S 2025APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. -ELECTRICAL
BUILDING DIVISION APPLICXPION/PF.RMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
Pe n'No
2025
BUILDIN(I N)DRESS:
2 / y33 ff�NNoJc/ G� T, O ND T -
SANITARY NO.
APPLICATION SUHMITLM DATI
o
HONE
OWNERS NAME: /� `�
410 97
CONTRACI'O2NA NO
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INFO
AHCIIITECTIENGINIiER: LIC NO:
ADDRESS /_h!A4�
Is
COMACC PHONE:
BUILDING VERMII'
Qnlpin ,`,�"O� �yJ�f��O�
,T f r ✓
❑Consultant Feces Paid AY Applicant (Iniliap
BL('c� tui ,Lome. nv[CII .
r•G/
LICCEENNSE/D`LCONTRACIOR'S UECLLAARAHON
I hereby arfntr ,hal I am urm.m under provt.h,ns or ehagrr 9 (voice mein,
with Nvninn]anolofnivi.ion 3onhe Brim... and Prnfmsr code, ardor aicerve is
%� Jar Zf
in hill fnrcuand effecL /� il��r oL�(Q/�
QTY. ELECTRIC PERMIT PEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ITCHES REMODEL.
"
PERMrf ISSUANCE
APPLIANCES - RESIDLNTIAL
License Class rJ Lies
I Dam Contractor
❑ADDITION ❑I'LU\iHNG K61'IPE
❑MULTI -UNIT ❑STRUCrUKAI.
MODIFICATION
ARCHITECTS DECLARATION
I undersmad my plans shall be used as public records
PANELS
' Licensed Professional
DECLARKr10N
j OWNER -BUILDER exempt
' 1 hereby altinn ,hot I ten exempt Iron, the ConRunnr'x Liceme Law For the
following reason. (Section 9831.5, Business and Professions Cade,, Any city or county
UP TO 200 AMPS
201-1000AMPS
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT C] SWIMMING POOLS
❑ BATH RIiMODEf/KEPAIR 0 DEMOLITION
❑UIH17R
OVlilt Ifllp AMPS
SIGNS I21,11C'IKICAL
j which rtyuite, a prmil Ion emmraet, alter, improve, demolish, ter repair any >tmel...
SPECIAL CIRCUIT'/M ISC.
i priorm its isw;nme. alms nyuires the applicant such permit to lite a signed aammem
that he is licensed pursuant to provisions orthe Cu eacto s Lutea, Low (Chopte,9
j (commencing with Section wlIX) of Divi,ma3oOK, Business tad Pmfesimns Cede) in
,hut he is exempt do,c ver and he basis fur the alleged eu:mprirm. Any violation of
TEMP. MISI'HR OR POI.E INSTI
COMMERCIAL:
El NEW BLDG/ADDITION [I DfiM01.1'1'ION
POWER DEVICES
• Section 111115 M1y:my applicant forapem I ... hjens the upplmun ,, a civil peadty of
not more than five hundred dollars 1S51XH.
C Q I, as owner nl the property, or my e,nplm)e¢with waste as Neir tele compensation,
will do me work, and [lie Ninclane is not intended ondfered lie,le (See 18,14, Buanens
• and Pmfmsims Code: The Gmmuctoi s' License Law does not apply as 0n over, oI.
❑TI?: N'1' El FOOD SERVICE
INOVEM1i hVI'
ITR
SWIMMING POOL ELECTRIC
OU THE FS-SWITCHIN - FIX TURESp
pro,,my who build% or improve% fusion, and u'ho does such work himself or through
his own employees, provided Thal such improvements are, nut intended or offered Iter
NEW RESIDENTIAL ELFCTR SQ HT.
SQ. FTFLOOR AREA
S/SQ. Fl'.
tele. IL however. the building or tar,m Innen, is mold within Inc year of .... plclin i, the
ownrohmider will have the burden of proving that he did not build (it improve for pur-
pow of salt.).
L]L as owner of the properly, ten exclusively contracting with) Iicenwd contractors to
SOA,- O
onswa he project (So,. 70,W, Business and Profession, Code.. Thc Comvaamrs 1.
scow Law does not apply it) an owner of pmpedy who builds or improves menan.and
QTY.. PLUMBING PERMIT FEE
whnsrmrac,x Grrvnch prnjecls with aemlei,bafs) Iicernwpurveam to the CaaN ,nr's
PERMIT ISSUANCE 3
Liansr Lmv
C]I am exempt under See ,R& P C for this re;uon
ALI HR - DRAIN & VENT - WATER (EA)
Owner Date
� VALI- MM ION
r�,.rlr//�//
WORKER'S COMPENSATION DRCLARATION
BACK PLOW PROTECT'. DEVICE
r Ihenhy effort order l'enaRynfperjun me of me folio wing declaration.:
fio
DRAINS- FLOOR. ROOK AREA. CONp.
I havtand will mainminn Ccnifcwe of Gmwm m.vell-insure lir, worker's Compen-
,goon. m; provided for by Section 31(X) of the Labe,' Code. for the perfinmunce of the
STORIES
'I'Y PE CONS', RUCflOt
work for which this permit is issued.
FIXTURES - PER TRAP
I have and will maintain Worker's Compensation insurance, as resume by Section
3900 ofthe Lamor ode. for the pc,funnanerof the work for which this protor i.issuqed
My Worker's rite nmsumnee carver and Policy nm
GAS -EA. SYSTEM- I INC. 4 OUTI.EI'S
OCC, GROUP AIN
�q
Carrier: , Policy No.:
GAS-IiA.SYS'fLMOVERJIP.A)
CEIi1IFICA'1'E OIr Es iMI"PION FROM WORKERS
COMPENSATION INSURANCE
,this action iced nm 4 completedifthe Permit is formic hundred dollars(SI00)
nr Ices.)
GREASEIINDUSTRI, WASTE IM HRCEPTOR
BUILT ION+E:.
- -
CREASE TRAY
PLANCHECK FEE
SEWER - SANITARY - STORM EA. 21X1 FE
n the
not employ any pc
Ioyanythrsaminperfmmnrb thewo kforpppppphich this'omni, is i.wud,o,rr-
Onner se}y IrecynL®Irj9ct toWnrkem'Con,pon-
ENERGY PEE
WATER IIEATF,It W/VIiM'/IiLGCI'R
Dae ]11 ��''11''//// !`OO
salmi Lowe of Cal _�
) nrphra,r,
"fian Li
GRADING FEE •`7 3 f / /U
L
NOTITOAPPLfrnna
1 (CANT:IL ofrer,making this Ccnifieurc of P,ncmplian, yon nhoold
borons, ob vat as the Workers Compensation m, man, of the labor Code, you amt
WATER SYS 'Mici REAUNG
SOILS PEE
forthwith comply with such provi.ionv or this nair shall bt deemed revoked.
WATER SERVICE
CONSTRUCTION LENDINGnageCY
1
PAID
NEW RIiS1DEM'IAh PLMR. SQ. F7.
that isattm See 309ending agency for perfomance of
I horwhich
ase Rcccipta
his
,be work for which this pcnni) is Msmrd (Sec. 3(191, Ci, CJ
Lenders
TUTAL: r
Lcndds Add Address
B .D G PEE
1 cendy that I have read this application and slate that ,he above information is
QTY. MECHANICAL PERMIT FEE
uomct.Iugrcemconrply wire all city and mnnry ordinances „nJ clam lows rclwins to
hmiicim"'Voz.n,.Jhrc err Yemhnrvc represcnmtives mf this city venter upon ,hc
SEI' IC FEE
abvcmc, nspr+dinn punows'
deneep harmless the Ciryof Cupeniar against
PERMIT ISSUANCE
:L. TR P.Eliahiltiex,mJeACFER
OR ADD TOMF.CH.
oDhamil.
Qonseyung
1'LUMR 'GFF.1?7APPLCANDSAN)WILT,
AIR HANDLING UNIT TO 10.000 CPM)SOUCE
COMPLY WI1li ALL.' )N-1' INT
M I tE
AIR HANDLING UNI I' LOVER 11110X) CPM)
CONSI'RUCrION
$igmm�rc nh pplie r nrr:¢h'r Uuc
fl LARDOUS MATERIALS DISCLOSURE.
EXHAUSTHOODOVIDUCT)
I IOUSINGMITIGAI'IO PEE
HEATING UNIT (10180,000 RTD) By
Will the applicant or future huildingoAtipant store orhandle hnrnNommarcnal
-defined by he Cnpunlno Municipal Cal, Chapter 9.12, and Wu Health and Safely
Cede, Sochon 25532(0)^
❑Yes ❑No
Will the applicant or future buihting orcupam use equipment or devices which
emit hmadouv air contaminants as defined by the Ray Area Air Quality Management
HEATING UNIT (OVER 100.his RTU)
PAID I
pan Rccciptp
VENTILATION FAN( SINGLE RESI DI
-
BOILER COMP ilii' OR 100,0(r) BTU)
I
Diarl<I^
ElYes 0 N
BOILER- COM P(OVER 100.000 BTU)
AIR CONDITIONER
I have need the haerrdmx mammal, requimmems under Chapter 695oflhe Cali-
forma I does & Scurry C'rde. en tern 255(15, 25533 and 25551.1 to, nalaml That if rhe
haven that', ismryn[pfn.ibilily to, Wemuuy.
the
ISSUANCE DATE
/'N _ n
Cry
NEW RESIDENTIAL MECH. SQ. IT.
of re,mcsmncurrearlywhich
nl the requirement, which most hearer prior m issuance of a Cenilimrm of (krnp0ncy.
/V
/ /fJx
�-
ISSUIiU Ii Y: v—
Owneroreuthmnmdagent Dam
T
OFFICE