S 2189'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
TY OF CUPERTINO BUILDING - ELEC'T'RICAL
IIUII.DING DIVISION APPLICATIONAPERMIT PLUMBING. -MECHANICAL
BUILDING PROJECTIDENT91'ICA'1'ION
PERP IT N0. 2189 189
S
BUILDING ADtD—R/ESSSS�
SANI'DARY NO.
APPLICATION SUBMITTALDATE
r
OWNER'NAME /tf �/ � PHONE:
� ��?M f".VYCi
'ONTRACf(IgqS NAy B: ^ µ LIC NO:
!'tw L[lr+dj�c L.�{i ,i. C-27s69P766
N/G,
❑
CONTROL a
:1111 ECIAHNGINEEIR LIC NO,
ADDRESS',
CONTACT: PHONE:
BUILDING PERMIT INFO
G �/C / �� /
V Y `DF- 25z• 1443
E] Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm That 1 am licensed under provisions of Chapter 9 (........orcin,
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT' ISSUANCE
with Secluer FIND of Division B offal Business and Prnfessams Codc, and my license is
in full lire and effect
I.imr, rrho. x-27 Lica cyi%c6
Dee 4, �';�Cnnlrn � —
RESIDENTIAL:
KIT
❑SFUfI ❑PILUMBiN RE PI E
El AD ❑PLUMBING REPIPE
❑MUI:f 1 -UNI '1' ❑STRUCTDEAL
MODIFICA'11ON
El INTERIOR [I CHIMNEY REPAIR
IMPItOVENIENT []SWIMMINGPOOLS
APPLIANCES -RESIDENTIAL
ARCHI'I PC1"S DECLARATION
I understand my plans ,hull be used its public romm,
PANELS
UP TO 200 AMT'S
Licensed Professional
201-1000AMPS
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's Uutrisc I.aw for the
following reason. (Seedon]BJ1.5. product and Professions Code:AnyclD mentality
❑ HATH REMODEUREPAIR ❑DEMOIJTIGN
❑OTHER
OVER I(MX)AMPS
SIGNS ELECTRICAL
which requites a permit to construct, alter, intpmve, demolish, or repair any structure
SPECIALCIRCUIT/MISC.
prior to its issuance, also ecyuims the applicant for such permit to file a signed statement
that he is licensed patauant to the pntvinions of the Connectors License law (Chapter 9
ann,ou., with Smile.700(nof Division B of l he Business and l on—lons Code)or
'I' EMP. MITER OR POLE INST
COMMERCIAL:
,In, he is cxcmpl Therefrom and the basis die the alleged exemption. Any viounie, of
❑ NI?W BLDG/ADDITION ❑ DEMOLITION
Seed.... 7031.5 by any ... hear, [or u,orlon,obje,e; the ap,I,,am fon..lullp,ad,of
POWER 13I7VIC13S
Ell ❑ PODU tiIHtVICI?
tt nano wnn five h props dollen y anipl
[]I,mnwnerof Nepropeny,nnnymnpinyeeswith wages avlheirsnlcttmtpcnaninn,
lhesume is am inccnded proffered for en sal. (S](W4, Business
will do the work, and trn
IMPROVEMENT
PROW
❑ OTI PLN
SWIMMING POUT. ELECTRIC
and Professions Code: The Connector's License Law does and apply to .n owner of
OUTLETS - SWITCHES -FIXTURES
NEW RESIDENTIAL ELHCr'R s SQ ET
property who builds or improves fiction, and who does such work hinwclf or through
his own employees, provided than such improvements are not intended or oflcred for
sale. If, however, the building or improvement is bold within one year of continental the
S .I4. FLOOR AREA
VsQ. FT.
e burden of proving [list he did not build or improve for pur-
ocrbuilder will have tire pro
pne of rude..
I, n of he p of the Sec.70y, am cxdusivelynd confessions with lammed cnntmann. i-
meso Ibc projael (Sec. ]044, it nova and Professions Cade:) The Contractor's
TOTAL:
enc I.aa all
c I..w Aun. suchplylo l.utwnerofpmperry whosedpnrant it) r Contra, ors
is furwch fm,jeclx wadi n cnutmnnr(n) licensed pursuant m the Convenors
whonse
QTY PLUMBING PERMIT FEE
PERMITISSUANCE
Lo
License Law.
rl I am exempt under Sec. , l{ & P C lin this reason
/
ALTER - DRAIN & VENT - WATER (PAT
Owner Date
VALUATION
BACK FLOW PROTECT. DEVICE
WORKERS COMPENSATION DECLARATION
1 hereby off rat mmor penalty of perjury one of the following declarations :
/ Z O p
I have and will maintain a Certificate of Conan to self-insom for W..rkers Counter,
satin, as provided for by Section TRXs of the Leber Code, for the unforn t nsc of the
DRAINS- FLOOR, ROORAREA, COND. Pss.
, SOORII-A
TYPE CONSTRUCTION
work for which this formal is issued.
O I have and will maintain Wader's Cnlnpensmion Insurance, us reyuirod by Section
9]1X).1 lira labor Cods far the perfurtnuncour the work litrwhich thlb p,ardl is Issued
FIXTURIIS -ITER TRAP
^
TAS-HA.SYSrIl INCAOUTLET;S
OCC.(' P APN
My WadCl's Com em; Irl; Innl;nlncc canlcr:mJ Policy num -
yy
Carrier S'Ide �.N Policy No.: IttV0/. p'i
(t
GAS- HA. SYSTEM OVER 4 THAT U
CERTIFICATE OP EXEMPTION FROM W ORKIR S•
COMPENSATION INSURANCE
GREASI9INDUS'I'RL WASTE ENTER CIiPIORal
/LqQVhILqN#1VISTON IIiPS
ITTivsemion need not be nnnplemA life permit is Talion. hundred Jnllvm (SIO(p
or IussJ
GREASE TRAP ISZ
P W NCI111CK P X.
I criifythar, imhe KnImumnmaflhc work fnrwhichadl; permit is is stud. l shall
not employ any Teemed in any tanner so as to become subject to the Workeri Compen-
SEWER -SANITARY- STORM EA. 20X1 Fr.
E
WATER HEAI ER W/VENT/ELECTR
GRNOTICE
cation laws of California. Date
Applicant
TOAPPLICANT:If, after making this Cenificamof liven;ptin. you should
became suhjcet Teo the Worker's Cnlpensulion provisions of the L.1-sn Cn to. yu mst
WATER SYSIENPTREAHNG
Ionhwitb comply with such plil annumthisformat shill hedewnwl revoked.
WAITER SERVICE
CONSI'R11CfION LENDING AGENCY
NBW RESIDENTIAL PLMB. SQIT'no
Receipt#the
X
work for which this pemlit Is Issued (Sec. 9007. Civ. C)
Lender's Name
TOTAL:Leaderi
Address
information is
TOTALI
-ren.
minify that 1 have lived this application and state that te above
l agree m comply with all city and county ordinances and state laws relating to
building conslmction. and hereby arborize representatives oflhiscily nn macrupom the..hove-mentioned
QTY M19CI1ANICAI. PERMIT
PERMIT' ISSUANCE(We)
property farInspcctin l purposes.
agree to _save, indannily and keep bulmlesi the Chy of Cupertino agulmlL'E
AIA 12R ()It ADD TO MEC){.
PI. VINO FEIi
Iinbili,us. factitive, ...... 1, and expenses whidt may In any very reenmaguinal nail City
in n,ulenceofthe grunllo, of thi,elood.
AIR HANDLING UNIT (TO MOST CFM)
MBCH (CAL P%li
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE: REGULATIONS.
AIR HANDLING GNIT(OVER BAR CFM)
CONSTRICT ION TAX
Signature of Applicant/Commmor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING kI'1'IGATION PEE
HEATING ON I r CIX) 100,00) BTU)
Will the applicant or future Talking occupant store or handle haetli material
as Ali tied by the Cupertino Municipal Coale. Chapter 9. 12, and the Health and Safety
CoAc, Section 2559200?
HEATING UNIT TOVEIT 100,030 BTU)
❑Yes 0 N
VENTILATION PAN (SINGLE RES] D)
PAID ^
Dam IF, tM
BOILIiN - CONI' (3111 ' DR IIXI,IXIII BTU(
Will the applicant ser(alae building byoccupant use ulir M cat WI1iCh
ByAe, Air
itis hunntlous air mnmminamx us dclincA by the Huy Area Air Quality Mnnugamenl
BOILER-COMP(OVER 100,000B1U)
listricl!
E] Yen QI No
AIR CONDI'I IONHR5
Ilwve real the hazurdws mmuriuls requirements under Chapter 09of Cali-
intim Health&Safety Code,Sectiuns25505,2553J and255l. I understood that ifthe
ISSUANCE DATE
'%^
NEW RESIDENTIAL MECH. SQ. 191
building does not currently have a tenant, that it is my responsibility, to notify the occupant
Z7----<7
..Tobe reyuiremems which mr.d be run prior to issuance of a Cenificme of Occupancy.
� r�
ISSUED fly
TOTAL:
Owner or authorized agent Moo
OFFICE