S 2525 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO.
BUILDING DIVISION APPIACATION/PERMIT PLUMIIING-MECHANICAL S 2525
BUILDING PRIJP,CT'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'Z'E
100 z9,1,xt 2- 2_3-9
OWN 'SNA N PHONE: COtI'g CI'OR'S AME: LIC NO.
\ '-, ejAljQg' r / NIC
CONTROLM
ARCHITECT/ENGINEER: LIC No ` ADDR[! : V ❑
F zyp 1
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) RLDG ELECT PLUMB MUCID
❑ ElZ1 ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE 1 hereby affirm that I am licensed under pmvision.s(if Chapter 9(commencing JOB DESCRIPTION
D00 with Section700)of Division Sol the Business and Professions Code,and my license is BESIDENTIAI:
OQ In full Tomo and eIf PERMIT ISSUANCE Ly�Yf.
PW� i�,y � tom . -3 FDWL ❑Kll'CHGN It1iMODH1.
UQ License Clens Lich - APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING 1H.PIPE
h Q a Dam I Ganl ectal
ARCIII'fIiCTS UECLA s 1O ❑MULTIUNIT El STRUCTURAL
[-may 1'ANI:I S
Z O'er Z I understand my Plans shall he used m public moods MODIFICATION
O__4—C IIP TO Ztq AMPS [I INTERIOR ❑CHIMNCY REPAIR
P41:2 Licensed l'n I..irnal 201.1000AMPS ,,,...,,,I[[[yyy.111MOVEMENT HSWIMMING POOLS
0.' J� OWNER-Ifilli-DER DECLARAI]ON py1;R 1(X7 AMPg IT I REMODEL/REPAIR DEMOLITION
I herehy initiation I am exempt from the Comracmrs License Law far the
6U followingbacon.(Section 7DL5,Baalte,mp Professions Code AnY city nscounty SIGNS IiLECfRICA1, �fl-_----�J /
LL 1" which volng bac a pemlll m 031.Nft,Biter,Improve,eni a6C or repair city
renemy
„F',�-� prior to its issuance,also reyvires the applicant for such Permit to file a signed statement SPECIAL CIRCUMMISC.
995 } that he is licensed pursuant to the partitions ofthe Cambodia',License Law(Chapter 9
�GO (commencing whh Section]IXNO nl Division 3oFlhc Business and Professions CodeO nr 'T EMP.METER OR POLE INST. COMMERCIAL_
a G that he a,esrmpt therefrom and thr basis lir the nllcgcd exemption.Any viola ion of ❑NEW BLDG/ADDITION ❑DEMOLITION
ySection 9031.5 by any applicant fora wrinit subjects the applicant to a civil penalty of POWER DEVICES
not mom than five hundred dollars 155110). TENANT [I FOOD SERVICE
} IMPROVEMENT
�6 E]1,as ownend the property,rr my employees with wages euheirwle compensation. SWIMMING POOL ELECTRIC
55550 willdothewrrk...dthe swcwre is net macirlwmoffi al for sale(Sce.JD14,Busiress ❑OTIIIiR
s3 and Professions Gdr.The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURIS
property who builds or interests themon,and who does such work himself or through
his own employers,provided that such improvements um not intended or elficasl for NEW RESIDENTIAL.ELECTR SQ PT.
sale.If,however,the building or impmveatent is sold within one year ofcompletion.the SQ.FI'.FLOORARHA $/SQ.F.
owner-builder will have the burden of proving that he did not build or improve for pur-
ms,c of sole.),
E]1,as owner of the property,am exclusively convecting with licensed comine ms to TOTAL:
omuuct the prnjen(Sec.7044,Business and Professions Code:)The Commod Lit-
sense Low does not apply to anow net of property who on ads tit improves theme,coal QTY. IUMBING PERMIT FEE
who contracts for such projects with a continuous)licensed pursuant no the Contractor's
License Law, PERMIT ISS A
❑I am exempt under Sec. ,B&P C for this reason
Owner Date Al:ITi1-MAIN& ;e
TOO(HA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby said.under penalty of perjury one of the falhnving declarations:
❑(have mod will muinmina Cenilicmenf Consennn ncllin>ure for Workers Gamper- DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPE CONST RUCTION
onion,as provided for by Sectio.3700 cl the Labor Code,bat dm peffn not ec of the
..,it for which This permit is iswcl, FIXTURES-PERT RAI'
1 have and will maintain Worker's Compensation Insurance,as requited by Section
3700afthc labor Code.forthepeffonma.ce nfthc..,k fnrwhichthis permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Workers a ansa syn Insurance carrier and Policy.y ar�
Cartier.,yej�_Policy Na: /7�s� GAS-F.A.SYSTEM-OVER 4 HA)
[iRTIFICATH OF E%E3MPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUS'FRI.WASTE INTERCIiPOUR
BUILDING DIVISION_ FEES
(This asdionne,4 nut be crngdard if the pvand is Tame hnndreddollnrs011q) GREASETRAP
or less) PLANCHIiCK FP,P.
Icertifyflat in theperfotmuncenfthewmkfinwhichthispernitisissued.[,hail S1iWER-SANITARY-STORM EA.2W FI'.
.m employ any person in any man 9 orae euhjc t to the Workma'Compen- ENERGY IIF.
O ,$
sat [awe(fCplifnmia.Du e •1r�F1 WATIiR HEATER WNENT/ELECIR
7 O Applicant h(�SL.. \ Z �_ GRADING THE
qy NOTICE'1�{i V�CICA , herMldg this Cenihcnmof Hxempunm You.should WATIiR SYSTEMn RHA9'INO
been,subject It,the Workers Compensmem provisions of the Labor Code,you must SOILS THE
forthwith comply with such provisions or this permit shall hat deemed revoked, WATER SERVICE
a0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PIAIL SQ.FT. PAID
UO DRccei p
(hereby affirmconstruction that there is a coction Lending agency forms,permanence per anence of M
the work for which this permit is issued(Sec.3097,Co,C.)
0 I--' Lenders Name DOTAL:
Ll Lenders Address 'TOTAL:
f17
I certify that I have read this application and swat tbat the shove inl'nrmminn is BUILDING 19717
Vat correct.l agree to comply with all city and county balancers and state laws diming In QTY. MECHANICAL PERMIT FEE
U Z building convection,and hereby amhstixc repractrmives ofrhis city to enter upon the SEISMIC ME
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree w save,indemnify and keep harmless the City of Cupertino against ELECTRIC FT:F,
Iishilities,judgmants,costs and expenses which may in any way awme against said City ALT' TOMECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR LING O II1,lNN0 )
SOURCE.REGULATIONS. MECHANICAL.PEE
TTI11 ,fi,12�1� 2 I/g/Q� AIH LING UNIT( RI0,1 CFM7 CONSTRUCTION TAX
Sissfi hApplicausConcrassfir l/ �a� E% T /[ CI HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future huilding occupant son,or handle torturous material IIING UNIT('TO 100,0008
as dented by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)' H A GUNIT(OVEN 11N1,(XXI BTU)
❑Ya PNo PAID
V, ID Date Receip X
Will the applicant an future building occupant use equipment or devices which
BOILER-COMP(3HP OR B'IL)
nit fanatics air contaminants as definad by the Buy Area Air Quality Management W,l1W L:
Dia.icl°
F7 Yes ]Nn 1101LHR-COM 11(OVER 100,003g0 BTI])
AIR CONDITIONER
(hove andthehaesrdne materials55 a5, 0533 ae under Chapter 69nd that Cali- ISSUANCEDA
�a
human gdoes&t comy Code,e a hou 255082553)and 25534.I understand that if the NEW NISII]F.NTIAI.MIiCH. SQ.PL "'1� �_
building dos not curren0y have m owns,that it is my rtsponsihility m natty the ucapom
the rtyuiremen�74 net priorm isauunce ofx CenilicJa a la��panty.
//) 9 n
or and refect age. I Unie� 'TOFAL: ISSUED BY.
r OFFICE f