S 2902 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEG I'RICA L PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF.CHANICAI. Q
BUILDING PROJECT IDENTIFICATION J
11t11LDING ADDRESS: 2902-
SANITARY ND. APPLICATIDNSURMI'19ALDATE
OSSo �,1 .t1X Lc,�9 -Z �-
OW 'fS NAMiiI „f E'. CAN CfUR'S NAME: I-IC Np j N/C CON'1'HOL#
.A C D'IiCflIiNGINEEk: LIC NO ADDRESS: 3 ❑
fxf
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT P UMB MECH
I,ICENSED CONfRACfOR:S DECLARATION QTY. ELECTRIC PERMIT FEF.
El
1 bomb,affirm mal[;,,a licensed malar pro,ki::n.of chapter 9 mm.nnnoh,g JOB DESCRIPTION
O�Z th Seaion](XN))nCDivision7oOhe Nosiness and Professions Crale,and mylimnu is 1
m O O Iv PERMIT ISSUANCE
yy ec= full force and effect./l� �G SEDWI. ❑KITCHEN REMODEL
6VU Lrcun"e Clgs TIL_].at Le APPLIANCES-RESIDENPIAL. ❑ADDITION ❑PLUMBING RE-PIPE
P Q a Date�tW re Comar., —
ARCHITECFSDECLARATION ❑MULThUNIT ❑STRULTUHAI.
F y H I underswnd a, I h II he used as MIe reconls YANF.I S MODIFICATION
ZOy�, Ypunss a Pu
OZ—O 11PT0200AMPS [:1 INTERIOR El CHIMNEY REPAIR
1=�FW Lonmed Professional NII-1000AMPS IMPROVEMENT E]SWIMMING POOLS
-� OWNER-BUILDER DF,CLARNMON
^I OVER u1W AMPS f4NATH REMOAEfI EPAIR DEMOLITION —
6 I herchy nlBrm th:e I am cxmn.I Taal(the Conuneuerl .nw fnr the `(s'Q A
O a U following reason.(Section]031.5.Rosiness and Pmfesaions Cad IAnYr:ty nr coumY SIGNS ELECTRICAL OTHI?li --ff
0.0 y which reyuime a permit construct,vllnq improve.Jams any amaam
Prionnit,isuancc,also oct,mres the nPPlicam lin xut pu t amgncA xtamn a., SPECIAL CWCUITIMISC.
yY7 Ihathe is licenser pursuant)me pmvixianx of me Ca acs Licenselaw(Chapter9
��0.'QC (commencingwithsecrim 00Kdr Dsion 7af the Ru a, JProfessiumcathOm TEMP.METER OR POLE INST COMMERCIAL,:
that he is exempt IhercGt n and the basis far I tamplion.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iG n_ Section 7031-5 by stay a kraal fnr o permit sum crs the upplicunnn a civil pcnuhy nr POWER DEVICES ❑TENANT ❑FOOD SERVICE
ac `A not mom man five hunt dnllan(55110).
k?O ❑ Lasownendthcpr penRonny e(k). cs%LEE ages as their sale compensation. SWIMMING POOL ELECTRIC LMPROVE.MEN o
Fwilldolbawork,andi -stractma,,mai a Inr marred Rvaale l Sce.]IH4,Bisinemv �OTHIiR
a0.e and Professions C<eJ The Conwcmr Licen lax Asxs not apply to un owner til OUTL131'S-SWITCHES-FI%TUHCS
d 3^ pmpcny who buildsr improves the n an is such work himself or Mmugh
his own emplayats, su inumotmenn ort not intended or offered for NEW RESIDENI'IN.F.LECfR SQ Fr.
sale,ll;however,the huildingari wern,al Lived withinoncycarnfcnmpiclum,do SQ.FE FLOOR AREA S/SQ.FT.
or-builder will have the boNcn coving the he JIA nm build or improve for pur-
ryvsc of sale.).
I,vx owner nl'the p I, riv con exe sisal,corseting with licensed contractors to 'TOTAL:
conswm tale project(S<c.]DW,Rmine.and I'rofeszions Cade:7 Tme Cnmmanfs Li
ml.awdoesmoapplyoe,nownero mpeny who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who semhuery k,such Pr jects with a eountroond licensed punuon,to the Character',
License Law. / PERMIT ISSUANCE
El um exempt under Sea .R&P C fin,this rcamn
ALTER-DRAIN&VI?NI'-WATI7R(EA) VAI.IJAI'ION
Owner Dale
WORKER'S COMPENSATION DfiCLARAfIDN RACK PLOW PkUTECi'.UEVICI?
I hereby ul tionmai under pen'elly is perjury One of IM followmare,lot Win
kar's Crouton.
❑on,a, n.will fo by uch,.3ac of Coo.emne Calle,sur a Ger Workerama,ofee DRAINS-FL(lOIt,ROOF,ARL'A,GDNU' STORIES 'TYPECONS'fRUCI'ION
svtma,m .video for by Section 3AN1 of nee labor Code,fill the perfonnanee of the
wo k km which this permit ix issued, FIXTURES-I'IiR TRAP
I havaand will maintain Wnrkcr.v Co cr of the w rk ho, hi n.required by Scali un
3]W of the L,Mm Cade,tier lM1e perfnrrnance nC the worn fnr whiclnhis Peranit is iemad. CAS-I?A.SYS'I'IiM-I INCA OU'I'LEi:S (ICC GROUP APN
My Work sCo. I.,
tyor In__syyruecycyrricru i,y"Nicy�Wr _a. Is
Cameo QCo #4GA1R/ /VA and I aLL7I�J;1Qu GAS-EA.SYS'I'i?M-OV T:Rb11CA1
CERTIFICATE OIL HXUMPI'[ON FROM WORKERS GRCASIJINUUSTRL WASTE INTIiRCEProR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thi,,enon need not he cnrnplemd ifthe permit iv Carona hundred dollas(S I(0) GREASETRAP or revs.) PLANCHECK FEE
I ccnit,that in lheperfnrmanccofthe wmkforwhichthispennit ksued,Ishali SEWER-SANITARY-STORM EA.200 FI'.
not employ tiny Person in any manner so as LEI hecome subject m the Workrus Cmnpen- ENERGY FF.F.
OZ. ...loin Laws M Califamim Date / WAIT?It HEATER WIVENflE1,UC1'R
z O Applicant GRADING FEE
.w y NOTICE TO APPLICANT:If.after nvaking adi Cenlficae of Exemption,you should WATER SYSTEM/1RC•ATING SOILS FEE bacon,Entire,to the Wmkcr'a Cnn pinsation provisions of the I.aleor CIA.,you muvt
W fonhwilh comply with such provisions or lhis permit shall be deemed revoAad. WA'1'Ek SERVICE
d Q
Z CONS'1RUC1'ION 1.I7ND1NG AGENCY NEW HF.S1U1?N1'IAI.PLMB, SQ,FT LAID Dam kseiP N
1..10 ihorw ichthi t hanherc iso ed(Set.30 len ding agency rim the pmionwn<c til'
Ne work for which this permit is issued(Sees 309],Civ.CJ
C) E-I Lenders Name SU TOTAL:
1 benders Address TOTAL: I. BUR-DING FEE
1 terrify(hal 1 have read(hiss application and stat that the alxrve art mnatinn is
rF+ y rorren.l agree to comply xith an airy and artery ordinances and state laws relating to QTY MECHANICAL P1iRMIT blEE
V muilJing cmnvuainn,:md herchy untharise nTresem:nive.of Ibis city mentor upon the ''ISMIC F'[E
uMrvcmcminned properly far institution purpmc,' PI?ItMll'ISSIJANCE
(We)agree msave,all and keep hamtiass the City of Cupertino against IF.CTRIC
liahilitics.judgnmmx,nrsry and expenses which may in any way vorneagainst said City ALTERORADD'COMECII.
' mseyucnec ut the grunting of this perrnll. .UMIN�JFi E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('1010.000CFM)
SOURCE D IONS. M[ iIANICAL P1iE
/) L AIR II ANDLINO UNIT(OVER IQIXNIOWL CONSTRUCTIOIWI-AR.h
Si((gnaSignaturea—fApplican[Zi n
onwor Doc EXHAUST I{fwU(W/DUCT) HOUSING MITIGATION5,
HAZARDOUS MATFRIAI,S DISCLOSURE
Will lhcapplictoor luuuc hudding:ccupunt sure,or handle bueurJ1amounarivl HEAPING UNIT(*I O IIn1,I11Nt B'1'lJ)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cala,Section 25572m)'I HEATING UNIT(OVER 100,000 BTU)
Yes E3VENTELATION PAN(SINGE RI:SIU7 IAIU Date Race #
II Will the applicant or future building occupant use equipment of deViCeS which
enth hvardous air cononrinmr,as defined by the Bal Are,Air Quality Manogentent BOILER-COMP(3HP OR I00,000 BTU)
District' BOILER-COMP(OVER 100.000 BTU)
❑Yes L."tdo
I havereud the humnlousmnteriuls myuineneea(,under Charier 6950 the Call- AIR CONDITIONER ISSUANCE DATE
firma Health&Safety Calc,Sections 25505,25533 and 25531.1 i mlemand Lha if he NEW RESIDENTIAL MUCH. SQ.En
building dmILE.nenlly huveamn:mt,thxt it is my m.gwnsihilhy to nrnify the aprpunt
oI the ant o In prinnnissuaace of a Certilicamol Oca:pmEty.
2�#net or aathmiaed ugm Data TOTAL ISSUED BY.
OFFICE