S 2278 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OR CUPERTINO BUILDING-EI,ECTRICAL PESITNO. ZZ7
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1 y
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PROJECT U)ENI'IF'ICATION
BUILDING ADDRESS: SANITARY NO APPLICATION SUBMI'FI'AL DATE
OWNER'S NAA PHONE: I 'ONTRACfORS AME: LIC NO:
M NIC CONTROL#
ARCHITECT/ENGIN LIC NO: ADDRESS: ❑ %IL
CONTACE ��/�3Pi19 - BUILDINCPERMIT IN.
O 3 A ❑ CrmMdtant Fres Paid by Applicant(initial) I1LDG1LECI PLUMY MECH
❑ E:] ❑
I.ICI:NSED CONTRACT'OR'S DECIIARAI'ION QTY ELECTRIC PIiRMIT FEE
1 hereby affirat mat I am licensed under pmvi.d6fis of chapter 9(contmeco ng JOE DESCRIPTION
CMZ won Semis i 7000ofni usion3 rime Basinessand Pro fa,:Toms COde.a.dmy license is RESIDENTIAL:
WOO PERMIT'ISSUANCIi
Fa ty.- in Pon force eiicct. ❑$I'D\41. ❑KITCHEN RIiMODEI.
aUU License Class Lic.p APPLIANCES-RBSIDENTIAL ❑ADDITION El PLUMBING RB-PIPIT
i a a Dam contractor
ARCHITECTS UIiChARAI',ON ❑MUCTFUNIT C3 SI RUCIURAL
Z p'/P Z 1 melcmand my plain shall Mused to public«curd.- PANELS MODIFICATION
14-a UP TO 200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
W Licensed l'ndeamad 201-INXIAMPSIMPROVEMENT ElSWIMMING POOLS
OWNEIt-BUILDEI<DECLARATION —!
a IY 6 1 hereby affirm that I ant exempt front the Comborm'a License Low for the OVER IIXXI AMPS ❑BA'I'II REMODFIAEPAIR ❑DEMOLITION f
d O
to.U following roar....(Semis 7011.5,Buel.oss and Prolbssians Coca:Any it,or county SIGNS ELECTRICAL 5i_ ❑M HER
3 t+-y which requires ape rout to compo t,alter,improve,demolish,or repair wry nrucmre !7
oa to itsissltance.alsore mc. hcllm for-vuch,crmit lotileasigned shnelncm
trial y.he tt 6 SPECIAL CIRCIII'i'IM ESC.
fly Emtbdcring With Section
1.heofDivionsr he C of
xnd Proe Law(chood0or
Wasp�O (commencing with Scctirn]IMNporDivisinnJof the Business and L'ndessiem CWOur 'IBMP.MCI ER OR POLE INST COMMERCIAL:
d p,m C Elim he is vacation Iherefmm and the Msis for me a11uged or upliva Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Ed Section 7031.5 by any appfirm,hr.permit subjects the applant to a civil l'cnalty of POWER DEVICES El TENANT ❑FOOD SERVICE
Bol afore than five hundred dollars(S500).
F Z Y OTHER EM11iNT
^tea ❑ Las awnerofthe tro"men"r is eI wrdcswithunges as theirclSolemntpensiirn, SWIMMING POOL ELECTRIC
F� will dolbewons ender he Con:iators License ollenad wdone,act apply(Site VO l4,lusowner
❑OTHER
m
and Professions Coda:The Contractors License Law rices nal apply In an owner nr (IUTLI:'lis-SWI'I'CIII?5-1:1X'I'USES
6 3^ ,,.,by who builds in impress,more...,and who does such work himself or through
his own ceoployees,provided that such improvements me not matmand or oB'med fur NEW RESIDENTIAL ELECI'R SQ FI'.
xuh.If.boevicr,the huildre,b,imtrovemmnl o orld w,thin onoyww
r of mtpletiorthe SO.FT.FLOOR AREA E/SQ.FT.
owner builder will have the harden of proving that he did not build or improve for pur-
pose oLwlcl.
L ns nwne,of the properly,umluco
.acsivat, .0aminu
g with Ii....ad cmmn c....liTCIA
msWa the project l See.]B44,Businesamtd Pmfe..in...Code:)The Connector Li- - -
alnseLawdoes not apply tounownet ofpropenywho builds oriniprovesmemon,and QTY. PLUMBING PERMITF-.
to contracts for such projects with a conaneror(s)licensed pursuant to the Connector's /!
Licenseisev. (.� /maQy)p, PERMIT'ISSUANCE 7
I am exempt under Sec. r� S !( lT'd�rihis9t.,
— ALTER-DRAIN R VENT-WATER FA) VALUATION�U
�(Iwner Data in
WORKER'S COMPHNSA'I'ION DIiCLAR61'ION BACK PLOW TWO ECT.DEVICE y)0 r0 C)
I hereby aBirnt under penally of pofrvry,one t) the followinsure for deeWorker's Ca /
❑Ihave and will maiby Scefion Certificate the Labor
Code.
Worker's Camper DRAINS-FLOOR.kOOHAREA,CONE, STORIP_S TYPE CONtiI'RUCTION
radon, r Wooded fur by Section J]000l the Luhor Cale,for the parfommnee of the _
work aveand
d his permit it orker' FI%TtJRlis-Plilt'I'ItAP 1
❑1 have aL a will ode,fon he per orr's Ca performance
of the w Insurance,h his ircd by issued.
Section 1
My of the labor Cuda for purfommnnafnhewrnk for which ilii,pit is ismtesl. GAS-IiA.SYS'1'I?M-I INCA OUTLETS OCC.GROUP APN
My Works+'a! eeoriur old Pulley Bantle arc:
Carticc—� —Policy Nu.; ,—/ OAS-ITA.SYS'I'I?MOV- 4(EA)
RICWPIG}ITii(➢'EXF.MVTION FROM WONKERS'
COMPENSATION INSURANCE GREASIJINDUS'I BE WASTE INTERCEPTOR
Ifl11LDING DIVISION FEES
11'hl4seclinn neW not he complGcA Tells tenni,lx fonnmbundreddullm',(SEEN) GRP,ASI?'I'ItAP
editors.) PLANCI{ECK THE "73
Icenifylhat inure pefforma.ceoOs, .,it for shiclohi,permit is issued*i,hall SEWER-SANITARY-STORM EA.NXI FT
not employ any pains in any manner sone In become subject to the Workers''C'mtcn- ENERGY FEE a �Q
Oz wiion Laws of California.Date WATER HEATER W/VENT'/PI.EC'1R GRADING FEE ,
z Applicant
to NOTICE TO APPLICANT.IL after but this Cenificatte of ExempOon,you should WATER SYSTEMG BEATING
hos n,arl,t m ma Worker's Gnnpensodnn....of.....of me Labor Gale,you atnal 50M
fonhwilbcnmply wim,uch prormirm,of Ihic tenni,shall hedemncd revoked. WA'I'BE SERVICE
0
�0. r CONSTRUCTION LENDING AGENCY NEN'RIiSIDENTiN,PLMIi. SQ.PI'. PAID w a���r/2j
�y� z Ic ItttU Q
�fs(TsJ�bp" Iherebr afrmn mull....Nacotvrtmmirn,emling asenur rordm pmmnaanca of CT 24 #
the work for which Ilii (' .3097.Ciy.CJ o
Lenders Name 19 TAE:
0 V Lcnderx Addrexx TOTAL: _
y1 certify that 1 have mad this ii,bramin and smm Ilial the aMrvc Information is - l ,Ap BUILDING NHL? Q
r�N cameo,l vgrecm comply with all city and asmyoninaneesmul sure laws relating or QTY. MECHANICAL PERMIT �%'o '
V z building constriction.and hereby actuator mpresemmives of this city to enter upon the u S
above-nmnlioned prup ty for Inspectionp.fpnec.. PERMIT'ISSUANCIi
(N'e)agree m save,indemnify and keep harmless the City of Cupcninn against ELECI'ItIC FEIi
liabilities,judgments.costs and expenses which unity in any way aecme against said City ALTER OR ADDIT)MECIL
IIP p
ameyucnve nr me grunting of this tennis PLUMBING ETIi
APPLICANT UNDERSTANDS AND W11.1,COMPLY WI'L'E ALL NON-POEN"I' AIR HANDLING UNIT CHI II1,lXq CIM) MECHANICALPEL
SOURCE 1�La tt A�T'IONS.
! t /�^/ ^�� AIR HANDLING ONIT(OVIiR 10,01X1 CPM) CONS'rRUCr10N'I'AX
Signature ofP or [�� Dine EXHAUST HOOD IWIOIIC'TI HOUSING MITIGATION FEB.
I IAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building nccalwit score or h:mdle so...dour material IIIiA'1'INC.UNIT(TO 100,000 BTU)
as deftmcd by the Cuperllvo M...died Gale,Chapter 9.12,and too Ilcalth and Surety
Code,section 25532m)? HEATING UNIT(OVER 00,000131U)
❑Yes -1 No PAID
VENT,LATIONFAN(SINGI.Ii RESID) Data Sierra,#
Will the aireamntmfuture building h, Bay
Air umrdeviceswhich
emithvuJss air c..mandsnts as defined by Bethe Nay Area Air Quality Management BOILER-COME'(3HP OR❑III,IXIB B'1"U) TOIAI
District] BOILER-COME'(OVER 100.000141t.)
❑Yes ❑Nn
AIR CONDITIONER
I have teed the h odrdom mans 2.1..9 5,2553 a under .T mad 695 of me Call- ISSl1ANCE E /�..
rrmw Ileullh&Snlbty Code Sections 255115,25533 and 25531 I mvdenuuW mm if the NEW Iii?$IDENTIAL MSCI{, SQ.Pf. y
naimingdPy..�e.. bavw tenant,nwt idrmyrc,l>on,ihi,ity lin nmi,ymc«.vpunl � � J��
j
m of the reymatcfyhichmm lino is f Ceni9fc le of Occupancy.
a
Owner nr au OumTOTAL: ISSUED Ii Yv 0 /9w7�~-�C/
OFFICE