S 2750 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.R'1'INO IIIIILDISG-ELECTRICAL PERMIT NO.
iMECHANICAL
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROjECIIUEN1Ih1CAT1ONJ 2750 7JO
BUILDINGADDRISS: SANITARY NO. N'I'LICATION SUBMI'PI'AL DATE
OWNIiR'S NAMI?: PIIONiI: CONI' ACfUR'$NAMIi: 5 LIC NO:
NIC CONTRUi.p
Gib
ANC111'1'F.CI]11NOIN;LIR: LIC NO: ADDRESS'. ❑
CONTACT: PHONE. BUILDING PERMIT INFO
❑ Consultant Fuses Paid by Applicant(Initial) HLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARnIION QTY ELECTRIC PERMIT FEE
1 hereby union Inas I uin licensed under provisions of Choprur 9 lcnmmetwing 1 DESCRIPTION
OaZ withSrelinI70(Xfot Division 3ofthe Basin...mA l'ml'urio t,Cade.anlmy[lino is - RESIDENTIAL
W O PIiNMI I'ISSIIANCIi
F
1= in full farce ands. cel Q SI*UWI. ❑KI'1'CIIIIN REMODEL
aU1- Lieenw Clan. 1# CO APPLIANCES-HISIUENTIAL []ADDITION ❑PLUMBING RE PIPE
F Z W Uam Contra
N<ti AHCIIITIiCI'S UFCLARATION PAMihS ❑hiU1,TI-UNIT ❑STRUCTURAL.
'Don
Z I mWers'ntJ'oy plans shall be nscd us Puhllc r.cnds MOOII'ICATION
'L O y OF 1'O 200 AMT'S
OZ�O ❑IN'1'i?BION ❑CHIMNEY ItI[i'AIR
C••¢ U,,a,d Profession.[ 201-IOQIAMPS IMPROVEMENT -E]SWIMMING POOLS
C6 v�
Y
OWNER-131I UDECLARATION OVI?H IOBOAMPS ❑B IREMODEI/REPAW ❑DEMOLITION
C I num[+ Ifu 'hal I amt exanp'I'mm the Cumrturn,Licem.Law for the
x 3 6 U following reason ISechon]11315.Bminesa and Profmsions Code Any city nr,only SIGNS ELECTRICAL 1'1111R
WLL b` which requires a permit e+amwmet.alter,improve,demolish ommrc
F
r repair any%rc
..W.0Q
print to ts issuance,also4 the applicantfor such Evans t file a signed statement SPI'CIN,CIRCUTIMISC.
E W y thatn p n t1 n I ti C I :I i (Chapter 9 .
M0 [win ncmmg w th Sees 7th)(Jul Dk
' o
v' t tot lot to
Buvnr:x, d in ,r,Cade)or 11I7M I'MICEROIt POLE Q COMMERCIAL
n.,L C that lie is exempt[fractions and the basis lot tic alleged exemption.Any violation of ❑NEW NLDGIAUUITION ❑DEMULI'110N
X W Sinaloa]031.5 h penni 1
W�'m t by applicant for rsuHcnstbc.%%lieu,,anvil penalty of IroW'IiR DEVICES ❑TISPROV El FOOD SERVICE
}
n'innrc Ihun Evc nunJreA dolMra(551X1). OILI;R IiMENT
,yam ❑ Lo the work.lndpe%tmct ,all isnot%[ryas wl'hwagwnv'hci(side nnnp.nsarion, SWIMMING PUIq il. Toe
F. will do the work.and, The on istols Liverdnrolwdoesnoale(See to aIfusmcof ❑O'I'HI?R
G 3 w and Profession Code:'Ibe Commnor'z Licenw Low Jces no,apply m.n nwtmr of OUTLETS-SN'I'1 CI{ES-h1 5
property who builds or iollson es themon,and who Aces such work himwif or Nnugh
Ns own cmployecx,provl led'hat each imprn'snoutx arc nu'imm�ded nr otlurcJ for NEW ftP_SIDEN'IIAL I?LIiCI'H 1'
.ule,If.hava,v,We luildingarlmpco,,aurm lsmld sontion,year ofu,mple'Inn.the SQ.ICI'.FLOOR ARBA EISQ.IrI'.
+ r-builder will have the burden of proving that he did nor build or improve far pur-
(nw1ofsale.l. TOTAL: /L1A
❑ I,:u owner of Inc prnperry,am exclusively amlmcling with IianwJ conu:'mors In L��\
......Inc,Ike p jetl(St,,7044.lousiness and l>ofesstnm Code)'Ihe Con r,so rs Li-
cease Law dusts not apply,an owneraf property who builds or hnproves lhercnnand QTY. PLUMBING PERM11IT FEE
PD
who contracts for such pts+jets with ucontractor%)licensed pursaam m we Commcmrs
License Law, PERMIT ISSUANCE- J 9
Iam cx mp'under Sec. .I1&PC or'his I
AUI'11H-URA IN&VEN I'-WATIHt 11{AI VALLAl'ION
• Ox'ner Due p
WORKIXS COty(11ISATION DECLARATION BACK FLOW I'H(TfECf.DEVICE
By
1 hereby u1'Bnu mtJo+Penalty of perjury one of following declurutlons.
I havcanl will,,main u Ccnifi,moulnnwnunwlf-insure f�rWurkcr:e Compem DRAINS-FLOOR,ROOK AREA.CONI). S'If ORIS I Y111 CONS'IR UC'IION
smirk, provided fur by Section 3](NI of the Icer Cuvde,mr tic perfnnnanee of the
work for
which this%coni'is issued. ITXTURES-I'[H TRAP
❑ I nave and ,It nminmin Worker's C su'alinn h+mmnm,n..quire.by Sedlan
.17v)of the Labor Code,ran liepc d'onnun,of'ne work far wharf, his pert..:[is issued, OAS-EA.SYS 11:M INC.40U1'LI?'Iti OCC.GROUP - APN
Aly Worker' gmpen.a' Inmm ce tamer not Policy num��l,yyy.qec
Cartier: Policy Nu.:c,I GAS-EA.SYSTEM
-OVER 41EAl
CERTIPICATIi Op EXEMPTION FROM WORKERS' CRI?ASEIINDUSTRI.WASTE Cut OR
COMI-17NSAIION INSIJRANC17 BUILDING DIVISION IHiIiS
(Thlxwclion rival not becnnrpl.mdiftnc Prnnilisl rrnne mmfi,llnllars($i00) ORIiASETRAY
or I...) PLANCHECK FEE
I cenitylhminfleperinion wrofineaaak orwhich thispermil is issued.Isia11 MiWER-SANI'MRV :TORM EA.21X1 IT
,ploy unYpc imynnr.
nuit,to lwconm..1,111'to the W..k,re'Co open, ENERGY FIE
OQ sof California. a
Dole WA1l' R HEAI El IV1iNTnill3c IR
cannlrvc FEE
npplieam
NOTICE TO APPLICANT 11,after making this Certificate(1l Emmption,you mould WATER SVS -M/IREAI'ING
.N. SOILS PEE
a > ficconm wN'lat m Inc Worker's Cump:n fi Ll provisions of he Luer C+xlc,you must
limhwilh unnply w'ihCUNSTN sinnx of thus%coni[shall rte dee'ncJ revoked. WATlilt 1RVICII
C. rw CONSTRUCTION LENDING AGENCY Nli RESIDIiNIIAL PLMB. SQ.Icil PAID Receipt ii
C.7 I hereby affirm that there is satisfaction lending agency for the lx surni nee of a
W 'h1 work for whichthis Penn..is Lvn..I IS,,3097.Cie C.)
Q U Lmdva,Name T(1'IAL:
W lender's AJJre.a TUl'AI,
r 6. 1 study that I h:mc read this application and.state that the above infamenu n is BUILDING ITIS
eons,, 1 ugr,,o c I,ly withal 61yand county ordinravo,and smite law,rclariog a, QTY MECHANICAL.PERMIT FEE
V Z building eons'mmion.and herebyaull we nprlvmmv,s I la,city m enter uponhe E1Ielc FL'E
uMrvc-'nentionN prapeny for inspection putpnws. PERMIT ISSUANCEIiLECI'RIC hlJi
(We)agcy m"a,.indemnify aad keep ha.1,,s the City of Cupertino against
Iiabiloes,ol,ncnl..cows and cxpmowswinch may in any way accrue againntaaid City ACIRR OR ADD'TOMECII. PLUMBING FEE
in ,sequence none gnml ung of Ihiv%anvil.
APPLICAN,UNDERSTANDS AND WILL COMPLY WI'TII ALL NON-POINT' AIR HANDLING UNIT('I0 10.0010 CFM) MECHANICAL I,EL
3
SOM", A'f1D _r9,4y AIR HANDLING lNIT10V1iR10,IXXICFMI C(INSIRUCIION TAX
/\ r I
Sign tpplicaHAZA DO D:nc li%HAUSI'IIUOIJ(WIDOCf7 IIUUSING MI'1'IG61'I(1N hili
HAZARDOUS MATERIALSD,mrsor URE
handlWill the appliram or fumy M,ilAing ceeupmn xmmor hundlchvalloov matenul chl ' fg . eHEATING UNITO I1. ) 'IU
odGtM byte Cuprninr Municipal Co ,Chaptr9.12,and the Hea1hand Salety
Cads,So25532POn 111AI ING UNI'I' VR OW I1'I
'LE
❑Yc. 0N VINTLAIIONFANSI 'LERSID)
W t h I g P t - r 1st x n (1EftCOY PUN I Wass) 'U
)
-
I'Ail
a
c /Receipt It
emil h ado. n � : - I I J hY' liA aAoQ Ity Management 1/Y
l
'AI:
Disin r NLERC 11 ROVE00010 1IUI
❑Y. ❑N ARCO IIONER / ISS NCPDATE
hive rcud'It,hen m , val,ntimos t u Ch:pac 6954Ate Ca /
b+mia flcAth&Safely Colo,Section,15505.25533 and 8534,1 undc...md that if Inc NEW RF;SIDHN'I'IAL MECIL SQ.PI'.
IN.ilding firsts ran cu dy have a moam.Nal it is my responsibility to nmify the«pacnpan'
'If rc - ,encw bin nhc met poor to issuance of u Cenifmmeof t k/
TOTAL:
Owns {�Y/aurhrriuJ ugcm Uam ISSI/1iD Ii Y:
OFFICE