S 23530
E
KI
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDP.NTIFICA'IION
PERMIT NO.
S 2353
BUILDINGADDRES S J' Is q i
VWI
SANITARY NO.
PP I'CAI'ON SUBMITl'AL�'I
V 3f j
OWNER'S NAME- I'HON1Ii:
�J j
CON/`''IRACfOR'SNAMGI LIC NO'.
N/G
❑
CONTNOLN
^�
ARCIII'T�1'/ENVGINFIR/ CNO: /
/)✓yi/
Ald)RliS A
`/P_
2 712-
CONTACT I P IpNE:
I p L
Consultant Fccs Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG _ ELrI-?-rCII PLI-U-Mr B MECH
LICENSED CONTRACTORS DF.0 .ARAI'IUN
y arm That 1 mit licensed umler provisions of Chapter 9 Qon carroumg
I hemhffi
QTY. ELECTRIC PF,RMIT FFE
JOB DESCRIPTION
I'IDRAfIT ISSUANCE
with sermon 7000) nfDivision 3,f me Business and Prefeashms Code, and my license is
in fall lured nail effect.
RESIDENTIA L:
❑SPDWh ❑KI'1'CIIPN REMODELREMODF
APPLIANCE?S-RESIDENTIAL
License C1nva Licp
etc Corrrocnr
;<ADDI'I ION ❑PLUMBING RED -1'11'13
❑MULH-UNLT ❑STRUCTURAL.
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT []SWIMMING POOLS
ARCHITECTS DECLARATION
1 undenland my plans shall he used m Public records
PANELS
UP TO 200 AME'S
Licensed It petticoat
201-1000AMPS
OWNER-BUILIABR DECLARATION
1 herchy affirm (hall nn excerpt Pram the Contractors License Law Ibr the
following reason. (Section 7131.5, Business and Professions Came c Any city or county
❑ FINE 11 RKMODI?l./REPAIR I] DFMOLI'rION
❑ OTHER
OVHR l0e)AMPS
SIGNS F.LFCl'RICAL
which acquires a permit m consumer. alcor, improve, demolish, or repair any museum
SPECIAL CINCI111YMISC.
Thar I I. :' 1 1 til pp 1 tf M1 n fl asigned .Trement
marl lad' n Ill P I II Contractor I - (Chapter
loom ' b 'a S r f I d :. ti f : Code)
ME:1'I"" OR POLL INS'('.
COMMERCIAL:
rI
,hot M1 pT Th t J Ill h I It,, alleged cu pl . A Y violation r of
. tit b
❑ NEW BLDG/AUDITION ❑ DIiM01.1'1'(ON
OWE
POWCR DEV ICI..
Sect 70315 by yapplicantfor a perinl object%the applicantt a civil pcnultyof
rn mom than five hundred dol Ian (S500)
E] 1, as owner of the proper,or my employdes with wages as Their sole mmpensatioq
mecmis eat inteedorommed I... sale(Set. 7044, answers
will donct work, anestmre M
❑'L6NANT ❑FOODSERVICE
t -i IMI'NOVFMENT. JO�!,ik�
KITH13k _��
SWIMMING POUL Ed ECIRIC
arilPml'esniuns Cale:'I'be Cnnlractar's License Law docs not apply In on owner of
OU'1'LI?'I'S-SWI'I'CHF.S-171X'I'UIdBS
such improvements and who docs umn tints ded o f m Ilrmugh
his own ..,c ccs, pm ding mitt such enskare not amerced or oBa¢d for
his own who hands m providedthat
sele.If. howm'er.the building orimpmvennm is sold within enc yea of cnmplminn,theSQ.
etherhadder will have the burden of proving that he did not build or improve forpur-6*71x
pas f: 1.)
I of the IY ly cantractial, with licensed Inn to
construct II project (S 7044 Business IP f .' : COLIC) ThContractors L'
NHW RESIDE?N'I'IAt. BLL'C!'R Sp Irl'.
FT. RWRARfiA
A '
EISQ.IT.
Z9 - I /
censeLow docs net applyt f proiTemy who builds p thereon, and
QTY. PLUMBING PERMIT FF,E
S(iOf
,1-umTmus formula pngens with a conrmeror(s) IicenseJ panuannmhe C ntmemh
PER TISSUANCE
License Law.
E]lam csmmpt under Sec. ,13&P C fit Ii, ream
•-Fee-y1/
�3I�7`�
Owner Dine
Al, . -D AIN&VENT-WNI FR(Elm
VAIDATION
WORKER'S COMPENSATION DECLARATION
HACK FLO R .DEVICE
I hereby affirm under penally of perjury one of the following declarations:
Q 0
❑ I haveard will maintain nCenificam MConsem mself-more far Worker's Conimn-
efotounce h
,anion,u....sided fnr by Scents, 3700uf t he Labor Code, on file pr of the
DRAINS -RO 00 RIiA, COND.
51'ORIP_S TYI'FCONSTRUCLION
FIXTURFs- 'I?R'IR P
work it,, which this actual Pa Issued.
❑ 1 have land will maintain Workers Congmn a ion Insurmme, us requirW by Section
3700 of the labor Code. for the Performance of the work for which This permit in issued.
GAS-EA.SYS'F 1-IINCAOUTLETS
OCC. GROUP
APES
My Worker's Compensation Insurance carrier and Policy namher arc:
Carrier: Policy No.:
I GAS -EA. SYS'IHM OVER 4 UUO
(IREASL/INDUSIRL WAS 'I'H INTHRCFPTOIt
CERTIFICAI'1; Olr EX13MP PION FROM WORKERS'
COMPENSATION INSURANCE
BUILIIING DIVISION YI?I?S
CI'hisseaiunneeA not hecomplemdlf9hcpermitlsfnnmchundreddnllun(411X))
or less.)
GREASETBAP------
--
PL, NCHFCK FEE
51300ER -SANITARY -STORM IDA. 2(111 fits
1 cenify matin The perform areemme work far which This pemur Is issued, l shall
not employ any person many uannerso as w become subject lac the Workcri Cnmpen-
13HG '17
WA'I FR HPAI IR W/VFN'1'/1'.1.FQIR
union Laws of Calf .arla. Lae
Applicant t
DING FEE
N(yDCE'10 APPLICANT: IL after making This Certificate of 1?xempti ar, yen ehouW
become subject nr the Worker's Compensation provisions of The Labor Code, you nun
WgTF.R SYS'1'IiM/1'REATING
WATER SRRVICF
forlrwith comply wimsneh providearsarthis pemrit shall be deemed revoked.
CONSTRUCTION LENDING AGI7NCY
I herebyuBinnlhanhem is anmametion lenmagagamy haunt psrformlanceof
NFW Rf..IUI?NTIAL PLMB. SQ, 1'I'.
are Receipt#
WIA
the work for which this permit is issued (Sec. 3097. Civ. C.)
Lender's Name
TA
Lenders Address
A -
Bonus.
I cenify that I have read this npplfeation and ,am Than the above information is
QTY. MECHANICAL PERMIT
I agree m comply with au city and coumy orlimneeaand smm lawsariafmgm
eom0achom, and nercnyaadrod.e rearesemmivestnm. nD mercer aLa, mo
above-nmmiomed property fur inxpemion purposes.
(We) agree m save, indemnify and kap harmless, the City of Cupcmimn against
1,Obladehrg
7
1'13RMI3' ISSUANCE 3 /
ELECf 1 'E
ALTER OR ADD TO MECIL
it
PL ARE FEE
Iiabilifies,judgmenT.s, costs and expenses which may in any way Verne against said City
in nscyuence of the Stuart ng of this perrrrit.
AB2 fiANULINO UNIT (TO 11/01111 CPM)
E'ICAL FEE
I N
APPLICA 'L UNDP :'LANDS AN D WILL WITH DLI. NON -POINT
$Ol1RF ) S.
AIR HANDLING UNIT (OVER M." CFM)
CO/Sl RUCTION TAX
EXHAUST 11001)IWNULT)
H SING MITIGATION FEF
S ApplicantlCnntramor Dec
HAZARDOUS MAI HRIALS DISCLOSURE
I IIDATINC, UNl'I' ('I'O 100,010 BTU)
Will the applicant or firm huddiog... ...peal more or handle hosanlon. mu¢dal
Code. defired M1y the Cupertino Mtmicipal Cale, Chapter 9.12, and the Hevhh land Safety
Section 25532(a)7
1117ATING UNIT' (OVER 100,0001 BTU)
E3 Yes ❑No
PAID
Date Receipt e
VENTILATION FAN (SINGLE BUSED)
BOILER-LUMP(3HPOR u),000 BTU)
Will the appliaamor Bruce building by he ay Arco Air Qulil, Mucti n....
mit M1uuvdnus air enmm�tinmvs as dcfitmA by the Bay Arca Air Qualify Mlnmgnnan
District?
❑Yes FIN.
AI
[TOILER - COME' (OVER 100,000(ITU)
AIR CONDD40NER
I hove read the harme, Se materials 5, Z5533l i under Chapter shu of the Cali-
forma Hrdlh & Safety Crate, Semitic, Recall,
does 1, drar, Mr, laid 255.341 umeeny h rnn if the
lucent, real it is
currently havroom Ceniy to notify Lha
IS!!lSIIANCF„1JA
Y
NIDW RI?SIU(?N'1'IAI. MECII. SQ. PI'.
li ua ce it a pancpnm
of me r �yuirenrems which nota be mer print m Issuance oft Cenificvm of Occupancy
ofre to
ISSUED) fly: �p
Owner or authorized agent Dam
OFFICE