S 2445APPLICANT -TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING - ELECTRICAL.
PIIRMI'INO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING - MECHANICAL.
S
BUILDING PRODICT IDEM I'IE'ICA'FION
2445
BUILDING ADDRESS:
/o/// el- vI6
SANITARY NO.
APPLICATION SEAMED IAL UNIT
-7 9
NAMENIC
OW kS�� ��� I H�� /
CONT'RACTOR'S NAME: LIC NO:
❑
CONTROL#
ARCHI'1'MIENGINEPER LIC NO:
AADRESS' // ��
CONTACT: PHONE
BUILDING PERMIT 1NP0
❑ Consultant FBCa Paid by Applicant (Initial)
BLDG ELECT PLUMB / ME Cil
1:1 El ❑
LICENSED CON I'RAGTOR:S DECLARAI ION
1 co,hy filial that I am Eceasn111mto, p ovkinn, nI Cnnplm 9 commencing
MOK1c1in r 700(Iof Division 2 of he l los
in full loa'c mud clfcct.
Licen.¢ .I'x- LietDECLARATION ns Codc, onJ my license is
#
Dam Con
ARCHI'I ECI'SC3
Iunderslaad my plans shall he used as public records
QTY ELECTRIC PERMIT FEE
Z
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=U
'aa
o,
JOB DESCRIPTION
1 TIA
rDWL ❑KITCHEN kIiMOUEL
❑AUDITION C3 PLUMPING RE -PIPE
MULTI -UNIT ❑STRUCTURAL
MODIFICATION'
PIiRMl'PISSUANCIi
APPLIANCES -RESIDENTIAL
PANELS
E-
.+G
LK �
d
a V
LL y
ON .Q.1
y
00
UP TO 2W AMPS
[_1 INTERIOR ❑SWCHIMNEY
IMPROVEMENT MING POOL
❑ SWIMMING
❑ BATA REMGDEIARiiI'AIR � DEMOLITION
❑ U'I'HEIt
Licensed l'ndcs.vlonA
he1'aby .Nieto that 1 1. exenlpr Poon the Cmtvns Co 1; Antro Law for Inc
Oat I a., If I111.UEf DBtheC arIONIg
following rcuxua (Section 7031.5,Nosiness and .r, derone Code. Any city or canary
which its iss s a Proune. also to requires
ewer, he,pplic ntfor such
h coutlt, err nasi, nay smrment
prior to issuance. also mquimsthe applicam for socM1 penniuo filensigned statement
that he is licensed pursuant to the prookionsoffle Contactors License l.ax(Chapter')
(eammencingwith Section 7(XX)) of1bvision 3 ofthe Business and Professions Code)or
20 61 WOAMI'S
OVER IIIINtAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUTI'INISC.
'I EMP. METER OR POLE INST.
COMMERCIAL:
c y
4'
m
yq
py
3 m
dlut he is exempt therRmm and the basis battle alleged exvnlpdml. Any violafen of
Section 7031.5 by ally applicant Into permit subjects the applicant to a civil penalty of
nmore than rive hundmd dollars 6500).So"❑I,axowaerof the pmperty,nnuywuployeuwith wagc.v ns lhcirxulucolnprosation.
will Jn the work, and thestmdnrc isnot intraded...offered forsor(Sce. 7044, Baoinas
and Prowsoions Code: The Contractor's License Law docs our apply to an owner of
pmpeny who builds err hall thereon, and who does such wad hiarrclf or th....It
❑ NEW BLDG/ADDITION ❑ DEMOLITION
[_1 TENANT C:1 FOOD SERVICEm
IMPROVEMENT
,0 U[
POWER DEVICES
SWIMMING 1'001. 1 iI.EC'I'RIC
OUTLETS-SWI'1 GIIES-FIXTURES
his an employees, provided that such impmvernenu ate nal intended or offered far
NEW RESIDEM'IAL ELECTR SU I -L
SQ. E'p. FLOOR AREA
SISQ. Fr.
sale. If. however, the building or improvement is soldwithin one year ofurmpletion.the
nerbuilder will have the burden of proving that he did not build or improve for par-
oo1,
1,ax owner it the property, an mot valy contracting with licensed cmmnlgnry to
'1'OI'A L:
short the police, Pic, 764, Ba,lnno, tod Proles nctore .. C�dc:) I'ne Cunb
Q'FY. PLUMBING PERMIT FEE
trust as apply to an owner of property who bnildsnr impmves therrunand
whoco onfisi barman projects with u contmetor(s) licensed pursuant m the Contactors
Littn.vc lanes.
CI I um exempt under Sec. .B& I' C lin this reason
'
PERMIT ISSUANCE 5a
-DRAIN & VENO '- WATER (EAI
Owner [)areALTER
VALUATION
WORKER'S COM PENSAPION DECLARA'I'I ON
BACK FLOW PROPEC'I'. DEVICE
I hereby oto rte under penally al' pc Jury or of the folluwing dedurofions:
DRAINS- 171,0011. 811017. AREA, CONO.
�Ihuvcand wllUnnintainnCu111ia11cul Cmseat mxcll ia.... ef1' Worker', Can .pelt-
sudon, as provided for by Section 391111..1' the Labor Code, im the perfaonance of tit
S'MIMES
TYPE CONS' I UC'I'ION
a k far which this pumif is issued.
FIXTURES- PERI RAI'
1 have and will maintain W'orker's Compensation Immense, as required by Section
3 afthe Labe Cdefor of the work for which this permit inissaed.
GAS - EA. SYS rpM-I INC. 4 OUTLETS
OCC. GROUP
APN
a 1.the
Policy
My We 1, 'L yOL/NNo
Comm O fu4 W ['.nomhe, No
)
GAS- EA. SYSTIiM-0VER 4(EA)
CERTIFICATE OF EXIIMFI'ION FROM WORT E:RS'
COMPENS NJ ION INSURANCE
frhiamcrl.... necrtl bol be ea..... fed l l thepemat is l inane hundred dUllam($100)
or less.)
GREASFANDUS'I'RL WASTE INTERCEFTOk
BUILDING DIVISION PRF
GREASE RAP
PLAN K FE
I..oily lhxl in ane peninmance nl the work for which this punnif in lssueJ, lshall
not employ any proton in any insurer m as to become subject office Workers' Co.".-
SEWER-SANI'T'ARY-STORMEA.200111'.
EMIR , E
WATER HEATER W/VIiN'PHLECTR
/O' 00
Z
0
nation I,mv,d Colinumi, Date
Applicant
GRA C E Lit
NOTICE IO APPLICANT: If, ulmr nwking this Cenihcnm of lamnptian, you should
the Labor Code, you mu
become subjvnl m rho Workers Compltvmion pmvleione of s
forthwith c..ngdy wits such prl..na or this pcnnnehull hadenmdrevoked.
WATER SYS 'TEM/IREA'I'ING
WATER SERVICH
to
501. 'EE 9
jOq
N EW RESIDEN TI AL PI.M B SQ. Irl
i z
O
H
j VLeaders
C1.1
CON 1.17N LI?N UI NO AGENCY
Ihcmhy storm mat mem is ucnuslracaioa lending ugcnny for lhu performancen(
the work for Machin, proun is i ... at(Sec. 30)9, Cie C.)
N..ne
PA ) yry
V Dale Receipt it
AOTAL VS Q
-
Lenders Add..
1 entry that 1 have read this opplicalum and sate that the snow information is
BUILDING FEE
QTY. MECHANICAL PERMrr FEE
SEISMIC FEE
(m
z,
contact. I agere to comply with all city and county ordinances and state laws relating to
building construction, and hereby Odel ec rejacentil of this city n emerupan the
shove-1ne111ioned properly for ilopeclion an,usea'
(We) ogre to swc, indemnify and keep hall Elm Coy ul Cupertino against
PIiHMI'P ISSUANCE
I!LBC'IRIC PEE
ANTER OR ADD 10 NISCH.
PLUMBING PEE
Iiabiifide,ludgmenis, costs and expcaes which may in any way accrucagall said City
in consequence of the granting of this permit
AIR HANDLING UNIT ('Its 10,000 CFM) '
MECHANICAL FEE
APPLICANT IENDERS'LANDS AND WILL COMPLY Wll'H ALL NON -POINT
SOURCE' �{�s�NS"
AIR HANDLING IINI'r(OVER 10.0i CFM]
CONSTRUCI'ION'I'
/Tq�
EXHAUS'P GOOD(WIDUCI)
HOUSING MITIGNI Ilii?
eiglumbeaI AffileanVCnactor X/Dat6
11 kUOI1SMA1'I7R1AI,SDISCLOSURIi
I IFNI INC, UNIT(TO 11X1,000 BTU)
Will tile applicant or runic hoildn"ocmryrat'd c..rhnnAlc hu>unlous nwlcriul
a deli Sell ny fhc Cupertino Municipal Codc. Chapter 9.12, anA Inc Ilculth and Safety
IIEAI'ING UNIT' (OVlilt IINLINM) BTU)
Code, Section 255320)P
E3 Yea 0 N
PAID
Daft Receipt It
VENTILATION PAN SINGLERESID)
Will the applicant or future building occupant use equipmere err devices which
unit tota a vii radial an defined by the Bay Area Air Quality Management
Dfntrictl
❑Yeo El No
BOILER -COMP (3HP OR 100.00) BTU)
TOTAL:
ItOILER-COMI'IOVIIt 100.000 BTU)
AIR CONDfI'IONER
thaw ,all fhc haauNous nmluials clinical under Chuptor n, 95 of the Coli-
ISSUANCE DATE
NEW RESIDENTIAL. MIKE. SQ. FI'.
main Droll, & Sufcty Codc, Smions 25505.25533 and 255]4. 1 undaaard that if rhe
building dresnnt currently M1evcamnant. the it is my rcspnnsibilitY to notify the occupant
3- ,� q
of the 'ch mus be lam perm to issuance ora Ce' creat Oce
\,
ISSUED BY.
TOTAL:
auhonecda rt Hhe
OFFICE