S 2218 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL FES IT NO,
BUILDING DIVISION APPLICA'FIONA'ERMITPLUMBING-MECHANICAL• 2218
BUILDING PROJF,CIIDEN'1'IFICA'I'ION
BUILDING ADDRESS: SANE"IAI<Y NO. AI'I`LICAI'IUN SIII1MIl9'AI.DAI Ii
U
OWNER'S)AMU: r�pDax P
HONE; NACIUH" AMG: LX_NIQ_ CUNTROLp
• ro
ARCHITCCUENGINEU U : (� Y
l Cl
CL
CON'T'ACT: PHONE: BUILDING PERMIT INFO
j�/Y �n 1„ n le,
�/-II /4 _ Q ❑ Consultant Fces Paid by Applicant(initial) HO LEC'I PLUMB H nl�
r (�LICENSNSE1)CON fRAC`R)R S DECLARIAFIIONLY`J QTY GLBCfRIC PfiftMIT FI:F. ]013 DESCRIPTION
C - set I hereby affirm that 1 mm licenced under ptnvicions of Chapter 9(coutomncing
7 In Scetio 7000)of Uivislo o3oft 5Hmmessand Pod cions We a dmyl'cen.e is RENIDENITAI:
{�p PERMIT ISSUANCE
� in lull lomcand effect. � 'p� ❑SpIDWL ❑KITCHEN REMODEL
aUU License Glc Lich C,Driel, APPLIANCES-RESIDENTIAL, []ADDITION [I PLUMBING RI PHIE
vl-i Z d Dmc Cantracurz
ARCI '1'C:C'1"SDLChARA11ON PANELS ❑MULTI-UNIT ❑STRUCI'URAI.
Z pHZ IunJrntanJ my plane shallh used os public neoNs MODIIICAIION
m- UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
pZ-�
F1nFly LiwnwA l'nrtc.aional 201-10(mAMPS IMPROVEMENT SWIMMING POOLS
Cy2� OWNIiR-RUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEIJREPAIR ❑DEMOLIPION
C R 6 I hereby affirm that I mm exempt from the Contractor's License Law for the
W C)LL U following"u'un.(Sectlom]IN 15.Business cum Profsxnionv Code Any city or el lY SIGNS ITL17CIRICAL ❑OTHER
y which requires a Penne to conswm,alter,improve.demolish or repair any nrucmrc
Ill orl t 'Ba re,oure,me applicanthownchl'e itt file a oi,n,d,t.tl.,c, SPECIAL CERCUI"IIAfISG.
E y
in.,Im is licensed p r,m l to thermc,o :u I are L cern I Law(Chahar,9
��Op (commencing 'th Section]TNM)) fl)'.to 1 fth Business and I.: C-odc)or fEA11'MCI I:R OR IT)LE(NST.
COMMFRCIAI
44 o CC Ther he is exempt Ihcafmm and the bouts Inr the alleged exemption.Any vmillum of El NEW BLDG/ADDITION
❑DEMOLITION
XmLL. Sation]0)IShY troy applicant fora pennon nnhjaels the applicvmmnuvil pen:Thy of POWIiIt OEVICGS ❑'fCNAN'I' ❑POODSidtvici
4 not mom than Bre hundred dollars fSSIM)).
IMPROVEh1'
1EN'
yQ (] Llln owner ul the prnpcny,or myclnploycn with wages-their solccompcmatie., SWIMMING POOL 1LECfRIC SOT HH
E. will dothe send.and thewrolare is nor intended or Nfecent for sola Ne,70J1,Im,me-vs
6 3 m and Vmfeedur,CNet:Tho,Climate o',License Law dons am apply m an owner of OU'1 KITS-SWITCIIIS-1'I%'1 URIS
pntpcey who built,m Improves thereon,and who does such work hlunclfor Ihrough
his own employees,provided but such improvements arc un intended or offered lira NEW RESIOIiN"UAL IILEC'IR SQ Ef.
sale lL hox'e'cq the building orimpmvcment isuJJ withinnnc'emofeompletiomthc SQ.I'1'.11.1)UR SISQ.t1'.
ownerhuilder will hove the harden ul pmv'ing than he did not build or improve for pur- -�
polosale.). TOTAL: f,
Fl [,;is f owner of the pmpi am exclusively almmning with licensed contractors to
n,umO Tho pmjeul(Sec]IBJ,Bucinuc tool t, I..turns Ctxle:)the ConoomoL.I,i-
cense Law does not apply toall owner ofprogeny who hwld.c or improves thereon,and QTY. PLUMBING PERN11'P• c'1- n asrM1(�
who contracts for such projects with n Cottrel n[s)licensed pnnaaa'uc the Contmam's 1 R (+ 1999 999
Lieemw Law. PERMff ISSUANCE
❑1 am exempt under Sec. .B ge 1'C for This.-on
AUI'[in-DRAIN.@ VENT-WATER(EA) VALVA ION
Owner Dme
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penally nl perjury one of the following declvrmism:
C1 l have and will intonation u CembericOI Consent losclf-insure far Workers Compel- OIMAINS-IIDOR.l10012,AIXI;A,C('ND. 71012115 "fYPL'CONS'IRUCTION
cation,is provided Inr by Section 370()of Inc Labor Code,for the permo mace of the
1" Iia which this Pnnmi.is i...... IBKIURES—PER TRAY
I have and will aonmain Workers Cull 1-cancel Ill—onee.as reyuiled by Section
1]1(3 of the Labor Code,Inr wo
the pxiburounecof the rk lel which this pe., is issued. GAS-GA.SYSTGA1-I INC.4OUTLETS OCC.GROUP AI'N
My Wn cr'a Cp mnnntinn lnsun rota s -'Y tat GAS-GA.SYSTEMOVGIil[GA)
Corti o Icy n.:
CIiRTIFICA'1'li OF li%GM19'ION FROM WORKERS' GRIiASFIINDU$TRI.WAS'I'11NTIiRCF:1'IY)R
COMPIiNSAI'ION INSONANCg BUILDING DN61DN IIiGS
(This r.cctionn¢J natMamtplcteJ it the pennh is lon:nchundred dollars(311X11 GRI:ASG'1'HAP
PLANCf{IiCK PER
or lcccJ
I cenifythun in the perbalnunce ofnl¢w�rk lorwhicb Ibis permin is iexucA,leh:J1 SpWGN-SANITANY-S'IORM IIA.200 PI'.
amt employ any pvnnn in any manner w as m beasmc subject to the Wrnkerd Cnmgem
ENERGY Il!E
Z nation Lawn of Calilnmia.Dam W'A'1'IiR HGAItiR W/VEX'/Ii1,ECIR GRADING FEE
0 APPlicam
'� Vy N(YfICE'10 API'IJCAM:If,ober making Whiz Cenilcate of Gxentptiun,You should WATER SYSTGMH'RIiATING SOILS FEE
F hcvnm slhjecl m nhc Workds Conllwnxalion provi.vions of the labor CoJu,you mutt
UJ
[anhwith cuntply with ' UCfION LENDING AGI NCY mal rcvokW. NF'I'IiR SIiRVICE
C: � CONSfRW RESIDENTIAL PLMB. SQ FT PND Date RccciplN
1 hereby vlimuhatthere is a c.moreti'm Icndlmg agency Inr the perfommncaot
{U F the work for which this Knoral is issued(See 301 Cir.C.) T( LI
O Le vC,Nmmc 'U GAL:
rU Icndcr'n Address BUILDING F•CG
1 1 ecnify that I have mad this application and nate that the above information:s
I ugtectocnmply with all city and camntyordinama+nnd state laws relating to QI'Y, MECHANICAL PERMIT FEE SEISMIC IliE
VZ building ecmmorron.and hereby modwa'ry mpmnenmtiven oftbis city m eater upon the
above-mentioned pmpeny for inspection pugnras. PERMIT ISSUANCH ELECTRIC I:
(We)agree m save,indenmi fy and keep hmndos the City al Cupertino oguinnt
Iiahilitiez,juJgmems.costs amt expenses which may,.any way acerae...inntsaid City At:]ER OR ADD'IO SUCH, PLUMBIN FEE
in asequence of the granting of this permit.
A111'LICAN'I'ONDERS'I'ANDS AND W11-1,COM PLY W I'It I A LL NON-POI N'I' A I R I IAN DLING UNIT l'1010.m XI ClM( MECHANIC I,IIBi
SOURCE,REGULAI'IONS.
4_ii;?9_99 AIR HANDLING UNIT(OVER 10.000CP14) CONSTRUCD NTAX
Signature of ApplieanllContmnor Dae 1I%HAUS'I'HOODfW/DUCE) HOUSINOMITIGA'DONFUE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or folate buildingtmcupunl gorun handle humNauc lnum:nal H GAT]NO I(NIT I'10 IIXllxNI BTU)
us defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,110X1 BTU)
Colic.Stt'lion 25,5320"
❑Ycc VENTILA'1'IONFAN(SINGLERESID) PAID
Dale Be cipt M
Willnhc:y,knot nr Lume hmlding omepam use cgnipmrem ordeviro.v which BOILER—COMI'(311POR 100,INX)BNI
emit narurdnus air ClmI niman,as defined by the B,Arca Air Quality Mawgensnt 'I(yl'A
1111.311 BOILER—COMP(OVER 100,000 BTU)
❑Vee dao
AIR CONDI'1'IONIiN ISSUANCE DATIi
I have andSo the ely Code.S c tions 2 R requirements533tol 25534.1nder d 6 95 of the Cali- -2-
building
/1
forma gdoes n teal Galea Saloons 255115,25533 esp 2s5JJ.I undvsy nd than it nhc NI?W RIiSIUEN'I'IAh MGCII. SQ.PI'. 7
guiding Jecz not currently here a Imam,that it is my responsibility m modify the arvgam
of thePi ems t'whl'hm tbc, tprinrmisuanee nluCenifcme f(kcu y,
wn/'»in'/
Oki I / 0 �
Owner autnodred aBem use Yc � �I� "te�� 'AL: ISSUED BY: /
OFFICE