S 2432 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECFRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 2432
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
/DLJ/ nit, 6 r- 2/4'
OWNER'S NAME: PHONE: COryT ACTOR'S NAME: 1,IC
O, - ✓ `X/ C NIC CONTROL p
CH ECDENGINEER: LIC NO: ADDRESS: _ /� ❑
C`ONNT�A�C�T�.���. PHONE: / - BUILDING PERMIT INFO
y�a"�' 7�� •"- p `l ❑ Consultant Fces Paid by Applicant(Inllial) BLDG/- ELEPLUMB MEC"
Ge Ce
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRICPERMIT FEE
I herehy affirm that I um li....ad under Provisions of Chapter 9(conmenciug JOB DESCRIPTION
�Z with Sceti.n ltNMl7 of Division 3u(Ihe Busineu and Prafesaions Gyle,and my license is RESIDENTIAL;
in fall(..am e0ect PERMIT ISSUANCE c
yu1�', L L�,� 0SFDDW _ ❑KRCXEN REMODEL
F<.ZU License Cls Lic.of APPLIANCES-RESIDENTIAL M� []ADDITION ❑PLUMBING RE-PIPE
N Z y Data
Contmcnsr
((.. ARCHITECTSDECLARATION ❑MULTI-UNIT ❑STRUCTURAL
a p�.yZ. I understand my plans shall he used as public recons PANELS MODIFICATION
;Z_, UPT02MAMPS ❑INTERIOR ❑CHIMNEYREPAIR
4�- Licensed!Profession.!C OWNER-BUILDER DECLARATION 201-1000AMPS I�JPROVEMENT C]SWIMMING POOLS OV101N7gMIF�
I hereby affirm that 1 um exempt tram the C.mmror'x License Low for the ER P5 ATH REMODEL/REPAIR DEMOLITION
O U
following memo (gmtimn 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
I••' which Iouires a permit 10 construct,cher,improve,demolish,or repair any structure
prior to in iswame.alwrequireslho,"ficamfar such permit o fiuitsignedsmtemem SPECIALCIRCUITIMISC.
} that W is licensed Famous to the pmysiom of the Commorm's License Law(Chapter 9
00 (commencingwith Section Division 3 of the BuainessanJ Pmfessions Come ar � COMMERCIAL:
w ) TEMP. OR POLE INST.
that he is exempt therefrom and the breis fa the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
o uy, num mo than
LSby oundredicam fore permit mhjmre Ne opplicammacivil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
zy 0 mute Nan Bve huMredty.or my employees
IMPROVEMENT
< OLavowark,Ne property, mmyailroadea"o wages in their WinBred f. .R(Sm.compensation, SWIMMING POOL ELECTRIC
G will Jothe won.and the swcmreia tors Laded Lawdoforsale(Se,to a Business Ei ❑OTHER
x,10 and nny who
Com:no Command License Low dac nor apply to it owner of Q OUTLETS-SWITCHES-FIXTURES Q r y Q
his o ny who builds a improves Netcom and who moa such ware himself offered Nraugh sj
his own employee provided Ihat such impmvemid w art nm ineMed a ena.far NEW RESIDENTIAL ELECTS SQ FT.
sale.IL haweva,the building.rimpravemenl is old within one year of compluian.Ne SQ.Ff.FLOOR AREA LSQ.FT.
caner-builder will hove the human or proving that he did not build or improve for purso
-
pose.holeJ. O
C]I.as owner of Ne progeny,am exclusively convecting with licensed conwcmn 1. AL:
wmvuct the project(Sed 7044.Business and Profeaamna Code)The Cancrum/ L -
came low does not apply to an.wner.fproperty who builds or Improves thereon and 'u,t.-PLUMBING PERMR,:f war FEET
who contracts for such pro3ecu with a contractor(s)licensed pursuant to the Contactors
License low. PERMIT ISSUANCE
❑Iamemmis nderSm. ,B&PCWrddxeason /� r
T ALTER-DRAIN&VENT-WATER(EA) QO VALUATION
'toner Dme }� /I
WORKER'S COMPENSATION er,on DECLARATION BACK FLOW PROTECT.DEVICE Vi/p y�` .00
I hereby affirm under penally toperjury one of the following deoker's m: TTT �.
❑hove mal will mai by anion 37M of the Labor
Codo.Cart far Worker's Com pen- DRAINS-FLOOR,ROOF,AREA,COND.
euion,u provided far by Sation I]W of Jte loMr Code,for the performance of the STORIES TYPE CONSTRUCfIOt
work for which this permit is issued!. FIXTURES-PER TRAP Q
❑I have end will maintain Worker's Compensation Insurance,as required by Section 11
3]UDofda Labur Code,for th perform ce of the work(a,
which this p
ermit is Issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OC .GROUP AP
My Worker Cw pepetio ...., edPolicylto.Y na+-a6 e'1�•�L✓D.C� GAS-EA.SYSTEM-OVER 4(EA) /s
Carrier. /KtA 3U3•
CERTIFICATE OF EXENIMON FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR r
OINGDIVIS
(This section need not be completed if the permit is for one hundred doll (5100) rf, ,.}v"•Y_-„i�s.BUIL
ws IO _ e:`(j"y y"•y?
or ma.) GREASETRAP N
I mtifY Nal in Ne perfamuae o(Ne ooh forwhich Nia permit ieiuued,lahell SEWER-SANITARY-STORM EA.200 FT.
etemploy any person manw m b
ner as ecomw
e bjmt la arm Worts'Compen- ENERGY FEE
Oza on N an
sation Laws of Caljfomm.Dam WATER HEATER WNENT/ELECTR
yyy O Applicant GRADING FEE
q y NOTICE TO APPLICANT:If,after making this Certificate of Beemptian.you shouldWATER SYSTEM/IREATINO
become+ubject m Ne Wot Competitor..Provisions of the Laser Codi you must
{ail t.nhwidi comply with such provisions or Nis permit shall W dcemed revoked. WATER SERVICE
Q
CONSTRUCTIONisaLENDINGAGENCY NEW RESIDENTIAL PLMO. SQ.FI'. PAID
V� Thereby efOrm Net thereemit construction lending agency for the Performance of %lim Reaipla
Ne work fw whteh N s permit rs Issued(Sed.309],Gv C 3
OU ImWe's Name ^ TOTAL:
WLenders Address T F 'V
y I certify Net 1 have read this xpplicetmn and sem that the above information BUILD :E'
W1 co�cl 1 agree m comply calm all c ry end c.untY nmman<ea and amt laws misting 1 QTY., rt MECHANICAL PERMIT FEE.. t y O
V Z building ewutrucuon,sed hereby mationse representatives of this city a enter upon IM1e - --v - ISEISMIC E
above-manlioad property for inspection purposes.
(We)agree W.I..indemnify onm kap harmless[be City of Cupertino against PERMIT ISSUANCE g ELECTS I E O
habilitiee,jumme
gne,cosm and expenses which may in any way memo against said City ALTER OR ADD TO MECN.
PLUMBING
in comequeme of the granting of Nis permit. _ _ _
NP If
APP 'ANT UNUERSIANDSAND WILLCOMPLY WI'rl1 ALL NON-POINT p�R HANDLING UNIT(TO IO,IMIp CFM) MECHANICAL FEE
SOIEREGULATIONS.
q AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Y, ere.fApplicanUConraaor Dae EXHAUST HOOD(W/DUCO HOUSING MITIGATION FEE
,,r.y- HAZARDOUS MA RIAI 4 DISCLOSURE
un'`wlM1he xtiplicemwfuwrehuilJing wcu(um nom or halMle haramoua mumri.1 HEATING UNIT(TD ImLIND BTU)
defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Code.Station 25532(x7? / HEATING UNIT(OVER i00,0110 BTU)
❑Yes Dytl - D PAID
/// VENT LITION FAN(SINGLE RESIUI Dam Rmeipta
Will the applicant or future building mention use equipment or devices which
.,of haraidous air conmminems ox fined by the Bay Area Air Quality Manion eat BOILER-COMP(3HPOR[00.000 BTU)
[_]Y. s.
BOILER-COMP(OVER IW0 BTU)
,m1
AIR CONDITIONER
Ilmvc mad the�aymouse ulsr yuCo
irei nu umkr Chapter 695 oI Nu Cali ISSUANCE DATE
fnmia ll hh&S-defy C,ffde,Sec 9ns35t 3 otd 25534.1 understand,nu if the NEW RESIDENTIAL MECH. SQ.F.
building d. tly hovel' hay,to t' nY rexpomihilitYmnwifY Ne aFycuukp�am) /_ Z/
arm Iho bich mu. !n ema •nifameoftRcoea—`!�
Owaroaut .gait Dare A ISSUED BY:
OFFICE