S 2110 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'RICIs 1'Eq\.1,IT No
BUILDING DIVISION APPLICATIONIPERMI.1' PLUMBING MECHANICAL
PES
2110
BEILDING PROJECT IDEN'L'IFICAI'[ON'
BUILDING ADDRESS: SANITARY NO. APPI.ICAIION SORMI'MAIL DAPE
v PA ei5oi4z4 23 `�F 9
O 'NER:S NAh is hi aftcu nide iic PIIONE: CO TItAC10NS NAM1IE: LIC NO.
�„ yy NIC CONN'NOLx
• AltClll'I'I!CI'IIiNGINIi E: LIC No. -I ADDRESS:.
I 1 ❑
CONTACT: M I PI1071i; S BUILDING PERMIT INFO
_'-89J ❑ Consultant Fels Paid by Applicant(initial) BLDi ELECTPLUMB ECH
LICENSED CONI RATIOR'S DECLARAUON QTY. ELECTRIC PERMIT FEE herehy antrm that ant licensed ander,mo,ki,n,of chapter 9(eom n,cia, JOB DESCRIPTION
nwz with sxdnn paM))nfmiaisinn Bnnhe Easiness and Professions a,Je.arena mylkense i. RESIDENTIAL;
a10 �f�p PERMIT ISSUANCE
FSI= ;n full force and
5ZL(XS' ❑SIUN'L Ll Kit REMODI[I.
aUU Licence Cb e Lic.x J APPLIANCES-RISIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPIT
p.Z❑! Dum Commclor
N6a ItClll l'E TSUEC LARAIION ❑MU1TI-l1NIT ❑S9RUC'1'URAL
'P w PANELS MODIFICAPION
ZZ_Z un
II,reand my pbr--mil be upu
seduxhlia records
O Oil T021XIAMPS
❑INTERIOR 0C IMN EY REPAIR
[71!1 f-W Liceal Professimal 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
�iy�j OWNIiR-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODELJREPA1R El DEMOLITION
C Q I hereby atlinn that I ata camp.from the C'ontractor's Liceme Law for the
aCBillowing mwun.(Section 7031l S,Bnninesn and I'rofesuo-Codon.Any city or county SIGNS ELECTRICAL ❑(YI'HI?R
F+I7 whidi reyu'nc,n Loma ,,n none,alter.Improv,Jmno„sh,or repair any s"em«
Oe, priormns inamncc.nhn n'yuins the aPPl¢ant for me hperminnfilousig.ednalemant SPECIALCIRCUIT/MISC.
EW}� that he is licanwd punue,n to he Provisions of me Conlocmrx I.Wcme Law(Chapter 1)
W MCI (commene;ngwith Seainn](XXgof Uiv;sionl nflhe Husineu and l'mfosionnCdc)ar TEMP.MISTER OR POLE INST. COMMERCIAL:
OL 6 C that he is exempt Ihcal and the basis for the alleged sorption.Any sodiu on If El NEW BLDG/ADDITION El DEMOLITION
K�Ic' Section 7031.5 by any. lieu Iba apermit sateen the.,lelul IT."Ill pe.Alof POWER DEVICES ❑'f1iNAN'I' ❑FOOD,SERVICE
y pp
n ,norm Igen fse mill dollars($500) IMPROVEMENT
=0 ❑ Luc uwnur of the Pmpeny.or my employees with wages To thdr sele cnmpennaf t SWIMMING POOL ELEC'IRic
F w,lldothewnd,andlhe,,memmi.enotinhenJWoroffcredfar sale lSw.]I Bu' ❑O'ff11iN
C 3 m and Pmfcssions Code:The Cnntmmnrs License law does oat apply m n mr o' OUTLIrlB-SWITCHIiS-ITXTURES
property who builds or improves thereon,and Is ho docs such work hini
his w mployces,provided that such impnrvemnns arc not in¢nJnl nr eft n Mi\ RESIDENTIAL ELhCfR SQ EL
-1.,
the bnillim,ov improvement is sold within ane you of complehian.mc SQ.PT.FLOOR AREA $/SQ.FE
enholdct will have the hunlcn of pmving oma he did not M1uilA o in,pmvc mr par-
lase nfole.). 'IOI'AL'
❑1,as owner of the Pm T am esducivcll contracting with licensed mntmdnn I
construct the project(Sec.TOL Hminms and 11ndesslons Cede:)The Cnmmcmr
close Law doe%not apply to an owner of prapeny who builds or improves thereon.and T P U
who contracd for such pro,jcnh with a contractor(s)licensed puraant LOIN Conuacmr's
License law. _ PER 'IS, AN(.
❑ Into"x Tu,and,,Sm. .Il A 11 C for his reason
ALTH -DRAIN& '-WATER(E VALUATION
Owner Doc
•
WORKER
under
COM PBNSATION DECLARATION BACK FLOW PR .UlIlIki
1 hereby affirm undo penally of perjury ane of the following dcdmanonr.
i] Ihave rout will mntmainu Ccrlificma of Comm,na self-Insure far Wot ker's Cnmpcn- DRAINS-I1,00R, )P.AHEA.CONU. STORIh$ TVI'Ii CONSTRUCTION
salon,ns Provided for by Section 110o of the Lad, Crede,lot the lednrmonce of aha
work lin which'his .,it is ilool FlCURUIN-PERI"R I
I have and wall nm;mam Workds Compensation Insurance,as located!by Section
1708.1 lmhe Law,Co .for the perfonnarri the wort for xh;ch this pertm';fit luissued GAS-ITA.tiYSTEM1f� OUTLETS
(KG GROUP AI'N
Carat 11 1
a rr(.I, C nod�IL1L1 'anPolicy NnYC �� ' •,.�• GAS-ITA.SYSTEM-OVER4(LA)
CERTIFICA'I'Ii()ITPlIVI ION TRIM WORKERS GRI?ASIYINDUS'I'KI,WASTE IN'I FRCEPTOR
CONIIIENSATION INSURANCE
-BUILDING DIVISION I F,ItiS
(Phis scaion need not heenmplch,tithe panni,osf witchvndreddAlmOS100) GREASETRAP
or los.) 1'LANCI{ECK THE
aendy that;.the pifomereem(the work fohi
r wch thispermi,is issued,l shall SEWER-SANITARY-STORM EA.200 I1'.
not employ any pc,am in any manner,.as In become subject ,,the Workcrs'Compcn- ENERGY ITiE
ZZ satins Laws of Culifomia.Dow WAI'IIR I MATER WIVENT/ELECI'It GRADING I'EE
2 Applicant
(n NOTICE 10 APPLICANT:IL d)cr making thin Cemki re of Pacmp.on,you should WATER SYSITNU RENT INN
f become suhjen III the Walker',Compensation provisions of the Lao.Calc.You must SOILS LLE
Wfnnhwimcomplywith such prokkup,or'his permiuhall IN darned evoked. WATER SERVICE
CONS'fRUCTION LENDING AGENCY NEW HI!SIDCNTIAI.PhMB. SQ.FT. PAID
hereby diirnn hall IIa,c,,nconstmeann lending alit"Ykt me performance uI
thwL m ReeeSpta
�� e ad iia M➢
which this pernnit in issued TOTAL:
ULender's Nano
D.1 Under',Address 'rOrAL:
} C 1 cendy But L have awl This appleadon and uoe ma the ul
awe inommit ma I' BUILDING
to correct.l agree to comply with ell city and county ordinances and state laws relating In QTY. MECHANICAL PERMIT FEE SEISMIC PEE
m
U Z build l ng unsmdon,and lil ammori.G Tprc rfd.,,n ofthirdly In cn¢rorynt the }�
uMery ncndnncdpropeny far....Mallon P-111,11. FERMI'I'ISSUANCE rV ELIiC'I RIC ITEC
(We)agree to save,indemnify and keep harmless the Cory rel Culanin,against
Imbilities,judgmenls.toes and expenses which may in any way occoncli nsl said City ALTI2R OR ADD TO MSCIL PLUMBING FEE
in canseyueme of thegraming of this I.R.
APPLICAN"L'UNOERS"1'AND.' 4ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON[I'(10 l(LrXp CFbD M[CIIANICAL FEIi
S I R-[I N X ULATIONS.
_ n AIR HANDLING UNI'1'(OVER 10tdXICPM) CONS'1'HUCCION'IAX
Signamwof Applin .ontmcl r �]( Dum EXHAUST HOOD(WIDUCf) HOUSING MI'OGATION ITB,
lAR X 1S MATERIA S DISCLOSURE /I
Will the applicant or lumr building wstore or handle M1aeallous material BEAT UNITOR)100.000 BTU) l�
as defined by the Capenino Municipal Cole,Chuptcr 9.12,and the Health and Sudety
Code.Sell! 1255320)'1 ��y HIiAfING UNIT(OVER 100,000 B'I'UI
Yen "Il7Y - VEN'I'l IATION[AN(SINGLE RESH)) PAID Dmc Beset,'#
,•
Willful applicant or sir macre building occupant use uipul l or devices which BOILI R-COMP COUP OR 100.00 ]'(1)
emit hwandous air communinan nas defined by the Buy Area Air Quality Manaw
genm 0 BTOTAL
District? BOILER-COMP(OVER 11X0.000 BTU)
❑Yes 4fn ItO '
II reedme Punvanl : mu¢nab hs under CL:,mrl95 nfthe CtJi- AIRCONIII'HONBIt ISSUANCE DAT F.
re4ui n m
Toot Ileullh Safety QW , alums 255(15,25511 and 25511 I unJcnland tRnl it the NEN'RESIDENTIAL.MIiCN. SU.FT.
in' t n urrtndy M1a antdurto o my O"ro;b;l try mno;ly We cupam /
11 p es which nm t - ante of a Cert�fiq t
O e udmnaJ ug rel O(, Da YtA IStiUEII IIY: ����
OFFICE