S 2908 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PUU.MBC%G-MECHANICAL S A O O
BUILMNC.PRoIECr LDFCI'IFICA'1'[ON .7 O
HULLOING ADDRCSS: SANITARY NO. APPLICAHON NUHMIII LD IF
II .0 NE S NAME 1'I NIi: CONIACIOR'S N I!I N .
NIC CUN'I'kOL#
AM
RCUUF.Cr/ENGISLER: LIC NII: All[ FSS: / gYZAR /�� El
CONTACT 1910NE: BUILDING PIiRA11T INPO
❑ ConsWmnl Fees Paid by Applicant(Initial) It ELELT .0 NIECH
❑ ❑ ❑
LICENSED CONTRACFOR'S DECLARA'nON QTY, hI,EC'I'RIC PERMIT FEE JOB DESCRIPTION
I Bunny:dfia:Lot I unl icer cd ander fauvist ul Chanter 9(colors, ing
PCZwith Section Uividon 3of the lfusmess and Prote.eions Cade,and my llcenw,is Ia' I NTIAI'
alp PI?RMI'r ISSUAKCIi
a10 in full force and e[[ect SPDWL ❑KITCHEN REMODELaUU Lwerve Cl ss La` APPLIANCES-RESIDENTIAL ADDITION ❑PLUh1B19G RE I'll'I'.
Co
F-Z 4: Dam mral
ARCHITECTS DECLARATION ❑NIUI.TI-UNIT ❑STRUCTURAI.
PANELS MODIFICATION
zc�z
I understand my plansshill be used.public mcmdv UP T02(M)AMPS
❑INTERIOR ❑CU[MNEY REPAIR
F-=W Licensed Pt....oil 2II-10(X)AMPS IMPROVEMENT C]SWIMMING POOLS
OW NIiIbIfI111.O1''a DECLARATION OVER IIXX)AMI'S C1 PATH REMODEL/REPAIR ❑DIiMQLITIQN
C 1 hereby aVina that I a:n uacmpl from the Cunm,am's License Law ton the
W U bollowine naso,.(Section 7011.5.Poor...and Profevsiunn Coda Any,ny or Bounty SIGNS ELECTRICAL 1IIiR
[il 3 a'y which requires a permit In convtnah;ajar,improve denudixh,or nePmr any,aaaarn
0
gPrior 1. iuwanm,shore,mac,lheapplicam fnrsuch ry:mtilm file......dsmtecorm SPECIAL CIRCLE UMISC.
f twfa,Y� that he is lirensed punmmmme pnisi
rvons Orme Cmmracnns Lieennelaw(Chaplcry COMMERCIAL
(commencing with Section]Il(IJ)ofDivi.inn 3oOhe Rmine,o and Professions Cali In, TEMP.METER OR POLE INST.
d a 5 in.,he is eaempl Ibceefrom and the hast.for the alleged esempuoa Any violation of [I NEW RLDG/ADDITION r]DEMOLITION
Section 7031.5byanyupplictmt far.Peratodjecmlhe applicanu.a civil penaltyof POWER DEVICES
not more than five hundred Jnllnrs lSSIXO. ❑'IMPROV FOOD SERVICE
SD I,asocano of the n OT14FR
IMPROVEMENT
grope umnry500). ccs with wngar rex lhcirenlc amtpcmw:.n, SWIMMING POOL ELECTRIC
will do me work,and the suncmm iv nal ar,m cd or oILined basalt,(See 7014,Bun ❑OTHIik
m
Y13 ti and Prnrc....m,Cde:'@c Cnn¢ucmr'x Uceme 1"uw doss nal aPPIY to vn owner of OUfLf3T5-SWI'I'CIIItS-PIX'rURCS
11 pmryny who builds(it improves thereon,and who doss such work him elf or through
hroimmne
ix own employees,pvided That such vocarenla anm intended or o(Icred for NEW RESIUCNTIAI.I!LIiCfR Sp
sale.IL however.the building or improvement iszold within tine year ofinmpletion.the SQ,17.F1IX)R AKI!A &SQ.Pr.
crhuilder will have me burden of proving that he did not build m improve for pur-
"I'e of aalej. Ur
i 10
I,., evoil of the progeny,am exclusively contracting with Interval contractors to
canstruct the project(Sec.711W,ncoaress and Profession,C,alc:)Thc Coal-"ti's Li-
sel.aw der,ma apply u,aoownerofpropeny whit Im lJ,mlmprovel mdrm,..and QT'Y. PLUMBING PERMIT
who :mmaafm.uchpmic.iswi@ aennlma..(,)Iicansed pu nano,,the Cnntnnor'x
�LINMC Law. 1'ERMI'I'hCSUANCI!
I u:u exempt under Sce. .B&P C far thh rcusun
ALTER-DRAIN&VI!NT-WA1LR 11!A) VALIJAII(1N
)wI1Cr Da¢
WORKIiRS CO PENSATION DECLARATION BACK FLAW PROTEGE DEVICE
I hcnby alma,under penally of pe jury one of the following declarations:rev
❑I haven.,a,and for byncene.37amof C.menrtoCodenFarmn Worker's Compere- DRAINS-Fh(J(JR.ROOF.AREA.COND, STORIES TYPE CONSTRUCDON
.tartan,ll this IIIlabyti,koj J]ql ar the LUMn C,dc.Farm,perfonnnncc of he
wo k far which this permit in iswuJ. I'IX'rURES-I'1!K'I'RAI'
I have and ,It malnmin Worker,Cnmpcnsall nn Imam ace.as remained by Sccdon
IXl tit ma LTM,r CnJq lar the Pcdunnunm of me work far which thio permh In iasuttl. GAS-EA.SY$'f!M-I INC.40L1'ILES OCCGROUP APN
,W..k- ...up. at F,4 u. c catr/crmtJPnliry:m� � GAS-EA.SYS'I'I!M.OVER4(CA
)
Carrier Polley No.:
C[RI'119.Ar[OF EXEMITION FROM WORKERS' GREASFANDUSTRL WASTE INTERCEIll OR
C01NIPENSAr10N INSURANCE BUILDING DIVISION ItiFS
(Thissclinn need not becompimeriflheprotan is fnronehundreddolla,($100) GREASE TRAP
EVAID
'
Loy any morinthe anylenencenf work econi which this the Wrkes'ConaMB SEWER-SANIIAHY-STORM EA 21X11'1'. ,I
not employ any pen any n :rev sn as e:hcannc vunjca m me Workers'Cnmpn,-
Z .........Law,of C,liannia.Date WATER
WATER HFAHIR W/VENT/ELECTIR ORAD
yQy Applinml
q r�} NO110E TO APPLLCAN'I':IL alter making thin Cerifica,.I Eve:nplion.You nhuuld WATER SYS'113M/1'RI!ATING SOILS199 11; neenme a1j,r,to the Worker's Cnmperosalion pro,.inns at'the Labor Code,you frostforthwith comply will,.such provisions or this permit shill be decmW revoked. WATER SERVICE
Z CONSTRUCTION LENDING AGI!NCY NEN'RFSIDENITIAL PLMB. SQ.EC
U O I hcreby affirm that there is a construction lending agency for Performance of
me wod for which this pmit eris issued(Sec.3197.Cit,C.)
OULerdcr'a Nina, 'IOINL' SO
Lcnivr's Address .
1 many Thal I nava read Ihlup,plicalina and orate that the above ulfillumon n BUILDING FEE
iH.: N amens.l agree lucomply will all city and county ormuinccs and state law,mating 1. QT'Y. MECHANICAL PERMIT FEE SIiISMIC FEE
U nuildiagennarunina,and hereby aulhorire representatives of this city a,aner Trym the
aMwe-ntvminneJ progeny far inspection purpmen. PERMIT'ISSUANCE HLECTRIC PEE
(Wry agree m save,indemnify and keep homins me City of Cupcnino agaifrw
Ilobililies.pd,um,.co.and c,cuses which may in any way accrue against said City ALTER OR ADD'IOMECM PLUMBING FEB
asequence of the 6ranfng of this pernll.
APPLICANTT p1
UN/7UIERtS/Q'J/1'ANDS AND N'll.1.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFhf) N11!G11AN1GALFEE
SOURCE/EG S
q AIR HANDLING ONI'1'(OVER 10lXWCPM) CONS'IRUC-HONTA
wu cif Ap,licantlCunt Boor Dom EXHAUSI'lIfN1D(WIDUCT) HOUSING AID IGAI'10 fill
HAZARDOUS MATERIALS DISCLOSURE
Willmeapplicumor future building oecupunuuneorhmdle haaallous mmerial HEATING ON]T(10 1011,0%01 BTU)
AM as defaul by the Cupenino N1uNdpa)Cult.Chapter 9.12,and the Health and Satmy HEATING UNIT(OVER 1Oo,IXXI BI Code,Section 25532EV
p Ycs ❑Nn PAID
VENTILn'I'ION PAN(SINGLE RESIU) Dae Naciplp
Will the applicant or future buildings,cuupunl me equipment or dcvlccs which BOILER-COMP(3HPOR 100,00[11 U)
mit hmardnus air cnnm din I,an ldlooal by @e Bay Arca Air Quality Maon
L
District/ BOILIFId-COMP(OVER I00,000 it I U)
0Yet p+
I have read me ha,uhm,nescrid, kr Cha tar b.95 of the Cali- NH CONDI'I'1(INIUt I9 I—I7t11vE
remwnnem.a nm p 5 g
fond.llcallh&Safety Code.Sections 25505,25533 and 25534.L undersand IMI if the NEW RESIDENT[Al.MECH. SQ IT.
building does not currently have a tenant.that it is my mnp:msibilby to notify the occepam
of the Waireaxnts which mm1 be met prior a issuare,of a Certificate of Occupancy.
Owner or undulated em uu )me - 'TO"fA1,: ISSUED BY
OFFICE