S 2160 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'I•[NOIUILDING-ELECPRICAL I'li'g�\X4�1'1'NO
BUILDING DIVISION APPLICA'FION/PPIRMI'I' PLUMBING-MECHANICAL V 2160
NUILUING PROJIrCr IDEN'I'H ICAHON
A
C,ADDRESS: • SANITARY IS APPLIC'AI ION SUBMITTAL DATE
a'(,A '` JF� 1'110N1i: CONIHACfOR'S NA.NIi: LIC NO: NIC COND ROLA
AiMii
RCIIITECIT!NGINIAi LIC NO: ADDRESS: ID
CON'I'ACI: PHONE: DUILDING PERMIT INTO
JnQ ��2�/O ❑ Consultant Fees Paid by Applicant(Initial) BLDG 171LCI, PLUMB MECH
l LICENSED CON I RAC'IORS DECISRA'1'ION QTY ELECTRIC PERMIT a
11 '1 r a I I f dad , .nrCl l t )[ rix. 'ng 1E 7013 DI?tiCR1I'TION
QZZ wuhS 1' 0000) 1Di '. 3 fid Buell ll f.aumt I ylccl RP,SIDENTIAI:
W p O PERMIT I ISSUANCE
aw. m lull force and elect ❑SPDWL ❑KITCHEN REMODEL
W-lV Liecn.e Clore LIeN APPLIANCES—RIiSIDENI'I h ❑ADDITION ❑PLUMItING RE-PIPIT
i.ZW c Contractor-
o:<'
onttor
Nab
❑MULTI-UNIT ❑sl RUCTURAL
ppm ARCHITECT'SIPANELS
II MODIFICATION
z Z 4 z I nndersland flay phos shall k used as public records UP TD 21X)AMINTERIOR ❑CHIMNEY REPAIR
YS
❑
1-'�+F-Y❑1 Liccavd P-les.ional 201-1Ul0AMPSLMPROVIiMENT �tiW IS
�c1E� OWNFR-BUILDER DECLARATION OVER 1000 AMPS ❑RAI F{REMODIBJNEP,\IR ❑D. OL TION
C5 a 1 hereby affirm that 1 an exempt from the Contractor's Liansc Law lot the
C,a U following rearm.(Section 7031.5,Business and Professions Code:Any city nor county SIGNS ELECTRICAL ❑OTHER
m which requires a Permit 6)Oneonta.alma improve,demolish,or repair any slrvclurt
E"t=tos prions its issuance.also.,mnc,nheepplfcam fs"act peremOn file a signet oamment SPECIAL CIRCUIT'/MISC.
�W} that he is licenwA p.....'to pro The Contractors License law(Chapter 9 COMMERCIAL,
W z00 (commencing with Section'I(XXBof Divivion 3 ofthe Business and Professions CoJC)or TEMP.METER OR POLE INST.
C.6 e C the he is acn.pt Ihcrefmm and the basis fm the alleged exemption.Any violation of 'BLDG/ADI ON ❑OIiM10LITION
k m LL Section 7031.5 by any applicant lair a Permit subjects the applicant In a civil pcwlly of POWER D17VICM ❑FOOD S17RVICE
W�y nut nu;m Thin five M1wdmA dollars(55110),SaQ I,novataof the n SWIMM I NO POOL 17 LIi(TFRIC T
prapc Y,or my cmpinyces with eases is Bear xnlc cnnlpcnxmi°n' ❑O"D{I!R
C F. I Jo the work,and the structure n not intended oro'@red lax suis(Sec.91114,Iiusinevx
❑1` atdl Calle:'ll C ameba,L L des,,nt pplyl ivr ,l ODU.EF$ SWITCHES-FIXTURES
43 prq,sty 11111 arld' I menrou,land h does ch kl... II' II;mOil,
[,I, employees,P wdsd t hal such'ru'ro,c cal, not .1andrd it eftned hr NLWRESI 'I'IAI.CIICI'If SQ FI'.
late.11•huwxrcr,the ln.ildingnor ilepmvmncnl is sold wnh'mnnc Ywle
rol ancille i ,(bc SQ.PIILOUR N11iA $ISO.171.I
v-hnllder will hlrve me burden of proving mm he did nnl build or ilnpruvu for pu1'-
pwc of sale.).
❑I,a. of the progeny,a ttle"v r,c'Inne ims with lwemad connaaon ,, 'fIYITI.:
outrun the pmPat(See.7014,lousiness and Professions C:de:)Ile Contractor's Li-
mLaw dole not apply In an owner of progeny who builds or i;npn.es thereon.and QTY. PLUM CP'2MIT FEE
who crnnraas fou such pcupi with a contrsnnt(s)licensed pursuant in the Conten or e
Liccnx Law. PERMITISS ,
❑Iantcx pit OTS .B&PCf..this warm
ALTER—DRAIN& — 'ATER(ITA) VAI.UAFION
m
w 5 ORP 'R'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEV
1 hand w off rpt under Cend sec of perjury nnc of the following dedurr's Co,
]
[have sent will mainmin aCcnifiate of Conwnuo self-inwmhn Wnrkcr's Cnmtpcn- DRAINS—FLOOR,FOR)Ir,ARE A CONI ES TYPI!CONSTRUCTION
.ration, is provided for by Section 370)of the Lbor Cale,far the performance of'he
work for which this pernut Is issued. FIXTURES—PER PRAT'
ZI I have line will nutinwin W..w,,Cnmpammion Irmrance,av reyuirad by Section
3701 of the Labor Cbdc•fee the pc,hncoreof the work far which his permit isl6wcd. GAS—EA.SYS"TEM-I 1NCAOUILEIS )C ( A APN
My Worker's Conlpen.otiou Insurance currier and Policy number am. OAS—EA.SYS'HCM-OVIE d HTAI
Carrico Pullcy No.'.
CI!R'IlI4CA'I'[70FEXI7MITIONI1tOMWBiKEIISGRHASEJINDUS'IRL WAS]17 IN ILRCIIPB
C'UMPENSAI'ION INSUIZANC17 B .DING DIVISION ITHS
1'llie sc.Bnn nttvl not be.... diacd ifthepermit is fur one hundeddellaa(5100) GREASETRAP
CK fl i
a less.)
Ioyanythat int in any
of the work for which Off,,,permitrka,,' oultel1l SI!WIiR—SANITARY—S'IY)HM PA.21X11'1.
not clnpinY ratty pvrnun in unY manner r,an m bcrnmc suM1jea In the Wudcr2 Compcm ENERGY PI[li
Z onion lawsof Culifomia.Date WATER HEATER W/VENT/ELECI'H
O Applicant 1:17)
Z'y NOFICI!TO APPLICANT IL after making this Ceniicam of limn Linn.You should WATER SYSTpN TRI!ATING
? become whjen h,the Worker's G.mponsanion Pns`'isiom nor the IvMo Code,yna mot SOUS ILL
W � forthwith comply Isinhsuch provisions or this penninshall be deentcl rxxiLJ. WATER SERVICE
OPAID
a' CONSTRUCTION LENDING AGENCY NEN'RESIDENTIAL I'LMB. SQ.FI'.
7z I hereby affirm that there is a construction lending agency for the performance of Ute Receipts
WD
O
'he work for which this pcnnit is issued(Sec.3097.Cie CJ 'TIDAL
p bender',Nance
} 110 I.cmddr Addm,, BUILDIN IFI11113
a. 1 rally that 1 have read this application;trill state that the above ino nru;tintt'is
to c mcl.l ligrcemcmnply wins sell nstate ty:md CtmnnY durance,and ate laws nebuingm QTY. MECHANICAL PERMIT FTE SEISM FEP
UZ boJd'utgnn.tmuliun,coA ectchy aathorimmer"readvex nfmircity to cnmrurynt tic
abavom.ntioncd pit:perty fnranspccnon pmpnru- PERMIII'ISSUANCE ELECTRIC F
0A4e)agree m rave,iadcnndly and keep Min...nnc CT'IT Ct4eldeo against
liathdoic,judglncnts,Cns1,and cxpcnms which may inxny way uccrncag;.insl.aid Cry ACI'ER OR ADD'I'II MSCI I. PLUMBING ILH
..Cqaucriof Om grunting III his pcnnit.
APPLICAN'I'UNOEI<STANOS AND WILL COMPLY WIT 11 ALA,NON-POINT' AIR HANDLING UNIT(G)l(thr ICPMH SITIHANICAI.I LI!
SOURCE REGUTA'TIONS,
AIR HANDLING UNIT fOVI?R 10000 07M) CONSfHUCfION'fA%
Signal mreof ApplicanUCnnnral Dam 1!%HAUS'F HOOD IW/DUCT) HOUSING MMI IGAI'IUN IUI.
BAZ\RDOUS MATERIALS DISCLOSURE!
Will the applicant or to,..bruldingoccupant save nor handle M1aadousmamrial HEATING UNIT(TO INUXX)B'I'Of
as dCBnW by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IOB(XID BTU)
Cala Section 25532(x)7
Yes ❑No VENTILATION FA N INGLI!HESID) PAID
Dane RecciptN gg
Will the applicam or future building occupant me equipment or device.which BOILER—COMP(}IIP OR Igl,(XXI❑'rUa
tin ha,ardnux air onnmminanu us JCtineJ by the Buy Arca Air Vm1itY Management Ill l'
6'vin'f
BOILER—COMP IOVER 100.IXX111'I U)
❑ver 0 N
AIR CONDITIONER ISSUANCE DATE
1 hav nu;l the M1n,urdmn mx¢ri;dr rcyuiremems under Chapmr 695 tit the Call-
lurniu IIc:Jdt&Safety Cada SCadnn.2$505.25531 send 255)4.I unde,swnJ mal If n'c NEW RWIDHN'Flni,MI?CIL SQ I)I'. /Vit
auldingdne ml aar"11yltavCaIcc Baht i.myrcnpn:nSbifnymnntily m,"tollut l l CD
III rey.dremelnp w4dcb nm,q he mit prior m ivsamCe of a Cuthill am of OIcul""Y.
Owner ar uulhori,cd ngnn Dale 'TOTAL: ISSUED BY: yT TQ
OFFICE
ADDITIONAL PERMIT FEES 2/ Q
iBUILDING PROJECT IDENTIFICATION VALUATION
emi
o-
A°DNfS 3.5- ?' pz k
DWA'HENS
FEE SUMMARY
F^ I` °rve
N°MEP°C�OPS BUILDIN
Q
LIC.. PLAN CHECK
coogSS NACrOF5 FEE
°NONE SEISMIC FEE t D d
CITY. ELECTRIC PERMIT FEE
63 OUTLETS-SWITCHES-RECEP jELECTRIC 0
l 1 LIGHTING FIXTURES
PPLIANCES-RESIDENTIAL BING
PANELS 'L2 ANICASIGNSSIGNS TRANS. O A
SPECIAL CIRCUIT
EMP.METER OR POLE INS. NENWII VALIDATION
MOTORS SE EE H.
0 SERVICE CHANGE
Z 2
F- ° TOTAL Ob
jr W ISSUANCE DATE OTV. PLUMBING PERMIT FEE eLDc. EJECT. vac. MEC..
CL E
0 2 ALTER-DRAIN&VENT-WATER(EA.) ❑ ❑ ❑ ❑
U O BACK FLOW PROTECT.DEVICE
UL I-
0 w DRAINS-FLOOR,ROOF,AREA,COND.
} N FIXTURES-PER TRAP
GAS-EA.SYSTEM-I INC.4 OUTLETS
U GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.2001t/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TOTAL � Zv
OTV. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT(TO 10,WOCF.M.)
AIR HANDLING UNIT(OVER 10=C.F.M.)
EXHAUST HOOD(WITH DUCT) 3 (�
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,0008.T.U.I
VENTILATION FAN (SINGLE)
BOILER-COMP(?H.P.or 100,000 B.T.U.)
BOILER COMP 10.•1.100p0ORUISEE FEE SCU,
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