S 2180 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ]IIIII.DING-ELECTRIC,AL PEtIT NO. 2 180 1 8 O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING PRO Ecr IDEPHIFICA11ON
BUILDING A OGRESS. �� /�� SANITARY NO. APPLICATIONS/U'B MISTMAIAII..UAtE
3 ( �
OW F W I Ir ^ Dy�'RACTOR:ti ^ IC O:
P1 rJ.Jr UY LG -NIC CONTROL p
•ARCHITF.CLIENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
2 y� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELEC/ PLUMB MECII
LICENSED CONT'RACTOR'S DECLARATIONJ GJJ( QTY ELECTRIC PERMIT 17EF Irk✓ (�G/
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z wilb Seeion JBRB)o(Divisinn 3onhe Businessand l'mfessions Costeardmylicense es RFSIDENTIAL:
O O PERMIT ISSUANCE
FW�F in erre Class effect. ❑SFDWL ❑KITCHIiN REMODEL.
Q,UU License Class LION
Dam Comracue APPLIANCES-RESIDENT'IAI. C1 ADDITION [I PLUMBING KL'-I'll'E
aF<1
ARCIII'I'I=S DECLARATION C1 MULTI-UNIT El STRUCTURAL
F 7 y PANELS MODIFICATION
czy Z 1 uealcom nil my plans shall he u.md es public records
— UPT0200AMPS ❑INTERIOR El CHIMNEY REPAIR
til Licensed Professional 201-11"IAMPS �I''M'"PR'�OVEMENT SWIMMING POOIS
G `4 OWNER-BUILDER DECLARATION gyswrrrrcF.MODEUREPAIR ❑DIEMQLITIDN
Q I hcrchy affirm that I ann exempt Inns Inc Commnor's Lucerne Law far the OVER 1000 AMPS
�G IY U mdowin,reason.(Sermon 9031,5,Business and 11..fit ainns Cede:Any city or county SIGNS ELECT RICAL ❑OTHER
a13O y which acquires a permit In cmtgmcl,alter,imprnve,dell,rlith,or repair any nnuclare
pdrr In it,lxemmen,alk regaut,tnc a,liennt forsuch p,nuit a filen signed statement SPECIAL CRCUI UMISC.
ppp jl•] Ihatnc ineing om Seeman
eemn1nu,11 DIVirne or the Conaonc,,ILiccnxellion,Cantcr9
p'p0 (enlnmencingwilh SedinJlx)110ur Divixinn7nfshe llu.cinen.v anA Prnfesainns Cade)or T13M1'.ME'I'ER Oil POLE INS'll IAL°
that he is exen,pl dmmfro;n and the basis fur the alleged exemplinn.Any vinlminn of NEW BLDG/ADDITION El DEMOLITION
W,,,y Section 7031.5 by anyapplieunt for a permit subjects the applicant to u civil penalty or POWER DEVICES ❑'TENANT ❑FOODSERVICE
>q not tome then five hundred dollars(S50B. IMPROVEMENT
Fya ❑ 1,as nwneroftho progeny nnny unlpinyues whh wages vs 0olr sole cnmpcnsaher. SWIMMINGPOOLELECIRIC
�FHO will de thework.nnl lhesuucnre is not Intended or afford for.sale(Sec.9014,Business LD OTHER
W 3 m and Professions Come'[he Contours License law does not apply to in owner nr OU'1'LF.TS-SWITCHES-PI%TURES
.. progeny who builds or improves them-tin.and who doer such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDEWIAL F,LECTR SQ FT.
sea•.If,however,the brildin,or lmptoement isxold wiahinow,cm emratithin,the SQ.FT.FLOOR AREA ISO,FT.
micau-builder will have the burden rf loving that he did nm buildor improve par pur-
pose of sale.).
L as nwnef of the pn,peny,.,,I.1co rrosi n,with licensed contractors m TAL:
, vuca the project(Sec.7W4,Business and Profession Cwn:)*Me Contractors Li-
venseLaw doesno,apply I,anlrr,dy who builds or improse,dowen,and QTY, PLUMBING PERMIT FEE
who Contrasts for such projects with a commands)BeenuJ pursuam to the Contrnod
License law. PERMIT ISSUANCEElI am exempt andel Sec., .�.B&P C for Ibis reason
ALTER-DRAIN&VISIT-WATER(HA) VALUATION
Etc
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE D O
1 hereby affirm under Penalty of perjury one of the following dedartiom:
❑I have and will mainminaCenificateofCnmscnloself-insure Le Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STOR&S TYPE CONSTRUCTION
comm.as provided for by Swed 13J(R of the Lmn Cage,for the perfomlance of the D
work for which this Permit is i.swcd. - . 'TRAP
❑I have and will amiumin Workers Compcmution Insurance,a. rcgmbed by Se
371)1 of the Labor Code,for l he p criumuce of the work for which IIs roil isi I G -EA. ' ?M-I INC.40UTI%I'S OCC.GROUP A1'N
My Worker's Comlxn.wlion Insurance can let Ind Policy nouber a
Cartier: ladies No.: GAS-EA., IM-OVHR 4(EA)
CER'I'IIICAFEOVHXHMI"1'IONFROMWOIIK1 �y a IN I NL WAS'rl?INTI?NCIii4
COMPENSAHONINSURANCE r UILDING DIVISION FESS
(Thisneclion necdnu becnmiewd Dbe pom,il is tnnme nuV, --dd.11.11 IIXpor less.) ORHASiiTlt ICemfylhal lnthoperl am,euflnemkle,whiehihkspeixcued,Ixall SEWER-SANII' Y-SIURMHA,2sol enspinyanytenn in anymnnneran nsohumma sulject to lM1s'G,ni EN
net
O Z-I amton Lowsol CeliRtniu.Duly II:AI'EI<W/VHN'Tll?LIiC'I'It
71.I Applicant
F7 ran NO'DCHTO APPLICANT:If:Enter nuking l bis Certifiuuse of Exemption,you should WATER SYSTHM11'REA'I'INC,
becmne xnbject ,,the Workers Cumpenen i pmvialons of the Iaher Code,you must SOILS P:v
W forthwith comply with such provisions or thus permit shall be deemed revoked, WATER SERVICE
Pr Q
GONSIRUGOONection NGAGgenty NEW REtifDENI'IAI.PLMIi.
r�7 .� aR ReceiltN
I heathy which
infirm that them Is s cumuuc.30 lending Clercs for the perfnnngnne of U� the workfar which this pemnit ix issue](Sec.3097.Civ.CJ
W. I"I Lender's Nanne TOTAL:
U Leader's Address T I' L:
W 1 certify that I have read this application and store that the above information is BUILDING FE D
oFs V) correct.I agree to comply with all city and county ordinances and suite laws regain,1. QTY. MECHANICAL PERMIT REE
U Z building construction,and hereby Euthodse representatives of this city to enter upon the ^ SEISMIC FEE
above-memioned progeny for inspection purpxnes' PERMIT ISSUANCE 'V O
(We)ogto save,unsoundly and keep ha tele,the City of Cupertino aguinaa ELECTRIC G
res '
Imbiliaies,judgmcnts.anb End capsaw,which miry many way accmeagainn said Cit, ALTER OR AGO TO MECH.
onseque coffin,gramingofahi"mot PLUMBING EE O
APPLICAN-'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UN1'I'('10141Xp CFM)
50 IRC.T1 GULATIONS. ^ MECHANICAL
AIR HANDLING ON]'r(OVER 110,IXX)CFM) CONSTRUCTION TAX
te
Sigammrc of A,ficanVConmmaor Daae EXHAUST HOOD M'/DUCT) HOUSING MITIGATION IME
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or hours,building lecupont store or handle haromus material HEATING UNIT CFO Hin,m)it i1)
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Cotlq Section 25532m)'I IR?ATING UNIT(OVER 1111,000 BTU)
Ye No
ElVENTILATION PAN(SINOLI?111iG1D) PAID Date ReceiplN
Will tine applicant or future building occupant use equipment of devices which BOLI ER-COM)'(3HI'OR ImO,(1001i'fU] din
emit hamnlous air a manduanls as m
detined by the Buy Area Air Quality Manageent O
Dusan'? BOILER-COMP OVPR WEN)OB'TU)
❑Yea 0 N
AIR CONDITIONBIt
hltvc mud then o de,S s Inamriex napdre33 oun under Chapter
ersou of the Cori- /]— ISSUANC AT
(aceta Recent&Safely Coda,ef, m i 25511.5,2i na, v 2%34, n salty nil thus if the NEW 1t13SIDi?NTIAI.MI?CII. SQ,11', /^-
oftheIf ngdoerurneorr,nlyhnd ntensa,,Ibarhis..yecuracertiyeeramifytheemay s
nr the regairnnnnma wnieh Irma he Inlet Film to kmaanenora ceniEcme nr Da.:pan<y.
Owner or a......
"d agent Dam TOf ISSUED BY: v �O
OFFICE