S 2836 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI FUCAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2836
BUILDING PROJECT IDFNTIFICATFON
BUILDING ADDR13-S ft SANITARY NO, APVIJCAI ION SUBMI'IIAL PAT'h
O vzNAMP PIb G: I e0 CO TRAGI"Il 5 NA ISE. -C IC NO: 411'41 R4
' L �(�yl �w �^ O NIC CONTNOLp
trW„CIPTECUENGINEER: _{VrJI LIC NO: ADDRESS: l ❑
G .O111
CON'TACD PHONe: BUILUINO PERMIT INFO
U 40
371 2� ❑ Consultant Fees Paid by Applicant(Initial) BO Ia.t❑l PLU❑l MEH
LICENSED CON'IR OR'SS D[CLARA'1'ION QrY. ELECTRIC PERMIT FEE
m,m
I hereby arum L am lieen,ed under pro lot rs or Client,9(c mourndmg JOB DESCRIPTION
D0Z with Section 7f)(lof Division 3of,be Business and Professions Cale.m,d my license is ID TI
WOO PERMIT ISSUANCIi
CSF AL-
in lull force trod effect. ,,� SPDWI. Ll KITCHEN RIiMODEh
QUU Liceden Clac% � I.icN APPLIANCES-RESIDEN'T'IAL ❑Al3Dl'lION ❑PLUMBING RI PII'li
y¢{{f
Core Coollacu,[
�m ARCIBI'IEC'FS DFCLA ,TI PANELS ❑MULTI-UNIT STRUCTURAL.
Z p H Z I understand my plana shall be used as public rcc MOHIIICAI HIN
OZ�C UP TO PINI AMPS I�Ip7ERIOR ❑CHIMNEYREPAIR
F+`3 k"LL1 hlanecd l'mfu%ional 201-1000AMPS / IMPR(IVIiMI?N'f []SWIMMING POOLS
Q S� OWNER-RUILDF:R DECLARATION aY ,� dic OVER talk)AMPS ❑PATH kI!MOD-1,RE'AIR (]I3EMOIJTION
�C uau11 Q I herchy aBlnn on I am exempt from the Climate,C's License Law for e,
(iFryi.5 i q U following renes.. ,min a 90.31.5,Iiu,incsx and improve.
de io demolish.
Code:Any city or wmnY SIGNS ELEC'I'RIGI. ❑OTHER
B+3 q h pri I inquires a permit c ta,nmmm,aper.improve.h permit t fie a sig any atement
Fq.�¢ Thinr m,E,rr 1,m,xomgnires theapplir,ol tie such permit Bleoei Lew
PIECIAI.CIItCU1T/MISC. F/ le-
Than
0
W .4 mhnt he ix li¢nned purnuem mthe pn,viaicm nl the Cnnv4ctot^v Lianm Law[Chopmr9
CC) (commm�cing with Section]O(10)of Division 3of,he Businnsand Professions Code)nr THIR MErGk OR)'OLE)NST. COMMERCIAL:
tl:t,he is exempt therefrom and the nisi,fur the alleged tsturn ion.Any vinlminn of ❑NEW BLDG/ADDITION ❑DEMOLITION
W rn SCRion 9131.5 by anynppllcant for a penal-leeeu the api,icimun n civil penalty 0 POW17R DEVICES 01PNANT ❑FOODSERVICE.
sot more than five hundred dollars WOOL
^Z> IMI'kOVIiMCN'I'
6 ❑ Lax ownerof nd pmpeny,or mycmntendes withwrge%an tnei(Sid- d44,B smc%s SWIMMING I'OOLIiLECBIC
�px.,q will do the work,and the stmnurcis not imm�Jca,Lawbahorsisalc(SccJ044,I3usinc,s t ❑(1THEk
pj m and I'mfeasions Calc:The Comrac¢,rs Liam,Law Jres air apply m an owner of OU'ILLTS-S ITCHES-ImIXTOkES
q'3^ pmlmrty who build'or imnpmvea(minm,obit no Ancx such work pinm%clf tar throuel
hi,own employee.,,provided that such Emprovemems arenm imenJcJ or nlTcreJ lie : NEW It ENTIAL ELECI'It SQ FT, f,
sale.If,howour,the bonding or improvement is sold within one year n(cunmplation,the FT FLOOR AREA ED
$ FT..
urhuBder will have the burden of proving that he did nen hold or hnpawe for pat- 61�27 APR "r 199 pecofsale.).1,as owner of the property,am exclusively contracting with liecmed u,mraaon In at
msaueT the project(Sec.9014,Beene„.,at Pmreexions Ced,,I he--o—e-
ciaorlaw does on apply to an owner of property who build,orimproves thereon.and QTY. PLUMBINGT FEE
who contracts for such projects with;,cometen s)licensed pursuant n,the Content50 B
License Law. PERMIT ISSUANCE l
Y
❑1 am c.empt under Sec. .H&P C for this reason
Owner Date ALTER-DRAIN At VIIJT-WATER(EA) r 30 VALUATION
WORKER'S COMPF.NSA'1'ION DECLARATION RACK FLOW PRIHTCT.DEVICE /5,060 O fit
I hereby alBnn under pcnahy of periu,y one of the following declaration%:
❑ I havemed voll moducali Cermirric,4Consmlln pelf-insure for Worker's ComPen- DRAINS-FLOOR,ROOF,AREA,COND. TYPECONS'I' UC'I'ION
sation,as provided for by Section 3711 of the Labor Cale,for the performance of the STORIES
ark for which Die pe alfa is issued. FIXTURES-PER TRAP 1//
I have and will meirem.Weaker,Compcnsmian h aumnac,m eaftered by Section
3900 of the Lothar Code.((it he perrmmance of The work forwhich this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLET'S O ( C.GROUP APN
My Wxrka's Cmmrcioun,Inxunmuc carrier unit Policy muntbe,aro 3S� 03
Carrier: Policy No.: GAS-8A.SYSTP.M-OVL'R 4(LA)
CI7RI IFICATE OF EXEMPTION FROM WORKERS' �3
COMPENSATION INSURANCE GREASPJINDUSTRI.WAS'Im LPfO
I ENG DIVISION II!IiS
('Ihissemisn neednm becompincJ ilthcpermit is foronemalreddollar,6110I) GkEASETRAP
or less.) I'LANCH
I cemythat in the PeOunce ecofthc work fit wI ichlfii,prr...t is issued.l Shull 511WIiR-SANITARY-STORM IIA.- PL'.
not employ any person in any manner m a , j;et to The Worlal Comped- Ek iE
Z anion Luwx nf6 Date c e WATER IIItATt?K WIVP,N'I'/ELECI'R
O CItAI Ify�
to
O Apphcaat ria va
NfyrICE TO API'.I( T.If,aper maki this em¢me of Emmp.on,you should WA'11!R SYSTEM/1'RF.ATING SOILS PI',
ahunme nub'Iccto t Workers Cnmpcnsution pmvisioneof the Tabor Cod.,you moot
W pmhwith rnmply nh such provisions or permit shall ledernmd revoked. 3VNFI7R SERVICE
0. Q PAID
CONS, NI!W RF.SIDEM1'IAI.PLMB. SQ.FI'.
U Z >um Itcu.ipt M
W. O l for
thi pcmatI ata ed TSect 30 len ding ugeney for the pcdi,rmancc nr
C)W. H the work rat which ami,permit is iewW(Sec.3(19].civ.C.)
lender's Nauru
Lender'e Atklrcs. 1 BUILDING PEE
1 certify that 1 have mad thin application and site that the ddoc information is
�., IA correct.lrgmen,comply with all ehy and county ordinances and state laws rchning To Q'(y. MECHANICAL PERMIT FEE
U Z building ennstoaction.and hereby aubmire representatives of this city to enter upon the SEISMIC FEE Q
above-mmniomed Inopeny for inspection proposes. PERMIT ISSUANCE
(We)agree b save,inderaddy and keep harmless the City nl Cupenlnn agulnet ELECTRIC PEG
IiahElEtics,juJgmems.ca<t.e and e.pcn,es which may many way.aan¢agaimmmid City A[A ER OR ADD'IU MECIL
PLIMBINC
nwmarce ofthegranaid,oGo, .FEL
APPLICANT UNDERSTANDS AND WI/Ly/D//[.'OMP1/LLYY/.WITH ALL NON-POINT ABR HANDLING UNIT TO 10,000 CFMJ
S( . IEGUTATION' r, (-+�-I �' MECHANICAL IIiE U
P F AIR HANDLING UNIT(OVER 10.00CFM) CONSTRUCTION TAX
Signa. c IPI,pImCantlConlmeler Ilam EXHAUST HOOD IW/DUCq HOUSING MIT[CATION FEL
HAZARDOUS MA'I'IRIALS DISCLOSURE
Il The applicant or future huilmageactTannoreor Iodate Incomouv mamriul HEATING UNIT(To 100.001 B'1'U)
u%de d by The Ceh emino Municipal Code.Chapter 9.13;and the Health and Safety
Cole.Section 25532(4)7 HEATING UNIT HOVER 100,000)ITU)
❑Yes IiNTILATION PAN ISI NGL E RISID) LQ PAID
Dom Receipt N
Widths it co ami Tums building by the BayAna a. Air vol Quality
Management
BOILER-COMPOHP Oil 109,100 BTU)
emit hazaNsus air contaminants as defined by the Hey Arca Air Vuality Atanagemem 1(
14
Di uicN BOILER-C)MP(OVER 100100 HTU)-C)MP(OVER 100,00 HTU)
❑Yes No
I Ison tithe hvum allainkedpintown,under Chapter 6.05ofmc Cali- AIR CONDITIONER ISSUANCE DATE
R min Health&Svrdy Cock.Sections 25505,25533 and 25534.1 understand thin it the NEW RF_SIDFNTIAL MIECH. SQ.FI'.
build nsmutremlyhwcamnant.the it is my rcsrymsihiliymnotify Tpc mecupam ZZ_�.R
nith•re, orn vvIodT m1 ITTuf n Ceniibeta (a
Owner ora Kori d agent ` )u e T L: e L ISSUED BY:
OFFICE