S 2181 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PIi II NO.
BUILDING DIVISION APPLICATIONIPF,RMIT PLUMBING-MECHANICAL 2181
BUILDING PROJECT IDHNTI FICATION
BUILDING ADDRESS: <) SANITARY NO, APPLICATION SUBMITIALDAI
23 / q utlpc_ —i/- 9
(1WNFRS NAME. PHONE: C(1 TR N/O CON'IROLI
AIIIIIIIJ
C'IOR'SNAME: LIC NO:
Ll•Z.,S L m
• ARCHI'IECTENGINGER: LIC NU: ADDRESS: 1 ❑
CONTACT: PRONE; BUILDING PERMIT INTO
1r 7 ^ /t_Q /�^ ❑ Consultant Fees Paid by Applicant(Initial) HI,DG ELECT PLUMB MECII
/ Y7 J � ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERM If FEE
I hereby affrnt Ilial I am ucfd
arn,ed under provoa,of chapter 9 Bm
omor
am , JOB DESCRIPTION
C
Z with Section 70XBofDivision 3ofthc Buniacns vnd Profc,niom Cudc,unJ
u]OC my license iv PF:RXtI"f ISSUANCE RESIDF,NTIAI;
F-LL.- i,full force and elycn L
<U U Lkco. Cas 1- Z Loc,p 7--� � 0�^ ❑ADEATISFDWL ❑KITCHEN REb10D E
NQL Dam Cnnua, APPLIANCES-RESIDEN'HA1, ❑AUDITION El PLUMBING R17 PIPE
ARCHITECTS DECLARATION ❑MULrDUNI'T ❑STRUCTURAL
p.7 N PANELS
Z C m Z I underet nd my plan,shall be used i,public recoNs MODIFICATION
OZ4;� UP 00200AMPS El INTERIOR [I CHIMNEY REPAIR
4�2F; Iicemed Pa&m.donal 2061X00AMPS IMPROVEMENT ElSWIMMING POOLS
CoQ III:dican ma Ilay.leu'mpltrmv Ile Convucor's Loccave Law In, he OVER Iml0AMPS 0BATH RF,MODEIIREPAIR ❑DILMOLITION
X0.Cl following leaven.(Section 7031.5,biomass and 1 aid..ion,Cock Any oily or,omay SIGNS ELECTRICAL El ER
tz1 It y which requires a Permit to cIm,INcl,alley.Improve,demolish,or repair any,maclum Y
< prim'....1,isuanre,also requiix,the applicant for such perotiuo fleasignadslmemem SPECIAL CIRCUIT/MISC.
f • (hat he i,licenced pummmt a.the Pnw i Ill the Comrucar',J,,., Law(Clmper9
nt�OO Icvmmencing with Section 71XX1)of Division 3oflhe Business,vnd Prafc,sinne G,de)or '(HMC METER OR POLE(NSI'. M R
a.m e C ilia,he i,-cm,Ihemfnvn and Ne basis Pair he alleged camnptlan.Any violation of ❑NEW BIDG/ADDITION ❑DEMOLITION
all Section 7031.5 by any applicant To,perrtit ,.hjcas the nppli,alno a civil penalty,,f POWER DEVICES
04^m nt more than five hundred dollars($500),
El TENANT [I FOOD SERVICE
❑ I,as owner of the prolury,or my cmptcyces with wages as lheirsole contpcn.smion, SWIMMING Po IE,ELECT RIC IMPROVEMENT
F will do lM1c work.imd the,Immure i.v nut intundnl on,ITured rpt Solt fSce.]044,6usinc,s OTHER
L3 To and I'roressinns Calc The Contractor,License[_a,Jean not apply a as owner of OU'I LFIS-SWITC.HE S-IIX'TURIi
property who no Ids or initiatives thereon,and who does such work himself or Through
his ,an umployceq provided The,such intprnvemunt,me not Intended nr offload lin NEW RESIUEN'IIAL ELEC!'R SQ F/
sale If.huni the huilding or improvement is within one year of c..ntplaion,the SQ.IT.FLOOR AREA 9SQ.FT,
owner-builder will have the burden of proving that he did nm build or improve for pur-
1 pa"ofsvle,).
❑1,as owner of the pm,cr y,ant escltimvely commcling with licenced contractors no I OTAL:
construct the pojut(Sec.7044,Business and Profe,sions Code:)The Contractors 1,1-
eemaLaw d..esnot ply to an owner of poperly who build%or improves thereon,and QTY. PLUMBING PERMIT FEE
who romrucu for such projects with a ennv;mtorp)licensed pursuant o the Cnnuaaor'%
License Law. PERM,1'ISSUANCE
❑ I;um Camnp ander Sec. ,B&I'C for this reason
Owner Dae ALI17R—DT
RAIN&VEN -W'ATER(EA) VALUATION
WORKI?R:S COMPIINSATION UF,CLARATION BACK FLOW PROTECT.DEVICE
I thereby o ffnn,m ter penal,of pnjm,anc of The following Jedmmion,I
❑ IM1ave and will mainmina Cenifeae of Consenunsdf-inwm Ln Worker's Compen- DRAINS_FLOOR ROIIPAREA,COND 5 DRIES TVPIi CIINSTRl1CTIC
,at n,us provided for by Seem,.3900 of the Latin, m,he performvnce of the
work for bith Thi,pcnni.is issued. FIX'I URIS-PI?R TRAP
El 1 have and will maintain Wnrkces Compensation Insurance,as required by Section
3700of lbe UP.,Code.knee pertamnance ufine work lar which this permit i,i„vad. GAS-EA.SYSTEM-1 INC.4 OUTLE-I'S OCC GROUT' APN
Car Wnrk,rj(awty: tlrysw,vncc cugjc Pand Policyolicy N.,n:ytt,��r:yy: SOTO Ir— .AS-
My 04111: l /)"1 X� Lc�.ti.l� Policy Na.: ! 1—1 BA.SYS'ERM"OVER A(EA)
CER IIFICATH OF EXEMPII(lN FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSI'Rl,WAS'IH INTERCEPTOR
or
Obis section need not he completed if the permit is forme hundred dol lain CREASE;TRAP
(S 100) BUILDING DIVISION FEES
les,.l
PLANCHECK FEE
Icenifyp int he Inctioany
Nebecorfor wubje this marithe W ivis'Conued,I,ha0 SEWIER-SANITARY-STORM PA.204 tT.
nm anpiny any person in any manner see as to Imenma subject to the W'orktti Cwnpen' !ENERGY FF,Ii
Oz cation Lmroof Calil'omia.Data WA'ILR IIIiAI[It WIVF.N'I'/ELNCIR
rz Q AppGca"t GRADING LLE
y NOTICE*10 APPLICANT:If.after making This Ccnifcateof E,cntptoom,you.M1nulJ WAI Ell SYS I'EMiTREATING
a ; bccomc .hjcet to the Workers Compemalion pmvi,imm.of the Labor Ctale,you am,l SOILS]Eli rx
5mhwlNutmply with net,pmvi,inmor this pNorm,ohodh be deemed revoked. RATER SERVICIi
cQ
U Z CONSTRUCTION LENDING AGENCY NIiW RIiS1UEiM'IAE,1'LM3. 1'. PAID
V O k too,whichloy This
that here isosed((Sec.
301lenJing agency for the perfonnance of )'t' RCce:plN
I, � NC work fur which thin pcmtit is isx:W IScc.309],Civ.C.)
O Land,,',Name 'TO'T'AL:
W Icndo,,,Addmss 'I
F dI Certify that I hove read Nis appheution and state Ilia he above information is BUILDING F43. r
t,') I'll,I agree m comply with all city and courr y,rain:ace,and,w¢laws relating ei QTY. MPCN A P�.' FEE
V Z huilding construction.and hereby authonae representatives or this city to enter npon Ne "� SEISMIC PEE
..hove-mentioned pn,peny In inspersion pugwsos.
(We)agree m,ave.indcnmiry and keep hurtle,,Ne Ciiyuf Capcninn against PCR IT(SSI NCE ELIiCTRIC PEI[
Iiobililies.judgmemi,an,vnd expenses which may in any wayaweagainst sail City AI:I' OR ADD'I'U MECII.
in nota, aof thpe
e gramingal his woman
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH AL1.NON-POINT
SOURCE REGULATIONS. AIRF 'e WF FM) MECHANICAL IEE
I AIR HANDLING UNIT(OVER 10.000 CFM) CONS"TRUCION TAX
Sgmamm of Apptieant/Crtmear Data EXHAUST'HOOD!W/DUCT) HOUSING MITIGATION TLB
HAZARDOUS h1ATERIALS DISCLOSURE
Willdo"ppliLat or future hmidingoccup;hit sloo,ohmalle haaallousnmtmial HEATING UNIT GO IIXL000 BTU)
I dI by the Cuperfmo Municipal Code,Chapter 9.12 and the Health vn,l Safe,
Cock.Scrsion 25532(a)' HEATING HNI'I(OVER I(1(IJX10 BTU)
O Yu, No
VENTILATION FAN(SINGLE REST) PAID
Will the applicant or future building occupant use equipment m devices which Data Roccipl X
crithmnadou,uirttmaouraints us dafimd by NC Bay Area Air Quality Mavugcmcm BOILER-COMP CHP OR 100,000 BTU)
Dimnml TOTAL:
❑Yc, F1 No BOILER-COMP(OVER 100.010 BTU,
Thave teedthe fooardo.,nmterlal,rep under Chaaar(,95 of Ne Cul i- AIR CONDITIONER
71 j
g1Orcn1fJ 1 to nISSUANCE DATE
litmiu H- &Safe Cade.Sections 25505,25533 and 25534.1 nndet,and Nat nNc NEW BESIDES I'I AL MECII. SQ�IT.
d n
bnal cntly have a tenant.that it i,my tesryrnsihili.y ot- cu ant
of rcol
/7( OYr
pt ,which mux.then tpr nmisaunnccofa Car- coli
Own ruwhon'ecd uF D c 'TOTAL:
ISSUIiD 13 Y:
dbr�,�
OFFICE