S 2147APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPWCAIION/PFRMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
rE IT NO.
2147
BUILDING ADDRESS: a
SANITARY NO.
APPLICATION SUBMITTAL DATE
O 'N ME: PHO I, D
C
CON'FRACI'OR'S NAME: LIC NO:
SIC
COST ROI.,
TAR dl^r'/IiNr DNEIi)t 'LICNO:
ADDRESS:
CONTACT '; PHONE:
BUILDING PERMIT INFO
^� �• � l // ^^ Q0
❑ C .... Rapt Fres Paid by Applicant (Initial)
111.33E ELECT PLUMB MECII
[� ❑ ❑ ❑
LICENSED CONT'RACTOR'S DECLARATION
1 M1erehy a1Rrm that 1 am liccnud under provisions of Chapmr Y (commencing
QTY. FLECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT' ISSUANCE
with Smlion FNOpd Divisimq of the Nosiness and l'nde,sinns Code, nnJ mylieense is
in full force and effect.
RMDENTIAls
❑$FDWI. KI'I'CIIIeN RF:MOUEI.
APPLIANCES -RF?VIUF'N'UAL
Datenu ClassLic. N
Date- Contractor
❑ AUDIT 'ION ❑PLUMBING RE -PIPE
�MUI.TI-UNI"r ❑S'fRUCITIRAL
MODII'ICA'I'ION
AHCHI'f.CT:S DECLARATION
1 andcrsland my plan, shall he mcd as Public accords
PANELS
UP TO 200 AMPS
❑INTERIOR ❑CHIMNEY REPAIR
MPROVEMENT SWIMMING POOLS
Licensed Professional
201-1000AMPg
OWNER- exempt RDEthe CoufION
I hereby ,(lien that am exempt from the Cantors Co : Any c Law for the
following reason, Sectioniin]0315,Businessand Pmfdearmis Cade:Anycity (it county
211 R EMODELIREPAIR ❑DEMOLIITON
❑ amcft
OVER 1000AMPS
SIGNS ELECT 'kICAI.
which mature, u permit m eorrstmc, alter, nttI.... demolish, or repair any
iv rh rmil mftleaei idernae
prat
SPIiC1A1. CIRCUIT/MISC.
heissisuancuzlso I,,lifetheapplicanithe ComotLaw
Profi Lnw (Chapter 9
iit pursuant m the provi,ions of the Comrunors and
Thal h¢ is l ir, with
fcalica, ingwithSection andlifhasi,nn3of theipedIsand Profusionslaamaof
that he Is exempt Iherc(mm IoW the basis for the alleged exentplinn. Any vinlwion of
TEMP. MITEROR POLE INS'll
COMMERCIAL,
E) NEW RLDC/ADDITION El DEMOLITION
Section 1131.5 by any applicant for a permit subjects the applicant civil penalty of
POWER DEVICES
❑IMPROV ❑FOOD SERVICIi
not more Than five hundred Dollars y employees
E) 1, as owner of the pmpeny, or my employees wilb wages as (heir sale compensation.
will dothework, or sn
solepplyi
IMPROVEMENT
❑OTHER
SWIMMING POOL ELECTRIC
serdofor
Code:ThetComisnots Licensean weer
and Profession Can1<: The Cnmmmors Lir<nu law Jaxs not apply In an owner of
DUTLISI:S- SWITCHES - PIX'ITJk ES
NEW RESIDENTIAL ELECT, R SQ
properly who builds or Improves portion. and who does such work himself or through
his own employees, provided that .such imp nvenmms am not intended or offered for
eule. IL however, the building or improvement i, hold within one year ofcsnnplction,the
T. )RAREA
LSQ, Fr.
owner builder will have the harden of proving that he did not build or improve for pur-
of soled'
0 1 i. Its owner of the property. aril Cxelusively contracting with licensed caatmclon In
° TOTAL:
construct the project (See. 1144, loomesx and Pro esiona Cale:) Me Comrunor, Li -
came Lawdus,maTplynt,n owner or popery who hail,ko, improvcsmemon,and
QTY. PLUMBING PERMIT FEE
who controls forsuch pmjahn wish ea .at rni licensed pit suan to, oC( tra a
PERMIT ISSUANCE
art, Law
I1 am cm p)and( -cc.reason
ALTIiR- DRAIN hVENT-WATIiR (EA)
VALUATION
OwncI miIsm
BACK PLOW C'
-! Wf KERVtCOMPE SATI NDEChANATION
.hetrbya uOder peoulry of do, one nf,he fallowing declarations:
n
y /� o
ent to self-inhn Workars Com
[�and will mainlvinu CcAOcalenf Consmre
t
count. its, provided for by Section 3000 of the Latin Code, for the Prominence of I
D -FLOG OOEA OND.
ST IpS
TYPECONSTRUCTION
work for which This permit is issued.
1'Uk:-PER 'I'RAP
❑ 1 have end will maintain Workers Compensation Insurance, as rcquiml by Seelit
310N0 of Ne labia -Code, for fieperacrmanee of the work l'orwhich this p¢mtil In issncl
OCC. GROUT'
APN
G EA.S A ETS
My Worker's Compenvtion Insurance carrier and Policy number am:
Cartier. Policy No.:
. 1 EA. SYSTEM OVER 4( .
C17RTIFICATE OF E ld"IFE'ION FROM WORKERS'
COMPENSATION INSURANCE
GREASEANDUSTRL WASTE INTE MPTIR
BUILDING DIVISION 617175
(Thixseclion need not b,completed ifthe permit is foronehundreddo1iars(5100)
or less.)
GRf
PLANCHECK FEE
I ceeifytbm imic,coormnnecoflhe work for wbichmN permit is issued. I shall
not employ any Person in any manner so as at become subject to the Workeri Compen-
SIiWER -SANITARY-ti1'(3RM ItA. 210 PI'.
IiNERGY ItE
WATER HEATER WNIiNTfr.LECfR
GRADING FEE
solion LawN of Cldifornia. Dale
Applicant
NO'T'ICE I0 APPLICANT: IL after oinking [his Certificate of Exemplion, you should
become subject to the Workers Compensation provisions at the Luber Code, you must
WATER SYSI'EM/1'REATING
SOILS FEE
bmhwdh enntply with such ovi mos nnbi, permit shall bedecntedrevoload.
WATER SERVICE
CONSTRUCTONLENDINGAGENCY
I hereby afinn that here is. corchatuinn lendingagency for the perforromer.f
NEWRESIDF.NTIALPI.Mil. SQ. FT.
PAID
Date Recciptp
the work for which this pannit is issued (Su. 3WO, Civ, C.)
Lenders Name
TOTAL
TOTAL:
snder's AJJres,
ISUILDINC
1 cenify that I have rescinds application ..it slate that the ,bane information is
correct.I agree it) comply with all city and county ordinfaces and sum law, relaing to
huiiAing amswaion, and herehy:mthordre mpmunwtives of This city m eater upon the
QTY. MECUANICALPF.R UT ITE
SEISMIC
PERMIT ISSUANCE
ELECTRIC FHT?
aMrve-menlmood pmperry for induction purprus'
(We) agree m save. Indemnify and keep harrnless the City of Cupertino against
PLUMBING fl?
Iiabililies,judgmenis, consand expenses which may in any way aceme against said City
in conuquctce of the granting of this permit,
ALI ER OR A DO' TO MSCI I.
AIR HANDLING UNIT (TO IDJXN)C'FM)
MECHANICAL FE
APPLICANT' UNDERSTANDS AND WILL COMPLY WITH AL1. NON -POINT'
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 11,100 CFM)
CONSTRUCTIO "AX
Signature of ApplicanniContlacmr Date
IIA%ARDOIIS MATERIALS DISCLOSURE
EXHAUST 'HOOD (W/DUCT)
HOUSING MI'FIGA' NFEE
GRATING IINITIT'0103,1X0 B'I'G)
Will the applicant of future building eocupanumre or handle havardon material
m dcOnasl by the Cupenin, Municipal Code, Chapter 9.12, tad the HuItB and Safety
Code, Section 255326a0°
HEA'1lNG UNIT (OVER 10T.000 BTI1)
❑Yes No
pelicans ,�re rt illding occupant use equipment or devices which
ee�IPRSSa as1, boure as defined by the Bay Amo Air Gadiy Management
Dishict'f
❑Yes ❑No
Dae Receipt Jr
VENT, LAT ION PAN IS INGLE RESID)PAID
BOILER- COME (3HI'OR I(0,(XNlll'IU)
T'A
BOILER-COMI'(OVI?R 103.00() B'I'Il)
AIR CONDITIONER
I have read the hammous materials requirements under Chapter 6,95 of the Cali
maria Heald AC Satu)(Cale, Scannas25505,25533 unit 25514. 1 understand that iflhe
building dares not currently have a tenant. that it is my responsibility to notify the occupant
ISSUANCE DATE
xA _Qom- g
( L
NEW RESIDEN' I'IALMECIL SQ. I'1'.
of the requirements which must he met poor to issuance of a Cedilicate, of Occupancy.
ISSUED aY:
TOTAL
Owner or authorized agent Dale
OFFICE