S 2252 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PI' IIT NO.
BUII,DING DIVISION APPLICATIONIPERMIT PLUMBING—MECHANICAL J 2252
BUILDING 17R IT IDEN'TIF'ICATION
I UILDINGSAM I'ARY NO. APPLICATION SUBMITTAL DATI
ADDRESg:
2D �b 3 COL-P, -5 E 6 i/tr Zd
OWNI?R:S NAME: �I TQHONG CON,'(TRACTOR'S NAME: LIC NO,
L F_N S3 p i501D ilS W 4i A� 5913??� NIC cGN ROLx
MW,\RCI i ITH ./ENGINIiER: LIC NO: ADDRESS: ❑
w 2) s
Con-rACf: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MITCH
❑ ❑ Fer ❑
LICENSED CONTRAMOR'S DECLARA'UON QTY ELECTRIC PERMIT FEE
0 1 beech,affirm mal 1 at ueensna uncus mevnlona nr cnamer a'ttnmrneing JOB DESCRIPTION
m Sermon]h0)ol'Uivish,n}of the Baeineaa and vmfeaah,na code,and my hcenae i> RESIDENTIAh
��� inthtll force andl u�zuf!' 5913 PCRMI'f ISSi1ANCL ❑SIUWL ❑KITCHIiN REMODEL
¢VV Gccn.c Cf is I.re0 APPLIANCES-RPSIDENTIAL []ADDITION ❑PLUMBING RIiPIPIi
,tZWM Uum Comramor�
F,Dm AHCfifillCI"SUECLARNHON PANELS ❑MULTI-UNIT El STRUCTURAL
Z O'er Z I understood my plans shall be used as public recnnis MODIFICATION
OZ— UPTO 200AMP5 ❑INTIiR10R ❑CHIMNIiY REPAIR
F��'ul Licensed ficsionri 301-1100AMPS IMPItOVIiMENT DSWIMMINGPOOIS
CY�-Wa OWN'liR-BUILDER DECLARATION OVER Hong)AMPS ❑RATH REMODEUREPAIR [I DEMOLITION
TY C Q 1 hereby ahnn that 1 am exempt from the Cannot License Law for the
iXyl 3 W F following reason.(Section]031.5.Basions and Probersiom Gale:Any city or county SIGNS ELECTRICAL ❑OTHER
y which requires u Permit at consrtuut,a1w,impravc,danultsh.or rccatr any mrvaorc I-_
E'I='c< prior to its issuance,uhu requires the o,leann foi penniuo file asigncd nonerecia SPECIAL CIRCU I 17 ISC. ALAI -111
that he is licensed pursvantto the provisions of he Confirr s Lieence Law(Cbapter9
W�pO ("anourengwhh Section 7U10)of Division 3ofthe Business and Prom—this Cade)oe TEMP METER OR POLE INSI'. COMMERCIAL'
d y e C nM1m M1e ix uanpt hcrclmm vnJ me hosts for the ellegcd exemption.Any violutlnn of ❑NEW BLDG/ADDITION ❑DEMOLITION
Xmu. Scotian]03156,uny vpplicam Luer mtit ab)tons the apPlieunue acivilprnalry of POWER DEVICES
W^rte ❑THNANT ❑FWD SERVICE
�Z
re man live hundred dollars(5500).Y ""no IMPROVEMENT
SSG 0 Lo hwncrafdm flue courn mycointended or offered foi(Se 7W4,Buan... SWIMMING POOL ELECT RIC
F wilWntbe worA,Code:The Curcrssol License Laa,dos red apply
7(HY.Bnsingss ❑O'T'HER
3m anderywhiob Grder'Ihe Contractors License is rows sucnotapply elf ownerof OUTLETS-SN'ITCHF_S-FI%TITHES
his n ny who builds or Improves thereon,and who does such rinte deed err tt bed for
his.IC we eycce provided that su such jmpnrve ld are nm intended n etion.for NEW RESIDENTIAL ELECTR SQ IT.
It
sak.ILhowcvicethcvi hefirmimpmvcmcnt tsar he
noncycandutmst,fee the Q.171I FLOOR AREA $/SQ.FI'.
crvhuildcr will bout me burden of proving that he did urn Mold nr imDmvc for pmor
-
,owe osmole.).
❑Las owner of the Sec.704,.B sines and Profession,
esscontracting,Cos hCThe Contractor
i- TOTAL:
nrve La me es out (See 701,Business and Py is he but CMr:)The Cnnmereon.Li-
wtsel.mwdccs mob ,„jc,%ply tu air ownanrpactemswcesedads orunt improve,,thereon.and QTY. PLUMBING PERMIT FEE
ho commas fur such prsrjcas with n amtmnodn)licensed pnrsnam m the Gimmcmr's
nse
Law
01I am cscTmpt undrx Sec. ,I{&p C for thivuw
m TERMI'IISSUANCE
ALTER DRAIN&VENT-WATER(EA) � VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION RACK 11-OW PROTECT'.DEVICEIN
I hereby aflirnt nndur penalty of per)ur,one of tiro following declarations:
I have and will mainmina Ccnilieum ofCamenuesclf-imm afur W..kern Cninpe DRAINS-FLOOR,ROOF,AREA.COND. NOV Sl TYPE CONS'IRUMW
tion,as provided for by Section 3]00 of the Laborn
Coal,for the ptrfenance of he
work fm'which his prima is issued. FM USS-PER I RAI'
C] I have and will maintain Worker's Compensation Insurance,its required by Section
370x1 of the lrhnrGNe,for performance of thmi
e work for which this pert is issued. GAS-EA.SYS'I'F,M-I INC.Y OUT[.ETS ILC.GR( P APN
My Wort 's� Insu'me can runJYallay^,bp _
Cumce l}��»Iurtic Polic NU.:g,L� �[1�laQ GAS-BA.SYS'1'f:N OV ER J(FA)
CERTIIRCNTE 01;EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIANDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FI?IS
((his ecninn ncnl not McontplcTeJ dlhcpcmih is faronc handsel dollars is Put GRF\SF:TRAP
or le".) PLANCIIECK FEE
I certify that in the an,instance of the work for which this permit is e,,C.I shalt
nm mnploY any pcmon in uny manner an as mbcr'amc suhMto the Wnrkcrs'Corn SI?WHR-SANI'fAHY-STORM EA.21x1 FT.
,z nation laic CaliE+miu.Dom 1 De^' IiNIRGY FEE
z 0 Applicant: '�! WATER BEATER W/VENT/I1.EC R
K�1 [C� U ckwwc FEE
N belonaNffl l TO APPLICANT,Work II',ager pen,ng this Certificateif
Exemption,you should WATER SYSTEM/fRF.A'TING
a ; Izcomo scoop ur the Worker'svision his permit
bol of the Lulus Glide,you nwq SOILS IgiE
Da
forthwith comply with such provision anM1is permit shall he leaned rm'oAM. WA'I'IiR SERVICE
a �
U z CONS I ton there
is�construction
nga?NCY NEN'RISIUENtIA1.PLNIR. SQ.FT. PAID
V Q Ihe¢hyaffnmha.iti isacd(Sec.ionlending agency for The perfnmmnm of Date Recciptp
F' the worA for which tots rytemil is issued(Sec.3097,Civ.CJ
C) U IctWcrs Name TOTAL
r Lender's Address T( 9
F 1 I emir',mal 1 have mad this application and state that the above information is BUILDING FEE Al 7
LN emmcl.l agree to comply with all city and county ordinances and state laws martini QTY MECHANICAL PERMIT FEE
L) z huildingamammon.and Mruhyuwhuriiu r,rcummtives of city to enter upon the SEISMIC FEE
shave-maminnul pmNmy for Inspection messes. PF.HNIII'ISSUANCE
(We)agreem save,indemnify..itmtico Aecp hathe City of Cupertinongainl i?LECTRIC IT1'
liabilities.judgnm ,cullsandexpatnas wltichntuy in Troy wayaecmeo,mma_,iJCT, ALTERORADDTOMECH.
in onsequerce IhcZ6,1"i
'vg ofdo,mntl. PLUMBING rE ,Sb
AI'P ACAN” NO NDS A ILL IMPLYµ41p ALL NON-POINT Allt HANDLING UNI'I'(I'(11110X1 CI M)
Sf IRCi ;GUI MECHAN LIT
-i
_ AIR HANDLING UNI'r(OVER 10.001 CFM) CONS'TRUCUf TAY
Sly alureefApp lcunmolar Date EXHAUST HOOD IW/DUCT)
HA9.ARDOUSMATHRIALS DISCLOSURE HOUSING MI Al[ON FEL?
Will heapplicam or boom buildingrecuPmt sereor handle bmardens material HEATING UNIT(10 100.000131U)
as defined by The Cupertino Municipal Code.Chapter 9.12,and the FEmIth and Safety
Cudc,Section 255320)? HEATING UNIT(OVER 110,00 RTU)
E]yes 0 N
VENTILA'T'ION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or dlms which Dam ipt
Rt »
emit baeanlous air comnntinatus as defined by the Bay Area lity Air QuuMevaaagemem BOILER-COMP(31111 OR 100,000 B'I'U)
District? TOTA,
E]Yes ElNo BOILER-COMP(OVER 100.1001ITO)
Ina, mo rehvaniouc nmmriulsre ctnndur Chv mr h.95 of dee Culi- AIR CONDITIONER ISSUANCE DATF,
1111
fornix health of .Sectio "'5505. 5533 vnJ 25531.1 unJmxtonA thin jf the NEW RESIDLNTIAL MP.CIL SQ.PI'. �/_
huilJing Jt erne elm my respunsibilitynt notify the mcupam )
clime Tn_ ore eraeenibeam moan erne,. G�
04
O r rumho izcJ agcm Date TOTAL: ISSUED BY:
OFFICE