S 2749 —APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT - PLUMBING-MECHANICAL Q �]7 /I 9[1
BUILDING,PROJECT IDENTIFICATION O 2 1 4
BUILDING ADDRESS: SANI IARY NO. APPLICATION SUBMITTAL DATE
��/
OWN' Mt.: PHONF. CO TRACTOR'S NAME:. LIC NO:
/G NIC CONTROL k
ARCI III ECUENGINBER: O LIC NO:. ADDRESS: - ❑
'A ` S
CONTACT: PI IONS: - y BUILDING PERMIT INFO
- ❑ Consultant Fees Paid by Applicant(Initial) _ BLDG ELECT LUMB MECH
❑ ❑ ❑
IICFNSFDCONIRACIORSnFCLARATION
hereby afrn That l I' : L d p : f Ch Ir 9( einsQTY. ELECTRIC PERMIT PEE„
WO
JOB DESCRIPTION
Ow
PIRMITISSUANCE RESIDENTIAL:
CWU i a 4II forceforce and-f S O ❑SNDWL ❑KITCHEN REMODEL
dVV IJcen, i.ie.N APPLIANCP.S-RESIDEN'I'IAI. ❑ADDITION El PLUMBING RE-PIPE
y<ts, Orale Cnntrnidnr
FPm - ANCiII'IECI"SDIiCLAh fION PANELS ❑MULTI-UNIT []STRUCTURAL
Z p so Z 1 understand my plans shall be used as public records MODIFICATION
024 - UP TO 200 AMPS
pp
EPAIR
f"W Licensed Prool"iunal ❑INTERIOR ❑SWIMMINGNEY POOL 2111-IINIIlAMPS IMPROVEMENT (]SWIMMING P001.5OWNER-BUILDERm the Con IONOVER I000AMPS TH REMODEL/REPAIR [I DEMOLITION
1 heasoeby.Rano onnl 1 1. eBusin frahn 1Pr CssionstCo IJeece Lnw for(hed U hick a mi...o.(Section"calla,Business mod.se.d raps Code Any city or county SIGNS ELECTRICAL OTHP.R
W y whinh its issuance,
operant re ennsoue,alley,nt Eimp nstein
in plural t or la siir any enmatpd
FSO pnofmns issuance,alto requires the applicant rnr.vucb pennilmfile avignelsWlemmdt SPECIAL CIRCUIT/MIFC.
[hal be is llcemed pursuanu)the proamomofthe Contractors License Law(Chapter9 -
P40
O (commencing with Section 9010)of Division 3 ofthe Businesvand Professions Crde)ur TEMP.METER OR POLE INS'f Q COMMERCIAL:
W that he is excmpl themf ver and the basis for the alleged exemption.Any violmion of El NEW BLDG/ADDITION ❑DEMOLI'T'ION
iC W
Section)(HISby' Yapplicantf p t: bl (the ppl tl 'Ipnllyof POWER DEVICES
W all []TENANT - [_1 FOOD SERVICE
oat Ib f handled d II' :(8500)
ZQ 1.n,owner if(he p p"y Y employees with Argos as lh ' 1 l i „ SWIMMING POOL ELECTRIC IMPROVEMENT
4CCC'f"' will) thek d0 1 t tintended ff df I (S 04
.94 B ❑OTHER
W�a
,,to Ptiflonian,Code The Contractors License Law Joe,our apply In an owner of OUTLETS-SWITCHES-FIXTURES -
prnpuly who bunds or improves thereon,and who does such work himself or Through
his awn employees,provided that such improvements rare not intended or offered for NEW RESIDENTIAL ELECTR SQ FL
sale,If h Ili h Id g P Id Militia due yot aramplefica, he $ISQ.FT.
b'Id will h' Ili burden fproving that hdid Ib IJ p fry par
p sea f ).
❑ 1 f Theproper,, exclusively r i g with licensed (x ters o 'PO'1'A L:
constructh project(S to
B :' :. odPmfso n C de)TheC to L' - x
claw
Lawdoes t hplyl nt perry h h dpimprovesIli and QTY. 'PLUMBING PERMIT FF.F,' MAR -I Q ��� '
whocontractsCor euchprojects w'thacoma ngs)liu.nad per:tavola theC nhaeor, - MAR 1 O (
License L PERMIT ISSUANCE
❑ Iamexcmplundar Sec. ,B&PCRrthis recon
Owner Dom ALI ER-DRAIN&VENT-WATER(EA) p VALUATION, x
WORKERS COMPENSATION DECLARATION BACK FLAW PRO]EECS'.DEVICE Y
1 hereby chiral boder pcnvly of perjuryane of ahs following deehnalions
❑ I havcand will member a C,nihcvte of Cotner,laself-insure for Worker's Compen- DRAINS-FLUOR,ROOF,AREA,COND.
satinuere,as provided for by Section 3900 of the Labor Code,for the parforn a of the STORIES 'TYPE CONSTRUCTION
mi
work for which this pert is issued. FIXTURES-PER TRAP -
O 1 have and will maintain Worker'.Contpemmlion Insunmce,as required by Section
37Moflhe Labor Cade,for the performance offal work for which this permit is touch GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wor pensvT Insumnw en rand Policy raw
Corrin: �1{($b� oto Policy No: GAS-EA.SYSTEM-OVER 4(P.A)
CERTIFICATE OF EXEMP'T'ION PROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTF. FPTOR d R Y y
„ x BUILDING DIV ISZOFRES *
('TM1ic section neeJ not he completed if Ihepermit Is forme hundreddnllers($IIN) - ---W
rr less) GRt?ASG'fRAP PLANCHECK FEE
I calify(list in(lie performance ofihc work for which this permit is owed l shall SEWER-SANITARY-S' RM EA.201 IT.
nal employ my pmm�in any mammy so as tobecome subject to the Workers'Cori ENERGY FEE
Z statim Law,of California.Dano
WATER HF.ATF.It WI :M/ELLCTR
Q Applicant 1 GRADING PGE '
faNOTICE TO APPLICANT:11 after making Thi,Cetlilealc of Exem (ion,you should'
5 , WA"I'EIt SVSTE IREA'IINC
N befluxasubject m the Worker's Compensation provit hal of the Lam, you must SOILS FEE
h� forthwith comply who such provisions or this permit shall be dcemad revoked. WATER SE ICE �
Q CONSTRUCTION LENDING SI
AGENCY NEW DENTIAL PLMB. SQ.PT PAID
U 0 I hereby aRimn that here is a construction lending agency for the performance of c Receipt on
I1r Hthe work for which this permit is issued(See.3097,Civ,C.)
V Landare Noma TOTAL
Lend Address TOTAL:
1 clantyffial I hall minibusapplication d. bal he shove dabout, -- -- BUILDING FEE -
FrIaG
correct,I agree to comply with all city and county counteractions]sate lawsrelat gta nQTY MP.CUAMCAL PERMIT P88
V ,7. building conduction,and h by influenced representatives orbit city o ,
enter upon The SEISMIC FEE
ab rvalentioocd progeny Tot inspection Curl
(We)agree to save,Indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
ishilhoes,judionats,costs and expenses which may in any way accme against said City
msegnenecofthe"a in'of Nie permit - ACTERORADDTOMECIF PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT('to 101,000 CFM) -
S(iig `CE REGULATIONS 9 / MECHANICAL LEE
- �^I7 x7 / AIR HANDLING UNIT(OVER 10,000 CF CONSTRUCTION TAX
Sdr uNlr�e oflA Cbnlrnemr Ila: / EXHAUST HOOD fW/DUCT) HOUSING MIT[IGAT10N FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fund building occupant sure or handle hazardous material HEATING UNI 11 TIO IEd I!)
its defined by the Copartner Municipal Code,Chapter 9.12,and the Health and Safety
Coda,Sectio 25532(x)? - - HEATINGUNIT(OVF. 001000B9U)
❑Yes ❑No - PAIN 9
VENTILATION (SINGI3.RFSID) f m I IewiplM
.� Will the applfcent rr from building omcupudl me equipment m devices which
emit air conmmivants as defined by the Bay Ama Air Quality Mamtgenenr BOILER-C P(MHP OR 100,010 BTU)
District?- "f0'fAL:
i ❑yes [D No BOIL- -COMP(OVP-R'100.000 BTU)
1 have read the hazndnm nnnerials re uimnnchns under Chapter 6.95 of the GLI- CONDITIONER
9ISSUANCE 4DAT
Terrain Hevllh&Sandy Code.Sections 25545,25533 and 25534.1 understood thin if theNEW RESIDENTIAL MECH. SQJeI'.
building does not currently have a Iunanl,that it Is my re po ramity to study the occupant
of eq cots tact he met priono issuance of a Cenfficase of Oceupancy
O e ( orizW agent pas TOTAL: ,ISSUED BY'
OFFICE
r