S 2345 —APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPFRMIT PLUMBING.-MECHANICAL S 2345
BUILDING PROJECT IDENTIk'ICA9'ION
BUILDINGADDRESS'. SANITARY NO APPLICATION SUBMITTAL ONE I
2o6/o gode ae6 Ave. Capk 1, CUa 15-D !`/s -f.
OWN NAMH: PHONE: CON"N CfORS NAME: LIC NO:
�N ' Q„ ; p p/ NIC CO/NTNOLM
BE ITEC1'/Ii 1 TER: LIOC NO'. O A RUSS: LO
CONT/ACL (TH// ,EH �{/�Q{- BUILDING PERMI•I'I NFO
�J Su.YI 6Q1 C�fT'O�'J,/ /�lI Consultant Fees Paid by Applicant(Initial) HLDG HLECr PLUMB MECH
CY Q L�
LICENSED CONTRACTOR'S DECLARATION QTY ELECPRICPF,RMIT FEE
1 hereby anion that 1 am licensed under provisions of Chapter 9 Reinoculate JOB DESCRIPTION
O a00 with Sectimi7RNHnf Divi,km3 afthe Hmine,,and Processions Cede,and my here.is pEHMII'ISSUANCE ❑RESIDENTIALN :
Fr in full forceandoll«L rSFDWL ❑KI I CII EN REMODL'I.
U License Class Liah APPLIANCIiS-RESIDIiN'1'I Al, gANNE ION [_1 PLUMBING RI;-PIPIT
vim)Z W Bade—C amemr
p..pm
ARCHITECTS DECLARATION [j MULTI-UNIT ❑STRUCTURAL
O Z=Z I understand my Alam shall be e cd ard
s public reens PANIIIti
CHIMN Y REPA
ON
Ill"1'O BXIAMPS � V ❑IN)ERIOR ❑Cf1IMNEY RETAIN
¢yF¢�.qF.W Licensed lTofevsional 201-10NIAMPS IMPROVEMENT SWIMMING POOLS
y a a a Ireubaffin format I am emoula s and PruC Into N OVI?R 11X10 AMPS El BATH RP:MOUIi1.BHPAIR ❑DEMOLITION
OWNER-BUILDER DECLARA'1'1f
hereby n I soak I,icenve Law Ibr the
L7�(O L U follnwin Code:Any dry....only SIGNS BLHC'I'RICAL ❑OTHER
W W y which m4mms a permit to com uf6 alma.impm\'e-demolish,or repair any"arame
F LL•Oa lot In its issueare,olstior,mreslheap,hemlfor such pennonn file a signedswtemenl SPECIAL.q1RCUI TIMISC.
E�} that he is licensed pursuant to the provisions of the Contempt's License Law(Chapter 9
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP ME' li RPOLE INS r. COMMERCIAL: 1
that be is exempt therefrom and the basis for the alleged exumpunn.Any vialmion of NEW BLDGIADDITION ED DEMOLITION
.. Scene.91UI 5 by any aPPliwn(for n permit subjects the npplivum m o civil penally of POW ITR U ICES ❑THNAN'I' El 1:001)SERVICE
F^6 It.,dome than live hundred dollars($501M
as ussncndlhe pmpeny.,a uyaaEd rc,with wase,aOlteirsole compensalinn, SWIMMINGP I.It :C'I'RIC IMI'ROVIiMIiN'I'
❑ 11 oche cork,and the smad.mv,mol intended molleced for sale(See NW.Business xx ❑OTHER
go an
3 d Rnfes,ions Code:The Contractor's Liecnae Law dries not apply to an nwncf 3 UI LOTS-SWITxTURIS
Instantly ?l
roperty who builds or impmves thereon,and who does such work himself or through
his own employees,provided that such iatpmvemems arc not intended or offered far NEW RHSIDENTIA .)-,.'k SQ IT.
sale.IL however,the building or inumsclmem is sold within nitcyenr orcompletion,Lha SQ,ET.FLOOR AREA s/SQ.PP.
er-huiWu will hive the burden of pr...nectar he did n t build or improvl for pnr-
pasecf ante). (7
❑I,as owner nl the pmpeny,mm exdu.visdy nm0aning with licenced ennvmw
m �rs 'I'OT'A
ansaud the Project(sec.]DLL Business ane Professions Care:)l'he contractor's Li-
omemLawdoe.s not apply to an owner of property wbo bunds or improves thcmnn,and QTY, PLUMBING PERMIT FEE f�J
who contents for such Projects with a eontmeroos)licensed pursuant o the Contractors LJ
License Law. PERMl'IISSUANCE
❑ Iamexempl Ic ,13&PCfm t
AM FII-DRAIN&s`1N'I'-WATHR(BA) VALUATION
Oil 11
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO HVICE! �`
L herebaffi
ynn under penalty of perjury one ofthe following declarations: rD
�]I have and rill maintain a Ceribcate of Consent to self-insure for Worker's Compcn- DRAINS-1100 .ROO ,A ' CO•D.
sation,as provided for by Section 3100 of the lalasr Code,for the Essamonmer of the STONE:. TYPE CONSTRUCTION
for which this permit is issued. VIX'I LARES-PERI'NAP
[_] 1 nave and will Imtinmdn Workers Cnmpensouon monamc.as rcgnirerl by Scmlon
3700 of he Lobo Code.fnnhe O,I adurroffiev,k J...which Ibis pontiffs issued. GAS-PA,SYSTEM-I LNC,401 HU FTS OCC.CROU P APN
sly Worker n CulmsnvaBnn Insurance carie.Policy
Policy nonuser arc'. q��
Carrier: Policy No.: GAS-1'w\.SYSTEMOVEk 411iA) /J1(i-/1
GiRUFI�%IMITION FROM WORKERS'
COMPENSATION INSURANCE; GREASE%INDUS"IRL WAS IR IN'I ERCEPTOR
I11111.DING DIVISION hIAS
('His scc(ian need not beanttpldcvl if the permit is fo[one handled dollars($100) GREASENAP
or less.) PLANCHECK.ITE 0
1 ucnll'y Ihul in Iheperfnnmmw nl'Ihc work fnrwMah Ihiv permit is ixslnl,101,11
not employ fury person in uny munuer.rna.,to her re ufbecl lolhu WorkaNCmnp.m SI:WI!It-SANITARY-S'IY)IiM IlA.20f1 F9'. Y.NEIiOY FL!
O Z sation Laws ol'Califnraid Date WATER HEATF,R W/VENT/ELECfR CItAD1 ,F
.Z Applicant
.N. NOTICE TO APPLICANT.If,offer making IhL Cenificme of Estur ion,you should WATER SYSTEMITRF,AIING
h , become subject m the Workers Cnmpenvation provisions of the Labor Code,you must SOILS :'E
a Q InnhwiN emnply wiN such pmvisinns or Nis permit shall be Aeaned revoked WATIiR SERVICE O
Eli CONSI RUC'I'ION LENDING AGENCY NI:W REFI DENTLALPI,Mif SQ,PII PAID
U O l hereby atlirm that(here is a eomaodmnlenddngnsency torr the perfnnmmmc of Dam keceiPt#
is
Ne work for which Ibis pentad is issued(Sec.3099.Civ,C.)
0 1"I Lender's No d ) A
U Lenders Address [Al.
yI certify that 1 have read this application and slate that the above information is O BUILDING FEE
LF. t) correct.l agree to comply with all city and county mdlnamcs and stale Laws actions m QTY. MECHANICAL PERMIT FEE
UZ buudimemtstnlcdmt,nnd herenyauNmbe apsesea(arvevnthis city mannl upon the SEISMIC e
alb regioned prnpary fitrin,seflon P,aPoc, PHRh11'I'ISSUANCE
(We)agree to save,indelnnily and keep haonlevs the Cuy of C.Evm o"gains' a ELIiC ?h
liabilities,judsmenrv,costs and expenses which mayinanY way aecmeagainnsaid Ci ALTER OR ADD TO MECI. O
in nswimence of the granting of this permit. PL M Ff:E
APPLICANT UNDEkS NDS DWI.L COMPLY WITH ALL NON-1'(11. 7 AI R I IANDIJNG UNIT(11)10,010 CFM)
SOURCE REGUI IG (/f f//�/O/'/�t M; (CAI.rC
AIR HANDLING ON]'1'(OVER 10,000CFM) ) ,' RUCTION'I'
In
IgralumniAlIfilawromenittn Dow LNHADSTHOOD(W/PUC) D NGMITIG T3 I.
HAZARDOUS MATERIALS DISCLOSURE;
Will theapplicant ter future hoddingeccupamsmre or handle foramens material HEAPING UNIT(To 11Nt BTU)
as defined by the Cupenim Municipal Care,Chapter 9.12,and the Health and Safety .n(\
Crile,Section 25532(x)? HEAPING UNIT(OVER 100,000 BTU) I J J
Yes2q,711—
rn
� ,,� VfiN'I'lLA'1ION FAN ISINGLPAID Ii RRSID7 Dul,v Rccciplp
hazardous II the nppliomu ur luwra builtling wcupanl eve uluiprncm ur Jevlesa wldch10
air conmmimms as defined by the Boy Arca Air Quality Management BOILER-COMP(31411 ON 1000N)BTU)
�X,t'r cl? BOILER-COMP(OVER Batista BTU)
❑Yes BP-11
L Id Ire h sari n Is AIH CONDITIONER y rcrtu.nl. oder Chapter of C.li ISSUANCE DATE.
film H'llh&Sdety f S 25533' 55111 1 t' Jlhnl flhc NEW RESIDENTIAL MECfI. SQ.I%'. /
hand' ,d : (lyl I t I. y I '1 hlyl notify thep it
eflae rcqu'ry hob nus be foot t suancr.oyb CctWsuMvoff remit
TOT I
Ownerur naized age Dm� -: ISSUED BY: r P
OFFICE