S 2368 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'I'YI OF CUPERTINO. BUILDING.-ELECTRICAL ...7
.R.%IIT N0,
IOILDING DIVISION APPLICNI'IONIPLRMIT PLUMBING-MECHANICAL S 2368
BUILDING PROJECT'I0EN`rIFICA1'ION '
BUILDING ADDRESS SAN1'1'ARY NO. APPLICATION SUBMI'MAI,DATE
OWNER'S NAME: I'IIONI3: CONTRACTOR'$NAMIi: LIC NO:
tG4IOG ` NIC CUMI'NOLK
AR /CII/ENGINHER: . _ LhC N( ADDRESS ❑
CONTACT: �/''P IONE: IUILIJING NERMITINFO
30� %�0orn Jb9aill -+5 IN-64000 ❑ Consultant Fecs Paid by Applicant(Initial) IIDG EI.FCT PLUMB MIiCH
A ZL,
LICI?NSIiD CONTRACIT)R;S DECI. RATION Q�-y IiLECTRIC PIikMIT , Plili 'r
1 hereby a1Bmt Baal 1 ant licensed ander proWsinns nr chapter 9(cm......using _ JOB DESCRIPTION
BOZO with Becton]W01 of llirision3of the Businexs and ProfeseinnxCde.and my licence is PERMITISSUANCE RESIDENTIAL:
F1_ in full Este and ettecl. ❑SIDWI. ❑KI"ICIIEN REMODEL
as U I'a Licenw,Class Lie.p
Q I15IIlEN'IIAI. - ❑ADDITION [I PLUMBING 107.19117iFZW Dnle Conaaemr -
AHCHITECT'SDI!CLARAI'ION ❑MU[J'I-UNIT ❑STRUCI URAL
Zboz Werse td my,lanssh.11 Famed in,add,m..Ns IANEIS MODIFICATION
OZ � UPT02(NIAMPS ❑INERIOR ❑CHIMNEYREPAIR
F� W Licensed Prof ssinn' 201-1000AMI'S IMPROVEMENT �SWIMMINGPOOLS
r'v Lireroc law f r Ihv
OWNER-BUILDI!R 111?CLARA'I'ION OVER 1000AMPS ❑BA'I'1]REMOINHU IEVAIR ❑DEMOIIHON
1 belt nn thnr am xnnpt.torn the Cnmrurn
...
COMER llnwing reason.(Saturn]031.5CBusinmxsmadHC,A,Aav oiyot SIGNS ELECIRICAh
which mimprove,demolish, rreparanyMamomc
prit . 1. Inc ap'licardbasalt pen
fl .6 Jvaement SPECIAL CBCUITIMISC.
}
that m is licensed ptt the prokions(ifth Cot ct License L (Chapter9
�y1` QC) (u,nmrngw'th Suet 7000oofOv.virt lufam lfu. tus.', IP (:.' 1Cn]a)or 'ILMP.MIi'fLIi OR POLI:INS'I'. COMMERCIAL:
0.y o p that Ice is me,npt himot r unJ We basix Iia Wdnlleged exentp.iun.Any vinlutlon of ❑NEW BLDG/ADDITION ❑DIiM01.1'I'ION
W..m Sermon 70315 by any applicant fnr a permit objects the appllcrmt m a civil Mpub,of POWER DEVICES _ ❑TENANT ❑FOOD SERVICE
not me'hall live hundred dollars(SSW E
FZ} IM1fI'kOVC•MFaNT
Q ❑Lo the work,the pmpeny,mmyempleyres troubled for
astheir(Sec. 044,Rsetion, SWIMMING IYIOL F.LECI'RIC
p5.� will P the work.and C.1c 'sw Cita is not,I.i,cintended umfw dot,or srI apply.]IWi,Business ❑OTHI?R
�-. and I'rulees,mns Cale:'I'Iry Cmnnrrnrn Lirense Law anus Bol apply oil air owner Old'FLP.TS-SWI'I'CHP_S-FIX'I'UNI?S
pmpcny whn builds or impntvos Ihrenn,and who does such work himself(ir Ibmvgh
his.,it entplvyees,prnvidcd that such improvements cru not intended or commit for NEW RESIDENTIAL,EIJim R SQ En
,all,If.hnwcra the bulldingorimpmvement vOmId within nneyeunf contplrivgtbe - SQ.FT.FLOOR AREA _ VSQ.FI'.
owner-builder will have the burden of proving that he did not build or improve fnr pur-
p aac of sale.).
[] I,as owner of Pn,per'.am excbrnivdy amhxring win,filcAcd lout, nnc Io JIM,L:
,.aslmet Bae pmjev.(Sea.71114,Bmsinexs sad Pmfessiona Code)The Conoacwr's Li- -
Iselawdocsnmupplymhn�wnernfpmpcnywhnhuilesnrimproveslhc,n,n,and QTY. PLUMBING I'1?RMIT. FE,
who contract for such projects with a contmcmr(s)licensed pursuant m the Commeors
License Ltw. PERMIT ISSU CE
❑ I ant cscmpt under Sec. ,B&P C for this reason
ACFER-1111 +N'I'-WSJ'1?It(EA) VALUATION
Owner Bloc
WORKER'S COMPENSATION DECLARA'I]ON RACK FLO 'R ' .IlliVl -
1 hemby affirm undor Penahy of perjury one of am following decBnnili UP
❑ I have and will maintain a Cenificate of Consent to Al f-intim for Worker's Compact DRAINS-FLOO ,.Rli A STORIES TYPECONSTRUCTION
,tion.m prnvidcd for by ScOion 3]W of me Labor Code.Ibr the o..of of the --�
work lir which arts permit is issued. Q FIXTURES-HER TRAP
I] I bone a al will maimuin Workers Cnmpcmation Insurance,as required by Section
3700of the Lahr Cale,fnr the para,rmwce of the work for which this panni.in:Dual, CAS-IiA. -11 'C.41
SYSTEM1U'I' iT5 OCC.GROUP APSE
My Wolters Compensation Insumme comer and Policy nn,nbe,are:
Cancer: PNicy No.: GAS-EA.SYSTEM-OVER ' ]
CERFMCAI'F.OF EXF.MM ION FROM WORKERS'
COMP17NSA'I'ION INSURANCE GkEAMVINUtJS'I'Itl.WAST'.:INTERCEI"FOIt
ll [,l DIVISION 19?E3
1'Ihie scctivn nnN nut hecomplete,.it dao prat:[ix ti,r'nnchundreJ dollars($1 W) GREASEI RAP
or EEY PLANC I.
Ipettily Ill., i any Dh kf 'h ata the
i:urs'C shall ShWER-VANITARY SIORM FA.2IXI F1'.
not ply yPerson' y t h rat subject tIh W k C open F.NI Y .i o
Z ,� AM I fC I fnrr D t WATCH IIhAI'hIi WIVI NTlla.l CI'N m
C Appl I - GRA G IEE
y NOTICL IOAPPLICAN I If,due,making acs Cen'ftic,l lbscraquion,you shouldS...VM?RCA'FING
h ; beeomc subject to Ne Worker's Compensation provisions of the Lahr Galt you must S 4S pEE
W forthwith comply with such provisions or this permit shall be deenred revoked. All
WATER Cli
aQ
CONSTRUCTION LENDING AGENCY 11L1NtiW RESIUI: 'IAL PI. SQ,FE P U
�-x"r Ihurchy affom that theft ixnrnrvmatinn lwdmgugcnryf the perli�rnrnneu or Dom RecviplK
U. the word fur which this peand is issued(Sec.3097,Civ.C.) C
0Ill. (•'r tender's Name Ll _ TOTAL:
Lender-sAJdm �sx TOTAL:
yI certify that 1 leave mad this applicationd state but the h l( tion' BUILDING ILL
In corn t I g t ply II II 'ly IY 1' I:rt I' i g V MECHANICAL U'., Flili
L) Z bui1hil tdneirnu lliclehy nutan yreenlif sJlhscty nems.[upon the . n SEISMIC ITI;
abnvnmcntinned property Iia iospocrom purEea' O
(We)ag,re m calm.indemnify and keep hornless the City of Cupertino against F.LGC'TRIC FEL
haallicro,jadgments,rn I and ex es whichmayinany wayaccmeag,i,wI,mdCit ALTERORADDTO MECI. 2 '
in conseymence of Ne gmmi of is permit. PLUMBING FHP.
APPLICANT'UNDERS'D NOS ND WIL1.COMPLY WI 111 ALL NON-POINT AIR HANDLING IJNIT CTO bo'hoo CPM)
SOURCE IIF LAI'IONS MECIIANICAI.FEE
AIR HANDLINGUNM(OVER 10,I0f1CFM.) CONS'FRUC1lON TAX
I
SigVScc,i.n
can Cumu for Dam EXHAUSTHOOD("MUM) HOUSING MITIGATION PER
11 I'AIJI QQUS MA�T�IRIALS DISCLOSURE
ppacentorfmuTEGngosnpant Mom...1, 11.amardaus nmtc,i,l 1117 [INC,UNN(10100.00110IU) -
as Cpcnino Municipal Cale.Chapter 9.12.and the Heald)halt Safety
Co532(h)'J I BATING UNII'(OVER IW,000 BTU)
01'es LJ No PAID
VGN'I'lLAT10N PAN(SINGLli FEES[Do Date Receip,M
Widou'riapplicant ormmm building walliby but ntyArea ,,cat c,QJoh,y Mona which BOILER-COM I'(3HP OR 100,00I[ITO)
mit hlvurJnus lir comuminums M ddincd by the Bay Anxr Alr Qualiry Mnuagcmem T
District? BOILER-COMB'(OVER IINLINNI BTU)
❑Vca ❑No
1 have mad the bu mmmriak myuiremene under Chun.,6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomiu I Iohlih&Safety ale,S coons 25511 25533 and 25534.1 undersaed Ihnt if the NEW BESIIIENTIAL MECI I. SQ.PI'. Cl
bit 11 dnm'rmt enact ylmv mm�nnl,lbw ilk myreslxmnihililymnoifylhc,x'vupnnl �(� 2— Z �L
of
nentx whirl ern be mer primrtu ixsttananfa Cenillcamo Occopency. o
Clete oI aJ,11116riscito, Onm T AL: ISSUED IIY: I _
OFFICE