S 2127 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT'RICA). PE IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2127
BUILDING PROJECT IDENTIF'ICA'TION
BUIIAING ADUlllis5'. � SANITARY NO, APPhICA'I'IUN SUHMITTAI.DATE
CWWX NAMIi 1....., : CONTRACTOR'S NAMB: LIC NO:
t m LL/ �YY-�/ N/c cord Rnl.a�
�ARCHITECf/EN dNE LIC NO ADDRESS. E] O Q O
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CONIACT': PUONE: HIIILDING 'ERNU T INFO
n _
ED Consultant Fees Paid by Applicant(Initial) HLDG li TCT, PIER 91
/ (-0 �7r/I
LICENSED CON'ITt CTOR'S DECLARATION QTY. ELECTRIC PHRMIT FEE
1 hereby affirm that 1 am IicatseJ under pmvieiatn of Chap¢r 9(commencing M JOB DESCRIPTION
OCZ with Section 70XDnf Division Sof the theinmsind Pn+rei,nors Cade,wd my license is J V RESIDENTIAL:
WOO / PERMIT'ISSUANCE J
F1— in full force and ellcet. 'Zfd t'3� ❑SFDWL ❑KI'ICl IEN REMODEL
�Urj Licemc Clucc_ _Lira .7 .�
e ContAPPLIANCES-RESIDES'I IAL CADDITION [:1 PLUMBING RE-PIPE
DwDECL
C
F.Dm ARCHITECTS DECLARATION PANELS AfULTI-UNIT ❑STRUCTURAL
ZOwZ I understand my plans shall he used as public records MODIFICATION
4)—C UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
544 Licensed Prnfesxiowl 201-10MAMPS IMPROVEMENT (]SWIMMING POOLS
•aj OWNER-EDILDER DECLARATION ❑ ./REPAIR CDENICHITION
erehy Afiim+that I anGmuLa
t nsen"I tram the a'an,Lieonse w far,the OVER I000AMPS BATH RNMOUIi1
aWyi5( y U billowing rea,on,XI...9031.5,Hal incxs and Profession,CoI Any any nr county MGNS ELECTRICAL a C OTHER
I++a n.i- which reyuin,a Permit m st
conruct,alcor,improve,demolish,nr repair any stmem
04..1 prior to its issunnec.al.so minutes the applicant for such permit o file a signed smmnmnt SPECIAL CIRCUIT/ SC.
f�} rhes he is licenxal punwnuo the provisions of the Cnmmnnr's License Law(Chup¢r9
.IYpO (commencing with grains700d)of Division 3 obthe Business and Professions CmlcO or TIiMIl MEN ER0 LIT INST, COMMERCIAL:
6,y e pL that he is usenpt therefrom and the basic far the alleged vermilion.Any situation of ❑NEW BLDG/ADDITION C DEMOLITION
allIn Smaon 7031 5 by any applicant fm n pennil mplente the applietmt u+a civil Tonally nl POWER DEVICES TENANT' C 1'IOII SERVICE
tel mom Ihan I'rvc ntmJreJ dollars(SSgB.
F Z Y PROVEMEN'I'
x6 01,as owncrofthe Pw,aary,nnay employers with SWIMMING POOL EI.Ii
F0 will Jo the work,and[lie swnnre is not intended troRered for sale(Sec.]OLt.Hmincs ❑OTHER
Wand Prows Cade The Conlmclor's License law dies nal apply to an owner of 3 OUTLEIS-SWITCHPS IXT RFS 2
pmpeny whu builds nr improves thereon.and who does such work himself or through
his own empinyvc,,pinvided that such improvements am not intended or offend for NEW RESIDENTIAL HLE YR SQ Fn
isle.If,howe...the buildup,Lnpmvenmtlt stand withinane year of cuntplminn,the SQ.PC FLOOR AREA VSQ.T4.
cr-bnlldcr w 111 hwethe hardan ufpmving that he did nal hnlld olm
rpmve baiter-
pace
a iter-
p nc of salcn. e�u�LYI/
FI I,as owner of the prnpenY,am exclusively contracting with licensed contractors m 1< w
nn.wm the project(Sec.701 Business and Professions Ctad...The Conwuorc hi- -
censeLawetxsnmapplyltan owner of pmpeny who builds(ir improves thereon,and QTy. PLUMBING PERMIT FEE
who comet,lit such projects with s cnmranorp)Harvard pursumn m the Connaaor's
License Law. PERMH ISSUANCE
I am exempt ander Sec. B R P C fee this reason
l AINEIt-DRAIN ATE )
Owner ❑nm &1 N�
WORKERS COMPENSATION DFcLARATION BACK PLOW PROTE- .D. O�
I hanhy affirm under penallyof Ierjuryoneofthefollowing Worker's
o
❑ce,as and will forbinetion acne ofCowwrI to Labor cell-insure for iforn—CnmPcm DRAINS-FLOOR,ROOF.AREA, O - STORIES '1'YI'ECf. TRUCTFON
slit,,ashicktowardi for mi Beckon 3]ql uf the Labor Gn e,for the pertmmance of the
wt k ave and this permit is i ormi FIX'I'11RE5-PER'IRAP I
{I have,L will maintain I se,rio Contpe i de, ink
In ce,as required by Section
J] Onfthelatbnt Cndc,far the per6nnvntm rel thework furwhich thispennili,ix,uctl, OAS-EA,SYSTEM-I INC yOII'rLE"' OCC.GROUP APN
My Work(((yyy C��-an��_,es,r99tin Imuruncrtarier and Policy lnyt at+� I��� GAS-I.A.SYST' )
Cartier: I jC�r?..,i Policy No.:d/ S L-/I VA
(.IiRTIPICATE OF li%IiA1PT10N FROM WORKER$'
COMPENSATION INSURANCE GkHA51%IN RL WA N CEYTGR
It tDIVISION RiIiS
(This genion need not be centplmuliOha permit is for(me hundred dollars(E10D GREASE TR 1
nr less, PLANCIIECK P ' o
I eenify thus in lhepertnrmance ofthe work far whielt IM1h permit is ixsurd,I,hell E
SEWHH-SAN' 1?A.21X1 Irl'.
not employ unY turd°ot�m ony ne be h,l-0 m the Wriest,Cnlnpcn- ENERGY FI71? fJ
A
ar
z ApPlicanws o' h ta. ala i� k�+ WATER 111iATE /VENI'1131.EC1A
GRADING
ti NOTICETO XMILICANFE If afro making th,Creificam of Exemption,you chnnld WA'I'1iR SYS'IEKING
a , become subject m the Worker's Compensation provisions of the Labor Code.you most SOILS FF.E
Wforthwith comply with such provisions or this pernal shall he deemed revoked. WATER SERVICE
Q
CONSTRUCI ION LENDING AGIINCY N13W BHSIDENTIAL I'LMB, SQ.FIT PAID
_O of ¢ Receipt
U b
1 herehy action that mere is s construction lutding agency forme perfnrmnncc
me work for which this permit is issued(Sec.3097,Civ.C.)
u" U LenddTOTAL:
s Name '1Y11'AL:
W Lenders Aki
I certify that I have real this application and state that the above information is BUII. :FEF. 75-
Q
rFa r�A correct.I agreeta cootply with all cilyand county nrdimmceseed state law,relining to QTY. MECHANICAL PERMIT FEE
U Z said ing anrvtmclion,and hateby atharize representaivax A this city to enter upon l he SEISM FEE
mase-memo rdpropdyforine"w"itn puptoses. PHItMITISSUANCE
(We)agrm m save,indemnify and krep harmless the City of Cupenino againel ELECTS FEE ZL
liabilities,judgments,costs and expenses which may in anyway Incme against said City ALTER OR ADD TO MECIf. O
in consequence of the granting of this prrmil. PLUMBIN PER
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ONI'T('IO 1(1.(WCFM)
SOURCE REGULATIONS. MECHANI LITE f
AIR IIANULIN ,UNIT(OVER 10.000CPM) CONSTRUC ON'TAX
Sign....col APPlinmt/Contractor Dam I;xl IAIIST H00D(W/DHCI) HOUSING MI'HGAI'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
NSIl the applicant or future building occupied stow or handle hvardous material HEATING UNIT(TO 100,000131"U)
I defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Cade.Section 25532(,)' HEATING UNIT(OVER 1(X1,000 BTU) It
❑Ye, EJ No VENT'ILAT'ION FAN(SINGER RESID7 I'AIU Dues iplN
Will me:p+plicn i or battle building cY,npanl use c,It Net or devices which
vent lsmrdau,lir contaminant,a%dclinW by the Bay Arcs At,Quality Managcmcnt BOILER-COMP(3HPOR I OLM)BTU) t
E]Yes Fl No - BOILER-COMP(OVER 100.000 BTU)
AIR CONDITIONER
I h amail Safer Harrel materials 5, adv Chapter 695 ofthe it in ISSj1AIs)r,E DATE /)
tom' Heidi kSftyCal Section,25505 is my 3513, de 'landIhtt fthc NEW RESIDENTIAL illicit. SQ.ITT / U Off(,
build gel : t s m fit rom,
n,i t t t yresponsibilityI notify tau p.n
of the reyu n rte rex which amt he,rel priono Issuance of a Crnnune d Ocetpmnvy.
Owner or undeterred agrm [)am TO 1'AL ISSUED BY. a
OFFICE