S 2527 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUII,DING DIVISION APPLICATION/PERMIT PLUMBING..MECHANICAL.
BUILDING PROJECT IDENTIFICATION S 2527
*ESN�AM"I"
ESS SANI'IARYIN APPLICATIONSUBM1II'LTALOST
: PHONE: C TR OR'S b1E LIC NO
�JL _ NIC CON'TROL#
ARCHITEC' . GINEER: •LLICCNO: AN) PSS' ❑
CONTACT: PHONe: 1311ILDINO PERMIT INFO
❑ CoOeDltatlt Pecs Paid by Applicant(Initial) BUIG ELECT PLUMB MRCH
❑ ❑ K ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
2 1 hereby Tfarn+dim I ar+licensed order rrn,nn+n,or Ch,n,,9 h ommencins JOB DESCRIPTION
nifu l farce and eR fUiloiun 9 el'the Buoira,tod l+nfenaua,C+wc.and my license is RESIDENTIAL:
QW cc PERMIT ISSUANCE
F•W ❑SFUW'L ❑KITCHEN RIEMODIEI.
CUU Licame Clu ' his#
CL APPLIANCIiS-RESIDEN'HAL ❑AUDITION [I PLUMPING RE-P[PE
HDulc T%DElo
FOH ARCHITECTS DEC PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O'er Z 1 unJcmmrld Iny plain shall beamed as public rce+N, CHIMN CARP(
OZ�- QI"H)2110 AMPS INTERIOR ❑CHIMNEY RIiPA1R
L inFW Licensed Professional 2014000AMPS IMPROVEMENT SWIMMING POOLS
aOWNIi&BUILUF:R UI CLARA']'ION OVER 100DAMPS ❑RA'UI REMODELEEPAIR ❑DI'.MOLITION
1 hereby ufiinn ohm I inn vacmpt from tire tr
e Conmters Liars,Love,for the
X R i U following reaPOTHER.
(Section 7031.5,Business and Profession.Code:Any city or county SIGNS ELECTRICAL
a
�v~i which requires n permit to nm,wet,alter improve,demolish,or,'pair any nwaure s'(,i /ow
prior led,,i.e,a.m,,.Io reclaims thc applicant Enmehpenniuo file usignN,tmemcnl SPECIAL CIRCUIT/MISC. IT —r te
ly.} that he is llccawd pursuant n the p orykiers of the Contractor's License law(Chapter 9
Wia�0 (commencing with Section 700(dofDivi,ion3 nfthe Bu,iic,and Protession.v Cock)or TEMP.MET ER OR POLL INS'I'. COMMERCIAL:
W
a a e a' that he is cven+pl deoct'mm and the h:ui,for the idle,,]escrunin o Any violation of ❑NEW BLDG/ADDITION []DEMOLITION
_t+- Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
N ❑TENANT ❑FOOD SERVICE
not mors,than live hundred dollars Wo)).
-~+S6 0 Los nwncrn(the propn
erty,ony ca+ployce,with wage,u,WoT
l,,ole c .o,er,min r. SWIMMING POOL ELECRIC IMPROVEMENT
p-. will dean work.andtha.tracture isnot lnlenaedoroRered(orm ❑
le(Sec,7044.Business OTHER
Wm and Professions Cods,To,Contmaur',I.iccn,e law docs not apply to an owocr of DO LETS-SWITCH ES-FIXTURES
prnpany who builds(it loprovos Iherc,) ,and who docs such work himself or Through
his own employees,provided that such improvements art not intended or offered for NEW RESIDENTIAL IELEC!'R SQ ET.
sale If.h.c,cr,me building or mpmvetent is hold within one year ofemnpletion,doe SQ.IT.FLOOR AREA $ISOs FT.
cr huilJm will have the bunko of proving Ibm he did not build or in for pur-
've of wlcJ.
❑ 1,a,owner of nor property,um enclu,nrly contraning with Iicvmed commcton m TOTAL:
sola the project Sec.9114,Isu,inco,m l I'rulc si.)to Cnde:)'Tre C.)ntmcmra Li-
cerise Cov does not apply to an tus ner of property who builihs or improves thereon.and QTY. PLUMBING PERMIT FEE
who controls for such project,with a contractor(,)licensed pursuer,to the Contractors
laccnm Luw, PERMIT ISSUANCI?
❑1 am exempt order Sec. .B Nr PC for his maim
Owner U:nc ALTER-DRAIN k VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declaration,
�1roo-od will mninmina Ccodwid.of Conxmun wl4ia,urc for Wnrkcr'n Cnmpcll- DRAINS-FLOOR.ROOF,AREA,CON'D, STORIES ECONSCTIII:
,lien,a,provided for by Section 3700of the Labor CMc,for the performance ofthewad far whichhis permit is >s md. FI%9LRE5-PER TRAP
? have and,11 nminfain Workers Cnmpen,mion Insurance.m required Fy Section7W l the Labor CesR.to,the puofnnnunaeaf the work lir which this permit is issued. GAS-EA.SYSTEM IINC.4 OUTLETS OCC.GROUP �My work,' Con n Inwm amcr and Policy 4CurrimysEPo1icY Nn.:� GAS-EA.SYSTEMd)VBR4(P,A)
GERI'1ICAl1iUE%IEMfT10N PROM OXK!RSs
COMPIENSA'I'(ON INSURANCE GREASE/INUUSTRI.WASTE.INTERCEPTOR
CI"M1is neolum need not he u+mplacd ifthe Permit i,Irl'enc hundred dollu,($lilt)) BUILDING DIV ISION RiIA
or Ions.) GRI3ASE'FRAY PLANCHECK FLEE
Iccnify that in the pcffonmance of the xor:(or xM1icM1 his pem+it i,i.uucJ.],hall SEWER-SANITARY-STORM EA.200 FT.
melcmployanypcnon in any Bronco sa unmb gy+ object mthcWo,oa,,'Com,wo-
z saian Lawn of Cuhour ia.Dmc 3. 4 ItNERGY I EE
� 0 Applicant✓d• WATER HEATER 0.i/VIENTMLECTR
z �-1 �(-��- GRADING FEE
ren loco CE L Wo rsu c Ing t .Co. oto of he Last �bor o d you should WA'fI1H SYS"rI!M?Ill?ATIN(l
a , hechwithcobject y it Workers Compcor this Paul
tom Blithe Labor Cede,you mm'I SOILS Il!E
�
forthwith comply with such provisions onhi,permit shallMelectrical mocked WATER SERVICE
0
Uz CONS I isacIONLENDING AGENCY NEW RESIUIiMfIAI.I'LMB. SQ,17, 1-AID
L.) I forebyaBirmthemiti ord(Section]7,Ci,agency for the perfirnnance of
Dat Heceiptp
h,wad for which Ori,permit i,ismcl(Sec 3097.Civ.C.)
O U Lender's Name TOTAL:
} WLender's Address TOTAL: S�
Ty 1 certifymit 1 have mal his opplicuoon;md,lase the,he above infimnation is BUILDINf
4 correct.I agrce.t)coloply with all city and county ordinance,and state law,relating no QTY. MECHANICAL PERMIT FEE
U z building comtmction,and hereby Thitherto,representatives of his city to enter upon the SEISMIC E
above-mentioned property for impcction purposes. PERMIT ISSUANCE(We)agree to save,indemnity and keep hunole,the City of Capertio n against I!1.ECF IC "E
liabilitics,judgments,costs and expenses which may many way accrue against said Ciry
in nx,rereeaf the grating ofhia enon ALTER OR ADDTO MECH. I'IA INGA
APPLICANT UNDER,FANDS AND WILL COMPLY WITH ALL NON-POIN"r AIR IIANDLI NI'T(TO ) CFM)
SQ1URCEREGULATIOI/y/"�. /// T1_
CONSTMECH 'ICII ITE
a *74.
7 /^�3 AIR II A NDI.fi� I'I'( iR I(1.)0 CFM)-1 1� 1 CONS'I'RUC'110N TAX
YYF11
lg4ol�c.) fppl�ica U ni/tmc� I D c /7 E%HAUSTI (W ET{ na�� HOUSING MITIGATION REE
HAZARDOUS MATERIALS DISCLOSURE y 319997-J
Will the nppGcam Volume building occupant xoom OrlldMlc humrdous material HEA'I'INGU (TO IINI,OfI(1 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
CMC Section 255}2(v)" IIEA'FINGD 1'f(OVI3R IW.lXN1BTU) -
❑Ycu No
V[MIILATI 6RLS PAID
Will the applicant or future building occupant use equipment or device,which Dam Receipt#
Ion1-Tied.,air cn rounimn,Nl coned by the Buy Aro Air Quality Management I3UIL13R-COMP(illl'OR IIX),INq N'I'U)
e
DutrieP BOILER-COMP(OVER 100,00()B'I U)
I have man the hazardous neaccools requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUAN h DATE
fmmia"c,olthtic,us Safety CMe,Sections 255(t5,25533 and 25534.I To no txmnd that if Inc NEW R E.SIDIENTIAL MI!CH. SQ.ITT Z(...��� 9
builAing Jac,ern afetyjCoodhr,Sections
2 that itis my rc,poru534.1 u+notify the occupant
.)fine mi,meristo u'Y nel motto issuance efa Certifcateof Occupancy.
Owner or uutnmiaed agent Date TOTAL: ISSUED BY:
OFFICE