S 2767 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECUANICAL (�
BUILDING PROJECT IDENTIFICATION J
2767
BUILDINGADDRESS: �r SANITARY NO. APPLICATIONSUBMITTALDATF
,4N Ave
OW�NLB'S NAME: PHONE) CON'I'RACrOR'SNAME: LIC NO
/1 O S NIC CONTROL#
ARCHITEC /ENGINEER: LIC NO: ADDRESS', El
CONTACT: PHONE: BUILDING PERMITINFO
Of esTe C40.4a,N t `SO S9j,;2 9s ❑ GOnnaltant Il Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
LICENSED CONI'RAC'I'ORS DECLARATION QTY. ELECTRIC PERMIT FEE
hereby affirm mut 1 an licensed under provinimm of Chapter 9 mammaneimg JOB DESCRIPTION
woonwz with Sevinn 7FB)of Division bathe Blionessvnd Professions Code,andoninenscis
Y / RESIDENTIAL-
in W 6O in full force and erten / PF:RMI'I'ISSUANCE
E-U rFj License Cless � Can,' ❑SFD EH ❑KI PLUM DUTIESREPIPREMODEL
y7[cl Dmc ,�—a.) - t / Can,'. APPLIANCES M APPLIANCES-ItE.41D8NTIA1. ❑ADDITION ❑PLUMBING RE PIPE
F,Oy ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT C1 STRUCTURAL
zoy Ivndermand mydans_chall be mialt Mie records MODIFICATION
ozsa� - UP TO 201 AMPS ❑IN'TER10R El CHIMNEY REPAIR
licensed Pmfecsional 201-1000AMPS IMPROVEMP.NT
OWNER-BUILDER DECLARATION r3 SWIMMING POOLS
W Q 1 hereby a fire met I an exempt from the Common,License I.aw far the OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
��G U following reason.(Sectian 901 Business and Prates ions Cod,Any city ar canny SIGNS ELECTRICAL ❑at HER
�yFy wbivl y p It I t II p d fa P' ) t elmre
0 poo t al q ' :Ih applicant p 'u fl signed troch SPECIAL CIRCUIT
man.-a that he Jmemcd pt rs vnuothc provieots o[me Cn uncmrs Lich,Law(ChaFte,9
pWWp�� (eonmmecingwith Section Division 3 elite Business and Professions Code)or TEMP.METER( .EI COMMERCIAL:
E o that he it exempt therefrom and the Innis for the alleged exemption.Any violation o[ ❑NEW BUNEADOTI'ION ❑DEMOLITION
kk Ic Section 7031.5 by any asst iwnt for a permit subjects theapphcuntmocivil penalty of POWER DEVICES
a1^m oat ninre than five hundreddellaa,SYM). ❑TENANT ❑FOOD SERVICE
�� (] I,us ownendthe propeny,mmy employees with wages as theia'sala eontpcnsmlon, SWIMMING POOL ELECA; IMPROVEMENT
!lIWWWXXX E'F will do visions Cojet he Contractors
o cis tonnmndnse La edo s not appy
ec.91 air Business ❑
.. and Provisions GMs:The Cnntthemo License Law docs not apply Im if owner of OUTLETS-SWITCHP_S-FI
4i h,noiis own who lip ea"or improves thuch i and who doss such wnrk himself or Ihmugh
fits own layers,IBfiid el such improvements are not intended or o[ferul for NEW RLSIUENTIAL ELECTR
salu.l pwver.lhe NJ;4
sold within ono yearofemmperms,the .. .FT.FLOOR ARRA .Ff.
yy��
van
e HIli11 r wEl I{ye, img hat nn both orbmpmve Farpw-
a� a� .), MAR 2 4 lgg❑1 nn p p ly -y -th r c 'd m eel :t�I If no
tm ' tt(({{5� a tnd r :cal )Tat c t , c-
d 5(1ply�n [[p b k r't pr a lh n d QTY PLUMBING PERMIT FEEt�t,r hnaah siesev sol nn am to me ea,o-.amra ByLi Luw' PERMIT'ISSUANCE.I mnpt un der So,. B A,PC for thisrcason
J ALITR-DRAIN X VENT-WATER(EA) VALUATION
Owner Ilnlc
WORKER. DECLAIiAI'ION BACK FLOW PRCH ECT DEVICE
I hemby afhno undo,Fenallyar Perla sof l he fel lowing deel.beams: 010
�O Ih d 'll m C r t fC tt If' :mthr Warkcra Cnnpen pRNNS-FLOOR.RODE AREA,COND. 6
STgkIES TYPE CDNS ACTION
:anis p iddf byi 3900ri tM1 Lh Cd fn the Pe,frnmnce,of the (/{
.,k fe,whichll' p r t :a d 4FIXTURES-PERTRAP
(] I have and wid renown Wrke-sComle ,nion Insomniac,namimned by Secfon
39n0of the latherCode,for the mrfomtance ofthe work fur which this permit is issued. GAS-EA.SYS'IEM-1 INC.4 OUTLET$ OCC GROUP APN
Maier r71�oTa �eo�irimrh ���cy n ' S 7
!�' re SL//37D cqs-en.sysTEM-ovER4(en)
CERTIFICATE F.(EMPTION FROM WORKERS'
COMPENSATION INSURANCE ORHASHIINUUS'FRL WAS'T'E INTERCEPTOR
Glia enion need not tw,mor eted'fth p ..Osfonn chundneddollns(SI00) ' - BUILDING DIVI910NFf:BS
ar le") GREASETRAP PLANCHECK IEE
I cenlfythat in mepeformance ofliework farwhiah dila Fennitis issued,l shall SEWER-SANITARY-S'T'ORM BA.200 Pf.
not employ any person in any mannerso ac m become smhject m the Workers'Cnnpen- ENERGY FEE
Q Z sation Laws of California.Dam WATER HF.ATBItWNEN'fNLEC'1'R (�
z C Applicant O"' GRADING FEE
rs NOTICE 10 APPLICANT If,after making this Certificate of animator,yon should WATER SYS'1'EMfI'RCATINC,
hemme subject to the Worker's Compensation provisions of the Labor Code,you nmol SOILS PEE
W fonhwith comply with such provisions or this permit shall he decried revoked. WAI ER SERVICE
0
Zoo)U O CONSTRUCTION LENDING AGENCY NEW RESIIIENTIAI.PI,MR. .P' PAID
I harwhich nn than them isncondonation lending agency fonhe Perlbmwnc of Dma Rewiptp
� P he work for which Otic permit is(,sunt(Sec.3119],Cr,CJ
0 U Lenders Name TOTAL:
Lenders Address
FG I certify that 1 have read this application vnd state that he above information is BUILDING v47
Z) correct,l agree to comply waban etyandcauny ordinances andstne lawsrelaiingm QTY. MECHANICAL PERMIT FEE
U z building comhnetion,and hereby auhona,mpmsentatives nfthis city to enternpan the SEISMIC FEE
(10
ahovo-memlannl Pmpedy rar eponionparpises.
ELECTRIC P(We)agree m ave,indemnify ad keep hrthe CirfCuption against PERMIT ISSUANCE '
IiaM1ilitiea,Judgmf the
ensm onJ.1 his eswhichmay inany wayaccrue mgvinslsaid City nL'I'BIt ORADU9DMEGH. PLUMBING FEL
xCANTe Nrim RSTAN S ANpermit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTAIR CANDLING UNIT Get 10,000 CFM) MECHANICAL PEE
SOUR
REGULATIONS �
AIR HANDLING UNIT(OVER 0FD0CFM) CONSTRUCTIONTAX
Signmurc of A,plicnatiCincearam, Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre building accupant.srore or handle harridans material THAT INC.UNI]'(I'D 100,000[31 U)
as dnhnnl by dm Cupertino Municipal GMB Chapter 9.12,and he Health and Surety
GMs,Section 25532(a)^. DEM INC,ON[P(OVER 100,04X)BTU)
�Ye, VENTILATION FAN(SINGLE RESIO) PAID
Dole Receipt#
Willthe apPlialtm grand,as
by
Bay Arcrim,rof con o
Air Quality
Manna whtlt BOILER-COMPfIHPOR 10Q00011TIB
mit hazardous air mnlvminunb vs dcfined by the Bay Area Air Quality Mnnvgemmn 'TOTAL:
Diinial9
El Yes BOILER-COME(OVER 100,000 BTU)
I have lead the h.W(...materials reculremansundn Chaptci 6,95 of he Cali- AIR CONDITIONER ISSUANCE DATE
forma Ilwhh A,Safety Code,Sedans 25505,25533..it 25534.1 understand that if fin NEW RESIDENTIAL MECIL SQ.1.7
building doer nut cunenlly hnve a nano mala is my respon,bil'dy m notify trio occupant
of 'namements which be amt prig cs earn Cenilicvteof0supacncc'.
C �i.-ata �sJ'/C
Ownaro�uuthoriud agent Date OTAL ISSUED BY.
OFFICE