S 2123 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PESIT NO.
BUILDING DIVISION APPLICATION/PERMIT MATURING-MECHANICAL �J 2123
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRFSS:� � SANITARY NO. APPLICATION SUBM1'f1AL DA'1'B
m6 6gi
OWNER'-'SS NN_/AME: - PHONE: CONT RAC'I ORS NAME. LICNO: I R
�,I/rV SET /J CONTROL#
-KRCHI'fF.CI/RNGINIJCN ADDRESS ❑ lC g 3
FIT PHONE: BUILDING PERMIT INFO
J��' Cao WT'A 100-10-V ❑ Consultant Few Paid by Applicant(Initial) BLDG EI,B t1MH_ MEGH
LICENSED CONTRACTORIS DECLARATION QTY. ELECTRIC PERMIT FEE C�Jf rJi �L�J/ IL/—J�/
1 hereby nfflnn that[not h"erv,ed ruder pmoi.ions of chapter 9 mcourra ng JOB DESCRIPTION
DMZ %ith Section 7000)of Awixion 3 ofthc Business std Pmreasionspude,ane mylleunse is RESIDENTIAL:
OO PERMIT ISSUANCE
F w-n in fall force rud el ear •' ❑SFD L ❑KITCHEN RIiMODCI.
AU Lieetue Clnsn Lic.# gPPL1ANCES-RESIDENTIAL DITION ❑PLUMBING BE PIPE
y�¢] Dom Contractor
2C2 ARCH]I'IiCPS DECLARA'110N ❑MULTI-UNIT El STRUCTURAL
z O t2q PANELS
I undecsmnA my plans shall he used D,public rewNe MODIFICATION
C UP TO 200 AMPS 2Z- ❑INTERIOR 11 CHIMNEY REPAIR
W Liecroed Pmfcssi...I 201-INOAMPS IMPROVEMENT SWIMMING POOLS
d ❑+y'..�I OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑RATE REMODEIJREPAIR (]DEMOLITION
o w Q I hereby affirm that I nm exempt front Lha Contrast...License Law far the
�(g wU following rester.(Section 70315,Business and Profession,Code:Any city it county SIGNS ELECTRICAL L1 OTHER
O y which requires a turret to construct,altic,-outlines,densilish,Or rapairy structure I �7ia0•TiON
F� < pfO I I a1. e4 Look h applicantl hl it fl ''g :i diemem S PECIAL CIRCUIT/MISC.
ap 'but h :d pronarato,the p n I the C trai License L (Chapter 9 COMMERCIAL:
Restructuring with Section 7000)ofDivision 3 otthe Harness unit imfessins Grdbi Or T EMP METER OR POLE INST.
p+y a that It,is exemia neutron and the basis far the alleged exemption.Any viol pion if [:1 NEW BLDGIADDCHON El DEMOLITION
Wmae Secret 90315 by any appllanoI rapermit odrets lbeatpplicam to o civil penaltyef POWER DEVICES ❑TENANT ❑FOOD SERVICE
nil oran,than firve lainfired doll...1$9X1
❑1 fth p soy y ply 'tl gen:th' lee �pen. fm, SW IMMING POOL ELECTRIC
IMPROVE
5y�(.: willl th k nJ rhes t i. fm dd R of r 'I (S 9044,Buie ❑0'fHl?R
It13 m and Pmfexs ns Code I he Contractor,L ...e Urns J t apply t t t w ofOUTLETS-SWITCHES FIXTURES
progeny who builds it improves banner,ant who die,such work him.elf Or through
[its own employees,provided that such improvements are not intended it offend fur NE - DENTIAL ELECTR SQ FT.
safe 11,howevai bulldingor i mprayconcen sold within nunfa+mpl
c yeare.ion.the SQ.FT.FLOOR AREA $ISQ.PI'.
'owner-lailderll have the burden f provis,(but hJin a(,,hold p f sera • �� q I f O to
pes f J, TOTAL. �p
El 1 propertyfthe ly contracting withl ed . t. tvto .S Ot
construct l p J i(S 91M4 B A Professions Cad )Th C trt :1;
ren La.d oes n lr,T], P crowns,ofp p cryWild. -rl therene,and QTY PLUM PER FEE 47
who t ts for suchp jectswth+contractor(s)licensed p .cant or the Cam- tors -
License Law. PERMIT ISSUANCE
❑ I mncxemst under See. ,B&PCfor this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Data +�
WORKERS COMPENSATION DECLARATION HACK FLOW PRO]HC'I.DEVIL' D � �
1 h achy offlour under penalty of perjury one of the following declarator, J
'Q (have and will mninlainaCerlidcrle of Comenl Inself-insure fur Worker's Cnmpen- DRAINS-FLOOR,RODE,AREA, D. 5'IORIE, TYPE CONSTRUCTION
9atian,os provided fur by Section 3900 of rhe Labor Code,for pedarmanec Of the
work far which this pronit Mrs sued. FIX'I ORES-PER I
❑I huve and is IF maintain Worker's CoinpenvttlOn Insurance,as reyriud by Section
3700 ofthe Labor Code,for the performance of the work for which this perm's is issued. GAS-EA.SYSTEM OCC,GROUP APN
My Worker's Compensation In sura nee carrier and Policy namher arc
Carrier Policy NOa GAS-BA.SYSTEM-OVER 4(F.A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUS'fRLWAS'I'E IN I'ERCEP'POR
(Thissmtonnwd not arstantletndiflhe pemdti,fomarlondriddoller,6100) *BU I N -IBIONPEES _
or to,,) GREASE TRAP E
III
I cosily that in the pbrournarce oftic work for which Nis prouit is Issued,[,[,all SEWER-SANITARY-STORM F.A.2110 FT.
sol nnpiny an nmon in uny manseLan�ajm beMJ{ne sub+cetmOO Wnd:ors'Cotnp r ' CY
Z
saiion Low'
oron Uate t__ •__L {aaQ WNIERHEA'I'ERW/VENT/E TR
70 Applicant�" (]- GRAD( .FEF
^� Vi NOTICE TO AI I ICANT,U aper making this Cenilleote o[Psyou shault WATER SY.STP.MITREATING
� ? basin,auhjcct lO the Worker's Compens+nion pmvisiunx of the Luhor Code.you must SQQS P
W faricomply with such prnvismn.or this pennil shall he deanal revoked. WA'PERSERVICE VV
Q
UO CONST'RUCT'ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
I bambyaffirmlbot there iiacou,no,finlending otters,for the perlarboure of Unm eccipt#
", F the work for which this senior is Lased(Sm.3097,Cly.G)
C ULender's Name
Lender's Address TOTAL:
I eerily that I huve rend this itatra nunr end ,are ttul It,ohne,contraction is ILL G FEE
h correct.l agree to comply with all city unit"fumy m Nuance."aad,mm laws"Ungm QTY. MECHANICAL PERMPP FEF.
Uzi bnilJingconxWetion,andherebynuihonze u,na,enmrvcofthtseity memerupon me SEISMICFee 1r' .o�
above-mentioned proposy for inspection proposes
(We)agree m save,indemnify and keep harmless file City of Cupcsino agvinst PER ISSUANCE ELECTRIC FEE ��_
Iiuhili0c,,judgnranls,uhM.and expenses wldchmay many way amrieagatnatand City ALTER OR ADD TO MEGH.
setter"if the granting of this permit, PLUMBING LEE
APPLICAN'I'UNDERST'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CPM)
SOURCE REGULATIONS. MECHANICAL 17EL 71x
AIR HANDLING UNI'I'(OVER I L000 CFM) CONSTRUCTION TAX
Signature of ApplicaraVontnnor Di EXHAUST FOOD(W/DI1CT1 IfOUSING MI'PIGA'PION FEL
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future holding occupant,mre it handle hoonal—smaterial HP.ATING UNIT(TO 100,1100 BTU) I /�
as defined by the Cupertino Mnac'TDI Code,Chapter 912,and the He,bh and ■,N Sanity 0,0 V
Code,Sermon 2559200? .// BEATING UNIT(OVER IfH1,OfH1 H'PU) ��q �`C/�/���-r��
❑Yes IN VENTILATION FAN(SINGLE RESID) PAID•-+r--e.e �V-
Dmc apt#
Will the in,enunciation
fuwrc hni lding cieby B ynic Ae,,At, ualitOr devices which BOILER-COMP(3HP OR 100,000 BTU)
mit NtzallouS air conwminant,as pclined by Be,Ne Pay Area Air Quality Mamtgemem TOTAL p�Q
Curts,P L.-JL^/ BOILER-COST(OVER 100,000 BTU) il
❑Yew
I hair read the lmwnlons materndsteyrirnnentsunder Chopin'6.95 of tic CDII- AIR CONDITION LR ISSUANCE DATE
fomin Health&Safety Code,Sceten,255(R.25533 and 25534.1 understood that rare NEW RESIDIN'UALMECIL SQ PC
building docs not currently here u teaam,that's iS my respunsibiihy to notify the Occupant
Of the myuimmans which moat he ten prior m iammteo of it COru9cnm olOmupuncy.
0,act or nalborircd agent Dme TOTAL', �.,to ISSUED I3Y'.
OFFICE