 undemmnd my plans shall he mod as Public co MODIFICATION
OZN� UPT0200AMPS TERIOR ❑CHISI,NEY REPAIR
F4F-W Licensed Prolessiowl 201-HNN)AMPS IMPROVEMENT C]SWIMMINGPDO S
�s„d��
OWNER-BUILDER DECLARATION OVER I000AMPS ❑BATH REMODELIREPAHO ❑DEMOIH"Z[ON
C 6 I hereby union that I am est min(foam the Co ioelor'N Liceme Law for the
55�k
LU Inlluwing mrnn.(Section"1031,5,Ihr n•uund Prnfcv' wry cryt
s Cook:Aor unit SIGNS HTXCI'RICAL ❑(U UER _
W 3 W h which requires it permit to construct,alta,impnrve demolish.or repair any stmctmu 6 O
prior to its issuance,also requires the applicant for such pemmino file a signed stmencrt SPECIAL CIRCUIT/MISC. �
17
y•„ that he is licensed pursuant m the Provisions of the Common/s License Law(Chapter 9
�ty�o 0 (commencing with Section 7 )of Di vision 3 of the Business and Professions CNC)or TEMP.MEI"IiR OR WL13INST. COMMFRCIAI:
a . C that he is exempt therefrom and the basis for the alleged exemption.Any violwlon of ❑NEW BLDG/ADDITION ❑DEMOLITION
X^" Section"7031.5 by any applicant for a permit subjects the applicant np a civil Penalty of POWE IDE 1CCS
umrethun live htmdred dollars($50). ❑TENANT F(X)U SERVICE
.,Ifdosownerordte pnq,my.n,o ono,
witnwagce rsole(s luorsnic 1o.Btilinws
SWIMMING I'oUL ELECTRIC IMPROVEMENT
W o will Pr Wewmk,nod the Xtmamera orofferead dos of apply to an. wnero ❑0'I'IIIiR
13 m and Professions CNs The Cnmmnor's Liana law dcen not apply np an owner ill OUThEI:S-ti TCI LS-p%'rIJRHS O
propery who bui Into or improves thereon,and who dose,such work himself or through
his own employees,provided that such improvemmms ure not intended or offered for NEW RESIDE" AI ECB SQ ET.
sale.If,however,the building or improvement
is cold within(one year of cnmptiinn.the SQ.FT FLOUR AREA SISQ.FT.
wrw,Imide,will have the burden of pawing that he did nm build or improve fill or.
pose ofsalc.), '1' 1.; Call
1,us owner of Ibe prq.cny,am exduxi,ely contracting wish licensed co unarm.to
mama the Ponca(Sec 9044.Baines and Profession,Cook,)Du.Comment-,U-
seLaw does nmapply manowner(if popery who builds or hnpowes thereon,and QTY PI,UMBING PERMITZ FEE
who contracts for such pujmts with a contrecwr(s)IicenuJ puramill to the Commemis
License law. PERMIT ISSUANCE
❑I am exempt under Seo. R&P C for this maven
❑Ihmeand will nmxinuinaCcN" 74,41, s. U11V 49 AL'I lik-GRAIN&VIiNT-WAr1iR Din) VALUATION
)wnG tlWf1RK1iR'S COMI'ENSAI'ION DECLARXI'[(ON HACK PLOW PROTECT.DEVICE O
Ibcreb Ilion soda IIY of lnrjury one of the following Ucdumtinns:
cacof Consent in self-i...rel ipr Worker's Camper- DRAINS-FLOOR.ROOF.AREA.COIN 11 f STORIES TYPIi CpNS'I NIJ[:I'ION
.amid p 'd i f b,i Ssi ped (th Lebo C sJ 1 sun pelf ce I the /V//O.„IV/�
orI h hhrh:P t ed FIXTURES PER TRAP
[ pc:f 1 9d by Section
tion
h d 11 Wk
J)rp ofb [..hot Cook,[ In,pvf f'he workf hiOh his Kormit is .:tied GAS-IN SYSrCM-I INC.JOIITLEI;S OCG GROUP �JNg
My Wnrk,,,Compemul na]t...once tiarr s,and Pco,nr m low,:,: I Yz,om`-���
Cunicr: Nib,No.: CAS-I?A.SYS'I'1'NM1tN'2kYt134F-�••��•
CI!RI'119CATE OF EXEMI11'ION PROM WORKEk3' GREASIHINDUS'm I. ASIR "TOR
COMPIiNSAI ION INSURANCE BUILDING DIVISION FEB.
tThisseainn..Nnot becnmplmvJ ilthc pmmit is for on chundraldollms(SION) GRFASHTRAP J
or less.) PLANCIIIiCK PER
I cenify that in the performance of the work for which this permit is issued,[shall SEWER-SANIT, -STr1RsEt .. 119
not employ any Person in any manner oo as no become subject In the Workeri Conmpcn- ENERGY PEE
� Z nation laws of Culltomiu.Dom WAFER III!A'rRk ❑N'Ill!LI!C'B
Z O Applicant Glt AILING Il!E
NOIICE TO APPLICAN'p 11;ulicr looking this Cmnihwm of EXnnpnon,you should WATER SYS'rl! 'RJ' TING
a > become suhjw to the Worked Compensalian posisions of(lie InMrt CNa Ynu omni SOILS PI!E
Lmhwith comply with xavh pawkiamo, his permit shall Is,deemed revoked. WATER SERVICR n /
Q v
Vn' CONSTe is eco amc LENDING NEW RISIUIiM'IAL PLMB. SQ.FT. PAID ate RmciPta
Inereby nl'Ertn rM1m there ins mmSec.iunlmndmg agency fa the perfommnec of
U f-s the work rat wldeh ndn orlon ins is'
"Ree.a(M)"1.efv.C.l
F•' lender's N:mw TOTAL:
{U Lvedcr's Addles TOTAL:
0. 1 cenify thin 1 have read this application and meflow the allor information is
BUILDING I� ' �
FVD comm.lu'rcen,comply with all city and county ordinances and slate laws relining In QTY. MECHANICAL PERMIT FEE C^O
U 2 building constriction,and hereby antounie reptnsenlatoce of this city m enter upon the SIi1Sh11CF F
ohovcmentloncd popery far inspection purposea. PERM]I'ISSUANCE ILLILCI'RIC pfi
(We)agree to save,indennify and keep harmless the City of Cupenim,against
lubilue,.jud,n-a..coat,nnJ cspcmcswhich nwy in any wry acurucugninstsuld Cay AI.TEROIIAUU'IYIMIiCH. PL11MItING 17I3
nnscyuenao til the'ranting mlthis permit.
APPLICANT UNIOERS'FANDS AND WIL1.COMPLY WITH ALL.NON-POINT AIR HANDIING UNIT(1010.000 CUM) MECHANICAL ME
SOURCL RIiGULAU
'1'INS.
i AIR I IANULING UNIT(OVER 10.00x1 CFM) CONSTRUCTION TAX
St',rcsooulllx of ApplicuruConmedor Valu EXHAUST'l 1UOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MXI'ERIAI S DISCLOSURE
Will the applicant ar liuu¢bu'Jding uecuPamstnrcnrhuxIIv haemo.,mmaiul HEATING UNIT TO 100, (x)If1'ID
_curd by the Cupertino Mmnci P:J Coda Chapwr 1.12,and the Hcuhh and Sally
Code.Section 25532(0'! - / HEATING 11NIT(OVER IINI IX11111'I'UD
❑Yen IZIG VIR I ILAI'[ON FAN(SINGLE BE SID) PAID
Done Rtteipt p
Will the applicant or lawn building occupant use equipment or devices which 601LF.R-COMP(3HP OR 10U.000 HTO)
emit haeamm%air contaminants us defnod by the Ray Area Air Quality Management TOTAL
DrslrcT! BOILER-COMP(OVER yLkio l'rU)
❑Yes .L ,Xn
(have mad the hamdom mmcriuls rc Is under ChaPlmrfi95 ol'Ihe L'ali A W LUN DI'I'IONER ISSUAN 'E DA ^y
yuimmcn /
fomia,it,-&Scurry Q.k.ee.Iiom 25505,255JJ and 25534.1 unae ry al that Nf the NEW RI31UIiNl"IAL M[CH. SQ,PI'. 2 L /n
,ifhenx,I neat wbndy harcumenant tlu lis my resp IF Ccmfi,ncofythemn,. `/�
nftM ley' +mwms wM1id mrM ep saner ofu Ccnifcme of Occupancy. o7-/y�J�
moor flunucd ngew Dete TOTAL: ISSUED BY: 1
OFFICE