S 2234 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO ButI.rorvc-ELECTRICAL PIttfl,No
BUILDING DIVISION APPLICATIOWPRRMIT PI.UMJ IINC MECHANICAL V 2234
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION$H9MI'TTAL UA'Tli
OWNERS Nn M `� I� 110 PHONE`e& rI �'b CON'I'RACI'OR'S NAME: LIC No
l alpAMgel IllY y G� NIC p� CONTROhp
ARCHITECI'IIiNGI HER: LOU NO, ADDRESS: ❑ y O
IPA CIL*
CON'T'ACT: PHONE, BUILDING PERMIT INFO
Sog foe StRL 303 411 78gy ❑ Consultant Fees Paid by Appliodnl(Initial) BLDG ELECT PLUMB MI!CH
Cb/ 0-� ❑ ED
LICENSED CONTRACTORS DECLARATION Q'TY ELECTRIC PERMIT FE17
I hereny alarm mal I ant fieenwd ander pro+..Ions of chapter 9(eontatenehlg JOB DESCRIPTION
aZ wlm cation am0)al Dlvimm�3nrne nnshesa non rrofeaNians Cndv,mdnayh1Owix RESIDENTIAL:
00 in full fitmeand effect. PF.Ith1IT ISSl1ANCli s ❑SFDWL C1 KIT CHEN REMODEL
�UV License Class Lia# APPLIANCES-RESIDENTIAL []ADDITION [IPLUMBING RE-PIPE
$
v z w Dale Contmmnr
>y ARCHITECT'S DECLARATION PANT:IS ❑MULTI-UNIT ❑STRUCfURAh
zOaK I understand my plans shall ha u.wd as public recants MODIFICA'T'ION
N U"T02fm AMPS
O'Z^O ❑hS'I'IiRIOR [I CHIMNEY REPAIR
1=�F"uJ Licensedlimic....nll 201-100AMPS IMPROVEMhNT ❑SWIMMING POOLS
qa , OWNER-BUILDER DECLARATION Corll OVI!R I"AMPS ❑BATT I REMODELIREPAIR 0DEMOLITION
a mall That I bolt xe�nm rfrontataeemm�temra Liratao Law for me
�O L U following Seeman 7031 S,Bmioess and I'mfessions Code:An t t ❑011117 t
xx g requires
u,( Y ci y or comity SIGNS ELIiC'1'RICAI.
W 3 LL F which requires n pemtit re cores the aper.improve,demolish nr,tt'. any imestranent
ure
II,":c
prior it) Yuunca,n9nreyulrcxthe appllcumfor suchpennil Inliltasigncd xmmmca SPECIAL CIIiCIJITIMISC.
Thal he is Imen,edpursuant in the provisions of the Conlranors Liceme Law(Chapter 9
ad (commencing with Section of Division 3 althe Bminess and Prdessions Clde)oa TEMP.METER OR POLE-414-n .R L'
a y o a thw he Is cwnipt here In and ho M1uxix for the alleged cxemplinn.Any violation of NEW BLDG/ADDITION []DEMOLITION
LLX7 W Senion]03LS by any applicant fnrapennil suhleds me upplicannnacivil penalty of POWER IJI?VICE.$
y not boom than five hundred dollars($511(1). IMPROV El TOO[)SERVICE
F�d I,no owner oflhe er(,mm Ineen with wed theirsole cern tion, SWIMMING POOL IiI.ECTRIC orTER IMPROVEMENT
p ❑ nano r renin r sen as nano
2 px.0 will do The walk,and lhesaenare is not immadednr nfrered rim le(Set.Tue.Business r.. ❑OTHER
6'3. and I,ac,,inow Cade:The Committers License Law does not apply o as owner of , OUTLEI's-SWITCHFs-PI%TURCS SQ
property who bands or improves Iheram,undo who does tach walk himself or through
his r,.,I employees,provided tical such impmvenenla are nal intended nr offered for NEW RESIDENTIAL BLECI'to SQ PP.
.to If,howcveathe building or improvement is sold within one year ofeanmletion,the SQ.PC FLOOR AREA $/SQ.IT.
owncmha9der win have the he rden of proving mut he did nal to Id or mill far Pur-
ofsnlcJ. #A�
sl,as in, of the PapeoY,am ason,vely contracting with licensed contractors In L' V
m ovet theT,moO(Sea.IIM4,Bmincsx andProfessionsCoda)"mCununema'sLi-
cenwLmwdoesnol all To aownornfProperty who builds ur Improves lhereon,nnd QTY. PLUM GPIiRMI'1' PEE?
who commas forsueh Pandects wilhire ae nn,)IicerswJ purnuanuo the Contmcmfs
Liceme Law. PERM[ SSUA ♦ J 1L,J
❑ I x, landerSec. .B X P C lie boas reewtn
ALTER-DR 'k .NT-WATER(EA) VAIAA'I'ION
D:nu
WORKER'S COMPENSATION DECLARATION BACK FLOW PROI':CT.DEVICE
themb aRrm under penalty of peaury one of the following deactivations: x�T
❑ I have and will naimaina Ccnlfiade ofGmsent to self-Insum for WmToOn Conquer- DRAINS-FLOOR,ROOF,AREA,CONO STORI(.S TYPE CONST RUCION
salon,as provided I'or by Seen 13700 of the I.ubnr Code,for the perban m er,of the
work far which Nis pennil is ismed. 1TX'1'UREs-PER TRAP
❑ I Nave and will nminti in Worker's Contpemation Inmmnce,us required by Section
3]110of the Labor Coale,for me performance or line work It,,which thin pmuth isisened. GAS-EA.SYST9M-I INCdOU'lLIOS 'tOU1' AVN
My Worker's Compensation Insurance comer and Policy number am:
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4 CA)
CERT'IFICATI;OF EXEMPT ION FROM WORKERS' GRI?ASElIN1ID5'I'ItI.WAS'T'E INTEItCF
COh1PFNSATION INSURANCE. IUILDING DIVISION 1:11CS
(TIN,vtinnneed mol beromplcted ifthcpnboit is from,hundred dollars WOO) GRHASETRAP 11F 11"U Z 4
or lcssJ 111 I!E
I certify that in the performance of the work for which this penNtis issoed.lshall SEWER-SANITARY-STORM EA.21 I'.
nal nnploy any peaon in any moaner so as to become subject it)the Workers Content- INE RGY FF
Oz nation LaWsol California.Dae WA'I ER I II?AI RR W/VENI'II:LEC'I'R B
`Z-t O Applicant GRADING F[
NOT ICE TO APPLICANT If,a9.r making This Comficntc of E,empaon,you should WATER SYS'I FMO READING
became ithl to the Wndo,,Compennanon pmvi,... of the Lahnr Code,yellmast S_ .• ..
forthwith comply%ith such provision or this pennil shall he deemed revoked. WATER SERVICE
am Ca
CONS'fItUC'fION LENDING AGENCY NI!W RESII31?N'I-IAh PLMII. SO=FT. PAID
'7 Z I hereby ammo that them is a con.amction lending agency for the perlommanae of Dane Receipt Of
U — the work far wtieh his permit is issaed(Sec.3111],Civ.C.)
w Lender's Nance / TOTAL:
} V Iandc/sAJJm¢ I al TI 'AL: -7 0
1..t � 1 coolly that 1 have read this application and sate that the shave infolmntion is LIJI G GI]i f)
Lt TA corce.Iagree to comply with all city are anumyordlnanccaaal able htwxrelating m QTY. MECHANICAL PERMIT FEE
buildingeonswction.and hemby motorize reprtwattiivesnfthiscilym enmrurym the SEIS CITE
olxme-mentioned property far impeclion puq'uxs. PERMIT'ISSUANCE(Wit)ngrec m cava,inden nify and keep monalmn 0o City nI Cuped inn ugnhst .QI'RIC FET? 0 O
liabilities.judginents.coslsandexpenses which mayin anyway ucemeagaind said City ALTER ORADDTO MECILD
in nwquence of the granting of this Permit. UMBING IniE
APPLICANT UNDERSTANDS AND WIhI.COMPLY WITH AL1.NON-POINT AIRHANDLING UNIT no 14111111 CPM)
SOURCE REGULATIONS.LATLA'1'IONS.ONS. MFCI IANICAh EEE
AIR HANDLING UNIT(OVER 140X1)CFM) ONS'TRUCPION TAX
Signature of Applicant/Conlmetor Date EXHAUS'THOOD(WIDUCD f{ SING MI'I'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will ThoapphOurs nr Mouraboild'mgocculmnlstemorhandlc hmmudoms mmcnal T RATING UNIT(TO 1009000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12.and the health and Solely
Code,Seelion 25532pn4 HEATING UNIT TOVI!R 1111,100 WITT
Yen No[3 VI!N'I'ILAI'ION PAN(SINGLE RESIDI PAID hale RceeipaN
Will the applicant or four.building occupant aw equipmant az devices which I{Oil Fk-COMP[311P Ok IfIU,EfN)NTU)
mit hazardous air ennmminums as delined by the Bay Area Air Quality Managm
eent Z YfA 1;
Dishier? BOILER-COMP(OVER 100.0041
El Yes E]No
I Lave aA the Imvalloumaar
N ial,s requirement,under Chapter e.95 of mAIR CON DT LION I!R e Cali- ISSUANCE DDATE9'
fain hre
earth A,Safny Code,Sections 25505,25533 moil 25534.1 andemand that Uthe NEW RESIDENI'IAl.MECII. SQ.ET. �/^ �1 (!
halholOmesnut torrenny have.tenuut,hmysp
in.,(Nom notil'ytheoecnpunt ( 2—I
of the recluireir a which must be met prior at issuance ofa Cetilisvte of Occupancy.
Gwneroraalhariledngent Del, TOTAL: ISSUI?D BY. �-�
OFFICE