S 2698 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO II-ELECTRICAL. PERMIT'NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBIN(;-MECHANICAL
IIUII.DINV 2698
G PROJECT IDEN'r[F'ICATION
BUILDING ADDRESS; 1 SANITARY NO. APPLICATION SURMI T9'AL DATE
OWNERS NAME: PRONE:aS - CONI
RAC'IOIfS NAME: LIC NO:
i4t�rc� g 3 I L2r�+y'Z C�1fs� J$ Ib NIC ONTRO p
CHI I'ELTINGINEER: LIC NO: ADDRESS: ❑
- mP.;T4AI.n'� S3 sa
rNTACT: PHONE: - - - BUILDING PERMIT INFO
b r.�� Q Consultant Pees Paid by Applicant(Initial) BLDG elEcq PLUMB MOH
LICLNSLD CON FRACPORS DECLARATION QTY.' ELECTRIC
IC'PERMIT « FEL
LJ JOB DESCRIPTION,ny fa d"l l am licensed a p of Chapter 9ennm ng
wonQxz with 5 i '1000)of 3 fth Business ndProfessions Code mA mylicea.els -- � RESIDENTIAL: -
�X 'nfullfrrrcv.delYec[ PERMIT ISSUANCE
W F r % S 58 8110 ❑SFDWf. - ❑KITCHEN REMODEL
a UO License Clash Lic'P APPLIANCHS-RfSIDF.NTIAL ❑ADDITION El PLUMBING RE-PIPH
rn 1 C Dme 93 S Commemr.T•4�J1t2 CGbST
ARCHI FECTSDECLARATION ❑MULTI-UNIT' ❑STRUCTURAL.
F...7 N PANELS
ZO Z.Ny.7y lunduuand my plans shall be naetl us public reumds MODIFICATION
Uf T0200 AMPSI _ ❑INTERIOR ❑CHIMNEY REPAIR
N4kgj Licensed Proll,,ecal 201-1000AMPS IMPROVEMENT (]SWIMMING POOLS
1 OWNER-BUILDER DECLARATION OVER IOIHIAMPS I El BATH REMOUI?LIRP.PAIR ODEMOLITION
a I hereby ff that pt Braila,Connectors,1' L for the
� U
falleat mrsom.(Section
94915 B d, al f CoIrAnY ty county SIGNS ELECTRICAL ❑OPHBR
pd�1yF whi 9 p construct, II p e demolish, repair Y.[ucmee ��ll//
in ior in Itsissuance,also y ' the 1pli r fit,suchpt tt II 'b aIcote.[ SPHCIAI,CIRCUIT/MISC. V
�.
lot,lie licensed trat „,the nro,kire.'ifib Contractor L (Chapter9
(commencing with Section 7000)If Diskim 3 of lie Bll tens and Prom,,fins Code)o. TEM P.METER OR POLE INST. COMMERCIAL;
W y o[C
that he is exempt therefrom and the basis,for the alleged corruption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
di Section 9031.5 hyary applicnnr fm.pcmnilsubjeets[heapplintinto acivil penalmat POWER DEVICES
not more than live hundred dollars($500). ❑TENANT ❑FOODSERVICE
[-�Y L IMPROVEMENT
d Las oin,worof he k.medprnpeny,armyotinoyees with wages as their sole mut.Fm tion, SWIMMING POOL P,LeCTRIC'
will da lhewnrk.and the structure is not imnrtded or offered far saldfSec.9Mh'i,wh mess ❑O'T'HER
W3 m vnd,Promsxioas Code ]'he Contractor's Liven',Law does nor apply m an owner of OUTLETS-SWITCHES-FIXTURES '
properly,who build,or intprrve.Ihcrcon,and who does such work himselfor hough
aIn his own employees,provided that such improvements am not intended or offered for NEW RESIDEND
' AL ELECT R SQ Er.
sale.IL however,the building orimprovement is sold within one year f completion,the SQ.Irl'.FLOOR AREA $/SQ.FT.
ovater-Imilder will have rat burden of moving that he did not build or improve for par-
. P...a aaleJ. .
1,ns owner of the property,an,exolu,,ely contracting with licensed convectors m 1 I(Yf
h,nteCildpromol(See 9044,B nine,and Professions Code:)The Conloader,Ll- - - .
1'
rise Low does not apply to an ownerafpropery whir builds or improves rherem,and QTY,' PLUMBINGryERMIT FEE
Who a Hemi for such projects with a c(snnamdir(s)licensed pursure(l)the Cnmracmrx ”
License Law. PERMIT ISSUANCE
El I nm exempt under See ,11 dr P C for this ren s..
Owner Data ALTER-DRAIN 6k VII-WAI'BE(EA) VALUATION
WORKERS COMPENSAI ION DECLARATION BACK FLOW PROTECT.DEVICE ro CD
1 hereby athrn under penalty(if perjury one of the following declumtlons:
I have and wil l trial had it a Cetificaleof Consent to self users for Worker's Cooper- DRAINS-FLOOR,ROOF.AREA,COND. ST IES TYPE CONS'rRUC'I'ION
as provided for by Section 3700 of the LuhorCtdc,for the perfimmmdice of the
work for which this Fermi t is issued. FIXTURES-PER TRAP -
I have and will mainuin Worker's Gsnpevwfon Imumnce,as reyuined by Section
3110 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP MIN
My Wrk 'a CIl
ueromp imn nsur:mea m[rrler and policy nmgrc,
Cardec ST1-lZC (•iJiA11 policy Na, i�er011]Z7-CLE GAS-L'A.SYS'rESI-OVER4RA)
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE GRE.ASEANDUST'RL WASTE IN'I'ERCHNOR
BUILDING DIVISION PEES
(rhisseetion need nm heodmpletrd if the pennil is for one hundml Jnllnrx f8l W) GREASE"TRAP
or less.) PLANCIIECK PEE
Icdrfy that in the bmFoccanec of the work for which[his permit is issued,I shall SEWER-SAN]TARY,-STORM EA.200 FT
an
employ any p,as..in any mourn so as to beodme subject in the Workers'Compan- ENER YME
O ,Z' scum Laws of Cali tonus Dale WATER IIBA'H?R W/VI?NT/ELECTR -,..+ -
7 O Applicant C G FF.IT
q h NOTICE TO APPLICANT IL,fuer making this Certificate of Exempt,.",you should WATER SYSTFiMRREATING
become auhjecl to the Worker's Compensation provisions of the Labor Curb,you thus,
L11 forthwith comply with CONSTRUCT ION LENDING sAGENCY meet revoked. NEW RESIDENTIAL Q p permihall he WAI ER
z. r PLM13. SQ.I'I'. 1 1 9 IU
I hereby affirm Iher them is u constmcoon lendiagugcaay for the perfornated of )rite tReceipT
00 the work for which this Permit is icmed(See.3097.Civ.C.)
4ti F" Lenders Nam, TOTAL:
U Lenders Address Fo TAL: .Fr" „7 a 1 nfy tl Ill read this Lure that thehinformation's rFEE
h
correct.1"ge i ply 't "E city d county ordinances addslow laws mining to QTY. MECHANICAL.PERM1'I'
U ,'� hull l' b u'
nstrur n.and hrd.hyalthor'ze p edmt sesafthxe'ty to enter upon the SEISMIC NHP. O
abovantcmioned property for inspection purposes' PERMIT ISSUANCE "
(We)agree[o ,or,indcrand and keep handless the City of Cuperino against - F:LF.CTRIC PEE 3 (S-"0
ludililies,jndgmenP.cmbandexpennex which may in any way acme against said City AVER OR ADD TO MECH.
in'moidiumda of the graining of hill pe',Fmit. - - PLUMBING FEF. -
APPLICANTUNDERSTANDSANDWILLCOMPLYWITHALLNON-POINT Alit HANDLING UNIT(TO 10,000 CEM)
SOURCE REGULATIONS" M17CIIANICAL FEE
AIR HANDLING UNI'F(OVER 10,000 CVM) CONSTRUCTION'IAX
Signature of Appllclml/Ce.tmctorr,•�' J Data? EXHAUST HOOD(W/DUCT) I IOUSING MITIGATION FEE ..
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicam or futarc building occupant,lord or handle lie...dousomorms .[]BATING ON[T(101W,00013'1'U)
as belled by the Cupenino Municipal Coln,Chapter 9.12,and the Ihand,and Safely
Code,Section 25532(a)I BEATING UNIT(OVER looryto BT U) - - -
OYr, VENTILATION PAN(SINGLE.RESID) PAID -
-
W❑
ilYleths e aalor.aero buildingocpunluseefiuipmemordevices which _ HData Reai
it hzrdous air wonlmnumd tediytheBayAeuAirQualtyMnnBOILER-COMP(3HPORIM,Q)C)HTI1)
beef? ugemem BOILER-COMP(OVER 100,000 BTU) .0
DO
I da,a mad the bee urdona mmeriuls requirements under Chapter 6.95 of[he CalAIR CONDITIONER ISSUANCE DATE
^
tennis Ileahh S Safety Cadq Smdoas 255ft5,25533 and 25534.1 undera[md that if the NEW RESIDENTIAL MECIL SQ"OF 3 C G
builn ng dmsnol cuemely have u lenam6 lint his my mUamihility to salify lheau'upanl
I",
re9uirea ants which uu[bwd ad tcsuaned of a Ceriftca"d Oaapancy.
M
owrirr andmdrml slim Dme 'roTAL. 1SSDEBBY:
OFFICE