S 2249 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ROD.muc-ELECTRICAL PEgIT No.
BUILDING DIVISION APPLICATION/PERMIT PIA1511fING-SIECHANICAL VC
2249
BUILDING PROJECT IDENT'IF'ICATION
BUILDING ADDRESS: - SANITARY NO. APP IC TION SUBMITTAL DATL
DSO L-V- toSoo 7
OWNERS NAME. PHONE:"bo CON'TRAGTORS NAME:
E CAN
gO:
N/C C(N'1'Hfll,p
�i ARCHITECTIENGINFER: LIC NO: ADDRI ❑
11ld4 NAT.o nl ALI# jity CA. 9K6
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
WLD to a`�3 ao1•.Z ❑ ❑ N ❑
LICENSED CONTRACTORS DECLARATION Q'rY IiLECTRIC PERMIT FEF.
I hereby affrtn chat I am licensed ander provision,of Cnapmr 9(cammendng 306 DESCRIPTION
WOO mfuB forme nnJ�or Division3nftheBmincu and Pnafessions Gde,and mylicense is RESIDENTIAL:
I.00 P[RMIT ISSUANCE, '
-e"Usag ❑SFDWL ❑KI'TCIIEN REMODEL.
aUU License hs. fl Lic.p APPLIANCES-RESIDENTJAL ❑ADDITION ❑PLUMBING BE PIPE
yGa nam CSolIDECL'
ARCHITECT"S UI!CLARAI'lON TAY. - A f.TI-UNIT ❑MODIF[CAHO
IURAL
(r '24 PANELS MODII7CA'I'ION
Z O-C4 1 undersmnA Iny plans shall rte usW as pantie recrme
oz—� UP'T02f1f1AMPS ❑IN ❑CHIMNIEY REPAIR
H,H.~IA Lmensed Prolcssinnal 201-l"AMPS PRO 0SWIMMING POOLS
y Y�� OWNER-BUILDER DECLARATION OVER 1000AMPS BATH REMODEUIREPAIR DIEMOLITION
ad Q 1 hereby ufftm that I am exempt Ism he Comrannfs License Law for the
x1,x 6 U following reason.(Section 7031,5,Bwarnie mW Professions Cuba:Any city or county SIGNS ELECTRICAL. OTHER Q
W 3 t H which requires a permit to conswcl,alter,improve,demolish,or repair any shrmume lid 'Q M'�1� k'II
��' pct: r l ': lminutestheI en permit CI :'yawl instructor SPECIAL CIRCUI VMISC. t,� _
7 buthe, I n. d1 r u tl p :uc : Irl C t do 1 w(Chapter 9 COMMERCIAL:
ul 0 (ennmencnywth Secton]000)of D'vin n9 flh,Buima ndlr f. ions Code)., I EMR.METER()It POLE.INST.
Q.ar� that M1e is exempt thcn•Gom and the basis far the alleged exemption Any violation of ❑NEW BI.DG/ADDITION ❑DEMOLITION
X m ob Second]1131.5 by any applicant fora permit subject the applicant m u civil penalty of POWER DEVICES
�Ztn nor more Than five hundred dollars(E500). ❑TENANT ❑FOODSERVICE
F Z i IMPROVEMENT
if
wi 6o the work.the pmpeny,or myemewithwages for sale
7094, urines, SWIMMING PW I.ELECTRIC
~m and Professions
coons Cuiandlc Th cticam Conti.tot intendedse Law rdo for of apply Loan,Business ❑OTHER
and Profexsianx Cale:The Cammemr's license Law dacx not apply In an owner of OUTLETS-SWI'I'CUES-FIXTURES
F pmpray who hands ur Ilnprnves firman,unit who docs such walk hhowif orthmugh
Lis own employees.p.vided that such inipmvemema am nor immalud or nlTemd lar NEW RESIDENI'IAh❑LECTR SQ ITP.
sale 11,however,the building orimprovement is sold within one yen',"ompletam the SQ.IT FLOOR AREA EISA.FI'.
owner-buider will have the human of proving that he did not build or improve for pur-
paw of sale.).
❑I.as owner of the pmpeny,am exclusively convecting with licensed contractors in) TOTAL:
am rmit the pmjecl(Sec.]f W,Business and I'mfcssions Codep Thc"'coca or's Li-
xeLaw does nal apply to an owner of pruriency who hands or Improves thereon.and Q'I'Y. PLUMBING PERMIT FEE
who contract,for such project with a ennlmangs)licensed puminnl In rhe Conlrunals
I.icense Law. PERMIT ISSUANCH
❑ Iamexcalptunder Sec ,B&I'Cformis.asun
Ower Data ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby affirm under peruny oeperjury one of the following de rker's o
❑ lSave and
o,ided I...by Seen..
37amnf theLbr Cod,forther Warkefs Cooper- DRAINS-FLOOR,RWP.AREA,COND. S'fORll!5 TVPIECONSTRUCTION
sml.., r pre[,tha lar by Section 3]OB of the Labor Code,for the Ierrnrnunma of(M1e
work far hit[,thlx pcnnil is issued. FIXTURES-PER'I'RAI' •
�I have and will maintain Worker's Cmnlm anawn Insurance,as.,hired by Section
Ip of the LaMV Cade.for the performance of the work for which this pcnnil is issued GAS-EA.SYSTIEM1I-I INC.4011TLE'I'S OCC GROUP AI'N
My
GAS-
Workenfs Cnmpensmion lny5�t n[e[artier and Policy number are:
Carrier. t,1 nQ RDONn Policy No.�lfL Q(x:av lGlB EA.SYSIF.MOVER1(L'A)
CIiRT IFICATEOF SATIOI'ION FROM WORKIEHS'
COMPENSAf10N INSURANCE GREASE/INDUS'1'RL WAS'PF.INTERCIiPI'OR
BUILDING DIVISION FEES
This section need are be comple¢Alrthcgalair is fmonehandraddollmx(EIIIB) GREASGTRAI'
nr]rax) I'IANCHIECK R!li
I certify lhatln the perfanlari tar ,,,it forwhich In,perail is iswed,Iahall SEWER-SAN['PARY-STORM EA,20o IT
mol employ any pctnin in any ma aubjem¢a rI Walkers'Compen. ENERGY FEE
zZ cation LawsTof Calilis aDete/^I��a_g��4 WATER HIEALF.R W/VIENT/ELF,CTR
Applicant dV���1TrT a _l,� GRADING IEIi
NOTICETO APPLICANT:If,after making this Carlinville of Exraptiun,you should µAPER SYSTEMT REM ING SOILS PEEa > hamate xobject lung,hWorker's Cnmpemmian pmvecturs ofine labor Code,you must
W forthwith comply with such promamosonhi.s Parma shall bedeenncl revoked. WAL'I!R SERVICE
d
CONhem iso [ON LI!NDI NGAGENCV NI!W RHSIOI!N'I'IAI.PhMIt. SQ.Irg ('AID
rti z Hum Receipt h
1,) pThor which thithamili issued(Set.30len ding agency In,the perlivinnnceof
Ice ward far which this permit is issued(Sat.VMI],Civ.CJ
Isndets Name TOTAL:
WLenites Address TOTAL r
17. 1 certify Ihm 1 bare read this vpplicmion and xmre that the alcove information is aur G
— 01 correct.l agree to comply withal]city and county ordinances anJstate laws relating ba QTY MECHANICAL PERMIT' FETE
G Z It dim,connmetionnndhereny autharae mpreaemvrives oflbis city turner upon the S. FEE
abovo*merflordal pmpcoy Iry inspection parpast"' PERMIT ISSUANCE r
(We)agree to save,indemnify and keep harmless the City of Cupertino against 'RIC PEE
liahilities,judgtnv :,coststmdexperon whiebmmy in anyway.cameagairater id City MATS OR ADD'1'O MECIL \
IZ�xm _ tingofthis amain toe ) int. :PIMPLY WII'II ALL NON-POINT pIRHANDLING UNTTfro IO,IXqCPM7'- NS. MGCFlANICAI.FEE98
AIR HANDLING UNIT'(OVER 10.000 CFM) TRUCI'ION'AX
Ignamreaf Applicun mhamor Date 17XHAUS'PHOOD(W/DUCT] IIOUSIN: "ION PEP.
HAZARDOUS MA'I'IEItIAi.S DISCLOSIIRIE
Will Ibe applicant or Tum.building aanpam amre or Lundie hazardous material I(EATING UNIT G 0 1 W,lhs1 BTU)
as defined by the Cupertino Municipal Coca,Chapter 9.12,and Thr Health and Safety
Code,Section 255120)4 HEATING UNIT(OVER 1010(a)BTU)
E3 yes Cl No VIENTI LATION FA N INGLE RESIDI PAID
Date Receipt H
1 )
Willthe applicantor future occupant use equipment or bwhich
audit hamnnm aircontaiminnts as defned In,the Bay Area Air Quality Management - BOILBR-COMP( HPOR IW,"BTU)
'f0'TAI
Disalcdl-1 yes No
BOILER-COM 11(OV IIR Iacc100 BTU)
�
1 have read the haramm omaterials mgm
nireems hatter Charger AIR CONDITIONERN95 of Cali- ISSUANCE DATE
hand.Health&Safety Cade,Stenon.25505,25533 and 23531.1 undcrsmne That if Inc NEW RESIDENTIAL.MECH. SQ.ITR
' building dos nm currently haver¢nanh that it is my respnsihility mnatify the acupanl lI r r Ip ( V
of the mquiremenu which nun bt mer prinnoissuance oft Cenitic:ne of(kcupancy. r
Own,,m rutharizcd aganl Data 'TOTAL: ISSUE[)BY:
OFFICE