S 2187 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPERTINO BUILDING-RLECpRICAL PE lTNfl.
ISUIIAING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2187
nuu.umr,rkodFICE IDENI IRICAIION
11UILDING AUURE.SS: _ I-Ir l SANI'ITRY NO, AI'PLICAl10Y SUIfMI'1l R
AL UA
76 �3 IrG✓�OQ Way , Ch 1�O/1/ ? '/ _
Min
q on �nN PHOFFO���� ONTRACI11k'$NAME: LIC NO'.
•.////IIky.IIII W„ T6
NIC CONI Rol.n
ARCHITECT ,GINEER: V LICNO, ADDRESS: ❑
CONTACT: r PHONE:/� ry BUILDING PERMIT INFO
i A1 A4"Y ��l #vO /16 4610 ❑ Cunsultant Pecs Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
' 8 6 �T El ❑
LICENSED CONTRACTOR'S D:CLARATION QTY ELECTRIC PERMIT FEE
1 hereby afinal 1 an licensed under provisions of Chapter 9 fmencing JOB DESCRIPTION
WOZwith Stenon 70001 of Din that
3ofthu B....u„end Professions Code.vnd my license is PERMIT ISSUANCE RESIDF,NTIAL:
C12 F, in full force and effect. PERMIT
El KITCHEN REMODEL,
U Licence C.lms Lie.If
6ZU APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
HQ� Umc Cov DECLARATION
f-Dm
ARCHITECTS use Us public ATION PANELS ❑M11UI:1'I-UNIT ❑MODCTURAL
Z p m Z I understand my plant shall he used as public records hf(IDIIICATION
OZr3—a UPI'O 210AMPS ❑TNTF,RIOR El CHIMNEY REPAIR
F�FW Licensed Pmuf siunal 201-I000AMPS IMPROVEMENT SWIMMING POOLS
�yOWNER-BUILDER Uh:CLARA'1]ON
OVER IND)AND'S ❑RAUBREMODEUREPAIR ❑DEMOLITION
C C Q 1 hereby lotion not I;on excu l from the Cuntruclors L iecnse Law for ills
U Iollowing notion.(Section 7031.5,Business and Professions Cot Any ely or county SIGNS ELECTRICAL ❑OTHER
hwhich rt,uims a permit a,o nttrum aIle......Pmts,demolish,or repair any%roman u
pnoTm its issuance,ab'witti s,floo applicant for such punniuo file a signed.s000noul S PECIAL CIRCUI UMISC. I
EryQ` that he is licensed pursuant to the provisions of NContractors e Contctors License Law(Chapter it
W C) (Poomwnaingwiln Section711WpdDivlsionSof theBa,inessand P..c,,ions Code)nr TEMP.M17ER OR POLE INST. COMMF,RCIAL
a a c C that he is exempt d•erfrom and the bask for the alleged uswunno Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
,kn LL Section]0315 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES
LLnntnrc tloo live It Red dollars(S500).
El TENANT ❑FOODSERVICE
S� ❑Lac owner of the property,or my cmployes with wages as their sole centpelcation, SWIMMING POOL.Y:LF.C'I'KI' IMPROVEMENT
F will Ju the work,and the usuctumnnot nnunJuJ or ulTertdfor-sule($ec.]BW,Business ❑OTHER
C3 ..it Pbnm'sinm Code:no Contr-nanr',Linnet Law doe,not apply In an ownar of OUTLET S-SWITCHES-FI lis
property who builds or improves thereon,and whit docs such work himself or Through
Ns own employees,provided den such improvements am not intended or offered for NEW RESIDENTIAL CLEto
sale.If,however,the haildingor tion ern in"',it wilnin int you-of utmpldinn the SQ.FE FLOOR ARRA 9ISQ-PE
her-builder will have Ne burden of pmeing that he did out build or improve for pur-
llsc
of the""ER
v exclusively contract ing with Iusesed contractors to TO AL
a.tract the p a '(Sec.](IW.Bminee,and Professions Castro The Comswun',Li-
cc haw dos sun apply m an nwtmr nt pmpcny who nuildc or impnwcs Ncreon.anJ QTY, PLUMBING PERMIT E
who cant,,,,..-for such projects with n coula out licensed pursvanl to the Contractors
License Irw. PliliMl'T ISSUANCIi
❑Lam cncmpt and«Sec. ,B&PC for Ni,moaon
owns Dmc ALDER-DRAIN&VENT-WA'1'ER(EA)
VALUATIONHKHR'S COMPHNSAI'ION 1401711111 ION BACK FLOW PROJECT.DEVICE.
I hereby affirm under penalty ofpedury one orthe following d iaranion.:
❑I have and will rainnin a Cerificam of Consent tocels-insure for Worker's Compere DRAINS-FLUOR.ROOKAREA COND. S'TORIFS TYPE CONS'TRUCTbr
talion,as provided for by Smiles 3700 of the Later Code,for the prrfonnunre of the
work fill which this permit is issued. FIXTURES-PFR TRAP
[] I hem—old will maintain Workers Compenvalimn Insurance,a.,yuired by Section
3700of Ne LaMn Gds,fertile performance offs work forwhich this pcnnil iiiasued. GAS-HA.SYS'1'EM-I INC.4OUTLETS
My Workch Cnmpenaainn Incumnec Gamier and Policy..'raw,ber ae: OCC.GROUP APN
Cunicr. i Policy No,: CAS-EA.SYS"CEM-0VEN J(EA)
CERTIFICATE OF NATIO INNIRAN WORKERS
COMPENSATION INSURt I,on GRHASI]INDUSTRI.WASTI?INTERCHITON
(This,lion nein nut beu,mplvteJ if Milo permit ief on 6undrcd dollen(glfMq BUILDING DIVISION FI?IS
or less) GREASETRAP
1'LANCHECK FEF.
testily that in the any ounance aline work Ins which Nis pcnnil is i cath,l shall HWHR-SANITARY-STORM PA.2011 I'L
not nttoull"YLaw,any person in any Mennen no a,m M1mwnv suhjcct m the Wolkcrs'Conywr- ENERGY FCL
O C) Applicant
of Calilnmia.Dae WA I'ER "RW-
Q APPlkanl '
GRADING 19iF,
.N.
NOTICE APPLICANT:If,Corr nmking Ihls CanlO Roe Exemption,you should WATE SYS RE l O
a > hceume.wbjea m Nc Worker's Campenvtion provisions Rhe haM•r Crdc.You must � SOLI ti PCfi
forlhwiln comply with such provision,orthic permil shat]be deemed revoked. W ICE
UZ CONSTRUCTION LENDING AGENCY NISW kLSIDIiMI I. IQ,IT PAID
Up Iforwhih this thathereistsued( ee.3nlenJing agency nils perfonnanreof Dem RaciplN
� � No work for white Nivpermit is issued(See.3097,Civ.G)
C) U Lend,,,Name IOTAL:
Tender',Admcs.c TOTAL:
Fa Icertify Nal I nave mad this application and score Non the aboveeforroaamr it BUILDING PEE
til) corecl.l agree nr comply withall city and county ordinances and atom Now,reladngm QTY. MECHANICAL PERMIT I'FE
U 'Z budbultcansrrol...I and el naNa.im orifeesemallve,nook ciryln core,upon the SEISMIC FEE
vMwe-na:ntioned progeny for inspection purposes_ 1'F.KMI"1'ISSUANCE
(We)agree to save,indcmnily and keep harollect Ne City of Cupenmo against CLECPRIC ITE
Iiahilineo,tedgmerb.costa and expense.,which may in any w;n accrue agvinel.,ald City ALTER OR ADD DO MECI{,
in cu
nwyuence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNITGOI(kOCFM)
SOURCE RIiGU`ATION'S. W MECIIANICAL FEE
AIR HANDLING UNIT BI V ER 10.000 CFM!
•�/ IAM CONS'TRIICTION'I'AX
Signature of Ap 'anUConeacmr Dem EXHAUST HOOD(W/DUCT} HOUSING MITIGATION FEE
IIAZARDOUS MATERIALS DISC F,
Will t heapplicnnt...future holdie'ece., I'no,nun
r hdie ho,aolus materiel HEATING UNIT(10100,W0BTU)
as defined by the Copeat..Municipal Cede,Chapter 9.12,and Ne Health and Softy
Coda,S ohne 25532(7), HEATING UNIT(OVER 110,000 BTU)
❑Yes [:J No
VCN'1'ILATION FAN(SINGLE RESID) PAID
1 Will the applicant or future building occupant use equipment or Jerire.,which Dau Receipt M
mit haardoas air concern,...n,defined by the Bay Area At,Qaaliy Manag uotf BOILEk-cUMP(iHl'OR IIXI,gMI Rl'U)
D"bar? T TAI.
❑Yes Fl No MOILER-COMP(OVER l 00.01)BTU)
I have maul da hazardous maarialk requirements under Chapter n 95 of the Cal i- AIR CONDITIONER ISSUANCE;DATE
loild Health&Safety Cuda.Section,25505.2s only and 25554.1 in
nroily th that if the NEW RESIDENTIAL MECI I. SQ.IT. Q
buire regircurets whicyhave rowlic n'mLhat ltisuarccofaCeglycolccfylhealey. C/
m sur regairenmmx which matt bu mu pour u.i„aame or a crndimm arfxeaptnryy.
Owner or amborracd agent Dane I O AL:
lssum
OFFICE