S 2649 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RU I LUING-ELF,CI'RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMIIINC.-MECHANICAL C C /� (�
BUILDING PROJECT IDEN'IIFICA'I'!ON J 6 4 9
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMIT'T'AL DATE.
' Z243 Rrsssieq-STntl 0R. I'D M NO i C1601
E' O� PH(. )/91::� CUN'I'ItACTOI;:S NAME. LI . f
N/C CON'IROLB
ARCHETEC1'/F.NGINEF.R: LIC NO: ADDJtEs ❑
CONTACT: PHONE. ry BUILDING PERMFI'INFO
Consul, I Fces Paid By Applicant,Hifidal) IILDG EILECT PLUMB MCC"
Akooun AnOf ❑ ❑ >L ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEF.
1 hereby n iimt Ran 1 am rcenxul coder prwisiom of Chupmr 9 rurm lancing ' .1013 DESCRIPTION
WOO with Section]pODof llivisii Sof he B"am'sintd l'ra visionsC^odgv Jnhy lic<nseis PERMIT! RESIDENTIAL:
in lull force and cR o� ❑SFTIWL ❑KITCHEN REMODEL
tX U i- Licensa Lic.M
QZV L�Cammcur APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-PIPE
uu a Dale
ARCIII'I IiCT'S I3ECLAItA1'IpN ❑Mllhfl-UNIT ❑SI'kUCTIJRN.
FONm
PANELS
ZO91p lundermand my plans shalt he used as politic records MODIFICATION
OZ=� UPT(121XIAMPS ❑1SUzIUOR ❑CHIMNEYRITAIR
F-ti t'w Live oil Pal...ul 201-10X0 AMPS IMPROVEMENT ❑SWIMMINGPOOLS
Q $-1 OWNER-BUILDER DECLARATION
5 a' OVER 1001AMPS El BATH REMO3EIA EPAIR [I DEMOLITION
D U 1 hreaso .(Sect that 11. cBanpt lions tba Connmmr's License -uw Iia the ❑ rD n -A�& a!£h ICIER
d following uirenn.(Section 90.1t.5, r,alter Businessland Ive,d suns Code
at Any city nr umntY SIGNS Bi.ECTRICAI.
w 3 w H white regairex a permit m consumer,alcor,improve,demoe.h.or repair any amnare _F GE/4 al-Jr t�0
0I anon in its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT/MSC. C24&cliaLl9;o4-
�y vthaislicensedpersonnuothepnmisioreoflheContractor4l.iccnseLuw(Chnpter9
U
gp0 @ ..... ingwith Sectlnit 701()of no,kion Sof the Basinus an.IP r,,ion,Cvao)., '[EMP.MISI'EIO OR 1101,17 INST. COMMERCIAL:
t1 G c C (hat be is exempt there0om mid due basis for doe alleged eumption.Any vinlation of ❑NEW BLDG/AUDI'ION ❑DEMOLITION
km_u• Section 7031.5 by anyappliecia fare pemi
rtsubjects them
appiicaat a civil Penally of POWER DEVICES
w m not more than five hundred dollars(S51X0. ❑TENANT ❑FOODSERVICE
F z} IMPROVEMENT
Q ❑ Lidewoowner
k,Ue the mall my employeedo,onedt agesrel o,ali solern4,Baoiin, SWIMMING POOL.131.13CTRIC
P�,O wilone dilh,sion,C o Creuemnr isnot,Licenseovdoesnin.,Sec.]0an owns,of ❑OTIIER
and Professions Cudc'ITe Conwnora License haw docs nm apply m un owner of pUTLE'I'S-SW1'I'CIIES-PIXY S
property who builds or impmves thereon,and who does such work himself nr Ibmugh
his awn employees,provided that such improvement,are out intended m offered for NEW RESIDENTLLL EU!CfR
sale.If,however,the building or imprivemenlla sold withinnnc ycurifeonarelion,the SQ.FT.MOOR ARBA V.%Q.1-1.
er-bvllder w111 hove the harden of proving Oriole did not hn'dd or iahpmva far pur-
pa c of rata.).
❑L to owner of the property,minexclusively contracting with Licensed smarm n,Int TOTAL: _
construct the project(Sec.TBW.Business and Professions Code:)The Contractor's Li- -
ansalawdoe,not apply to an owner nfpmpeny who builds or Improves Parent,and Q'I'Y. PLUMBING PERMIT FEE
wan cvnlmds for,acn projects with it commmnds)I eansetl Pursutmt nth the Cana rnetors
Liccnxc Law. PERMIT ISSUANCE
❑Ivo exempt under Sea ,B&PC fanhis roman
ALTER-UR(Uc1,�YliCIT....W6TER.(lipy- VALUAfI(1N
Owner Dale
WORKER'S COMPENSATION DECLARA'I'(ON BACK FLOW R I EC I�V eVICH
�I I hereby affmn mike penalty of Perjury nncnftne fnUnwing declarnrons - 50 , 00I k)P. 1'
❑Ihaveaad will nuhionar.Cenifeatnof Camtt
enoself-insure for Worker's Coope, DRAINS Nh R( AREA.COND. S'1'0RIES 'TYPE CONSTR UCRION
smion,as provided lar by by Section 37M of the labor Code,Births performance of 0e I
work torr which 0is perm is issued. EST URI3S- R'I'RAIu� Y 0 7 1999
❑ I hove and will maintain Wroak"'s ComPcnsnhm Insumnco,as regnired by Section
3700 al the Labor Code,for lire performance of the work for suds ilia pemdtlsisssuued GAS-13A.S 1!1E10-1 INC.40UTh7I1S OCC.GROUP AI'N
My Wnr C u u WPalic' -yuXOI
Cam'cr. rICAI EXEMPTION FROM
SIL�ILL-F.�/1"vad GAS-EA.S 5 .M.OVERi(BA)
CF.R'OFICCO EXEMI'N INSURANCE
WORKERS' Fit
COMI'IiNSATIONINSURANCIi CRIiASIJINi STRi:•WAFTF.HMT+iREiiATEBt
tlIIILI3INO DIVISION PERS
IThissection nec:6nm M:wmplmed if the pcmhit isfonmchundreJ Jnllnm(81(q) - -' - - ' ---
or Les,.) GRPSE'fRAP PLANCI II7CK FER
I cenfly0al in the per!onnuneeo!the work for which Uinpennit is issued,l shall SEWER-SANT fFARY-STORM EA.21X1 FT
not employ any pmsnn in any manner so as to II a subject to the Workers Coolant ENERGY IEE
C) Zi s,nion Law,of Csfi1 in.Date ' WATER IIIiA'I ER W/VIIN'I'/IiITCTIt GRADING ITEApplicant
NO]ICE TO APPLICANT.If,after making this CcNficme of Encmplion, an should WATER SYSTE OKHATING
7 becnnte subject to the Worker's Compensation provisions of the talar Code,you must SGILS FEE
forthwith comply withsuch provislmmor this permit shell he devowdesvoked. WATER SERVICE
Q
CONSers,,aI ION,unamuENDlNG AGENCY NEW RESIDENTIAL NUMB SQ FC PALO
L)Q (hereby a(Brm that deris uenn,wminn leach ngagency for Ueperformunce of 'Dalt Iiceciplp
the work for which this permit is issued(Sec.3097,Ci,C)
U Lender's Name TRIAL:
O es
W LenderO's Address TO
I certify dual I hove read this application anal,Into thw the above ink omnation is BUILDING FEE 8L I
aV]s correct.l agree nth comply with all city and conmy ordinances and stale laws resting to QTY. MECHANICAL PERMI'P FTE
V Z building construction,and hereby authorize representatives ofihis city to enter upon the SEISMIC TEE
rivia,mentioned Pmpeny for inspection Purposes.
(We)ngrceersave.indcutnify and keep hunnlexs UO City of Cupertino again', PERMIT ISSUANCE ELECTRIC FEE _
(fist ilaicypstftnnM,cost J expenws whlchmvy in any wuyuc,me against said Gly ACD7R OR ADD TO MEECH.
nnsequenceof Ue ming his permit. PLI]MBING FRR
APPLICANT UN <S' S NUACILI•'Ok1 WITH ALL NON-I'OIM' AIR HANDLING UNI'I'(TO IU.fXXI CPAP)
S(IURCF G ' .I' MECHANICAL FEE
AIR HANDLING LINE'1'(OVER 10.000 CFM) CONS1RUCTION'I
Sign rc of App tCnnwe r Bum GXI3Al15'f HOOD(W/I311CT1 HOUSING MITIGATION E
IIA9.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material BEATING UNIT(TO 100,000 BTU)
m defined by the Catrnimr Municipal Cade,Cupar 9.12,ant the Health and Safety
Cale,Section 25532(x)? HEADING ONE"P(OVER 100.00111111)
C]Yes n VENf11.A 1'ION FAN(SINGLE RESID) PAID
. - Doe kcttipl a
Will the indeirr vnlnr moreamrsa Willing by he BayAea Air rra or Qcahty Minnuennwhich BOILER-COME(311P OR 101000)BTU)
mail hvnrdaus air enntutninanu as defined by the Buy Area Air Qunllty Mnn:tgetnenl (1'1.
Dlevim'Iit,❑Vey &oBOILER-COMP(OVER 100,000Bit'U)
1 have read the hvardnm all requirements under Chapter fi 95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
bruin health&Safety Code,Sections 25505,2553,1 and 25534.1 understand that If the NRW RI!SIDENT1At,M1iC H. SQ.Fr
hnddingdocsnnlnm tlyhe t hat it In my rexporvsihllkyonnOtythcuccnpant
of tilt requirements alct p orC c n,Beate of Occupancy.
Owntt nr auUorirvJ g Date TOTAL.: ISSUED I1Y:
OFFICE