S 1894 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull ; ELECTRICAL Pli1$ IT NO. 1894
IIUILDING UR'INu)N APPLICATIONWERD11T PLuSuunc-5n!cunNlcAl. l`J
NIIILDENXI PROJEC-1 IDF\l'IFICA'1'HIN
DUII.DINGAI)PRESS: TT SANI'I'AKY NO. AI/PLICATION SUHMI"1'1'AL DAr17
(�iAVIQR 5 .� PHONC: �r CO AC'TOkSN 1C LIC No:
l a '� -��� NIC CUNTROLI
.AHCHITECANGWEER: LIC NO: A!AIRIjS' ❑
CON'1'ACl: PHONE: 0-0BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) IH ) ELECT PLUMB MINCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT' FEE
1 hereby omen mm I..I licensed order pmci,iam.of Chapter a fr ntmtencing JOB DESCRIP'PION
CxZIh Section l0( dD vidgp3.Iaw Busincs Professions Crale.mal my heense i. RESIDENTIALif :
mpp .1 I'EHMI'I'ISSUANCIi
C mI F- full forcem � ❑SFDWI, [I KITCHEN RLMODIiI.
aUU hicou'c Cla LIc.N APPLIANCES-RESEDEN'I'IAL ❑ADDITION ❑I'LUMBIN .RE-PIPE
l-+Z ce Dm
vl6 a ❑MULTI-UNIT ❑STRUClUkAI.
ARCHITECTS UEC. ✓1 PANELS
Oou,Z Iundemlllntlmy,limenhall m..ul aspuhlie record, �Q-fes/' 3��ODIFICA (N
Oil 10200 AMPS 0INTERIOR IbINEY REPAIR
W liecowd Professional 201-10010AMPS IMPROVEMENT []SWIMSIING POOLS
.s42; OWNER-BUILDER DECLARATION OVI?R 1000AMPS ❑BA'I'Il REMODEUREPAIR [I DEMOLITION
d O W V I hcreb,affirm thm I am commit,from the Comencmr.License L.w fill the ❑arDER
3 a U following reason.(Section]0315.Business and Professions Calc:Any city or county SIGNS ELECTRICAL
iw� w whth y . fe nit I f f dart. p J h M Y � cmm
F'4•pg pr ort I Iv 4 the pplie It h loomall file a signed.Pt meat SPIT IALCIRCUITIMISC.
fical he is 1 Ip su o fic p n s ofin C t I ,Ijeem,Loo,(Cnptery
,al (sot b OSm ]11l1(11ID'':it Y 10 If ' JI CNynr II;MIIME"lERORPOII!INS'll COMMP.RCIAL'
d
on he is comm,.Ihcntrnm and IM1c hair for the iJlcgeJ csIopt on.Any v n 0i of of El NEW BLDGIADDITION 0 DEMOLITION
Section 7031.5 by anyappliram for a permu.ubject,the applicannnacivil,rnnllY of POWER DEVICES ❑TIiNANT ❑FOOD SERVICE
w emote In..five handled doll.(9500).
~=GLas owner of the norm Ioces with wiles as their sole compensation, SWIMMING POOL ELEM RIC OTHERVEAIF.N1'
C Q property. Yen IP Y g Persil ❑GTIIER
F. will dothe xions Cocc:and he cture Contlaoot m's LicJed nse Lli ercoes no,applyA(N4,Business
6'3 m and Professions GWor ice, Contractors License 1,aw dcec nal apply s if ,,act of OUI'Lf:?S-SWITCIIILS-PIX'lURES
,mitery conn build.ar ,ided net
srco and who als are notwork e himself or through for
hie con mtloyws,PnwideJ Thal sucM1 int,.is... Ic are not intended m nlfmmJ for NEW RESIDIiNTIAf.ELLCI R SQ IT.
sll:heitwcvcr,Thu builAing nr infpravamnn la null within aril Ycanrt camplction,IM1m SQ.ITC FL(RIH AREA $ISQ.I'I'.
cr-builder will have the burden of proving doc field nal mond or iinprnve lo,iPur-
• paw cfsolm.). TOTAL:
❑I,as owner of the pmpeny,am conclusively contracting with licensed contractors to
eemtm a the ponce.(sear](WI.Business and Profcalorn Cout The Commcm/s Li-
cents,Ease for,notapply to an owner of tmpcny who bmId,.,improves thereon.mJ QTY. PLUMBING PERMIT FEE
who contracts for such projects with a curnewo qs)licmned pursuant to Inc Gmfmctor a
License Low. PERMIT ISSUANCE
TUT exempt under See, B do P C for this mason
AIA'EN-TRAIN h V ENT-WA[liR(EA) 7ALl1A1'If)N
Owner Done �/ s
•
WORKER
under
COM PENSAeyON DECLARATION HACK PLOW PRO]ECT.DEVICE / !
Ihereby ill mai under penalty of Iwrjoryonet) the ircure following darkers, o
❑(have and will maimnina Cenificare of Cnnsnno self-insure Ra WorACA Compen- DRAINS-FEWRRtmIi AREA.COND. STORIES TYPE CONS'1'RUCIION
us OmviJef fur by Scclion 31(X1 of the ImMo CoJc.for Inc performance of the
a nk fur which(his permit is iswcd. 19XI ORES-PER TRAP
I have and
will maintain Worker's Compensation Insurance,as required by Section
.1( her Cod,,for the pc a nt 'Om work fill which tilt.Pcnnit is is d GAS-EA.SYS'rEM-I INC.4 OUTLETS OCC.GROUT' AI'N
MY Wu( v rytut loon cn� iL .)folic
'nlicy No OAS-EA.SYSTBM-OVER 4 UA)
Currier. !� .:
CEKI'I FICA I OF EXEMPT[ON FROM WOR KESS' GREA: GENIF.R E )H
EIJI COMPENSATION INSURANCE BUILDING DIVISION RES
(Taksccfinnnccd nm becomplefed if the permit is fofonc hundred dollars(SIM) GREAS' P
1'LANCHECK FEE
or less.)
Ime anylnatintheperfmannce rIn)he sit)bek for
mewobjectch to the ait is Workers
C.ltat- SIiWIiK ITARY-STO M .
ern em In .n n manner In)usmhecn euhJen lu the Workerc'Cnmpem �� E
NERGY FEE
r yany iddi any man
Z talion Lown of C:Jiliim:n.Uulc WAI'IiR TER ' IL,iG112
�O nppncanl
zz = NOTICE TO APPIACAN'U It,after making Iii,Cenitieare 0 Exemption,you should WATER. TEM/I'RIiA PING
C , hceo at subject ionic W..kers Compelismion pmvi.ian.of the Labor Clue,you mus
Irnnxith comply withwch pommi t nr this permit shall be deemN readcd. WATERS' a —
0 CONSTRUCTION[.ENDING AGENCY NE 'REST IAL PLA1H, SQ.FEciPl NVC' Ihereby.f0nothauberei.anntnouclion lendingagencyf,),11,'erlimnanceof
IL the work for w1hich this Permit is issued(SeeAN)1,Civ.C.)1,a in,Name '1'(YI'n V.V Lcndcrs Addrx. 'TOTnI.N GI ready thin I have read this applicationand state that Inc thole lnfl o,num is
.F. V) nmccf.I.grec ,,comply wish all sip and onunty rnlinancen and same laws rclmin6,o QTY. MECHANICAL PERMIT FEE SEi15MIG
V Z building construction.and hereby auffinow representatives ofthiscfly to enter upon the
obace-mentioned propcny for impcclum por ,... PCRAIIT ISSUANCE f:LliCl'SIC FEE
(Wo)agree to save,indemnify and keep hannlesc the City of Cupertino against
lirbififiex,judgments,costs and expenses winch may in any way meeme against said City ALT ER OR ADD TO M EC11. PLUMBING EE
Sin Oscgmma of file 6rawm,of this cmtl.
N' TUNDWIL
E.COMPLY WIfll ALL NUN-POINT AIH HANDLING UNIT(10 10,000 CFM) MECHANICAL FEE,URCEREGI% I
_7'9 9 AIR HANDLING UNI'1'(OVRH 10.000CFM) CONS'IROM[ON TAX
Signature of Applican9cooname,lorJL� Dale EXHAUST HOOD(W/OUCI} HOUSINGMITIGATEON FEB
HA%ARDOUS MATERIALS DISCLOSURE
Will thma,Flicamar fmtrebuildingoccupantcmm.handle haunedon material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal GMe,Chapter 9.12,and the Health and Safety
Cndc,Section 2553200! VI.)'PING UNIT(OVER If0.IX0 B'N)
�Ye. No PAID
'I'ILATION PAN SINGLE SCSIU)
Dole Bono N
Will the Ipplicanf ry fuse hmlding nccnpam sew equipment or de,ima which BOILER-COMP(.)IIP OH 100.001 BTU)
,,at,LeurJum air nmlami war defined by the any Arca Air Quality Management T
Dixoia^. BOILER-COMP(OVER 00.000 BTU)
E]Yes
AIR CONDITIONER ISSUANCE DATE
Ih ad fhvh Jf `1 y' t. a Ck pt hJt !tile Cafi /'�
Ito u,Satity C I f :25505 5513 J 25534 1 I 'e 1 thm d Inc W:W RI-SIDEN'TIAL MI?CII. SQ IT. Y
IJdin o"I r:t:e:nyanponahil11 in notify ocuparf �—
im t "I'M nt mcf phior no, a of a'e "I of( p` y.
Owne,conalmin .gent Date TOTAL: ISSUED I3Y:
OFFICE