S 2198 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI RICAL p17til"NO. 2198
BUILDING DIVISION APPLICAT'IONIPERMIT PLUMBING-MECHANICAL \V
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: k/Y SANITARY NO. APPLICATION SUBMITTAL DATE
O - NAME I'110NE: C NTRACI'OR'S N,p�s is 1 C O. ^��
• ZS2— 2 � O /Y( SOa(7Y � Z9 C^/ NIC CONTNOLN
ARCHITECVENGINEER: LIC NO: y)DR'S5: _Sr
/C C4 S IS ❑
CON'FAC F. PHONE: �Ol` D B ILDING PERMIT INTO
SOUP 6J -/� ED Consultant Fees Paid by Applicant(initial) BLD ELECT PLUMB ME❑C'H
LICENSED CONTRA OR:S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby adding that I am Bcennt miner pnavinions of chapter 9 mmmmcncing JOB DESCRIP'CION
CMZ withSemion](NNB of Divisinn3nf me Rosiness and ProfessionsGde.and mylimnu is
RESIDENTIAL:
in full force add cRc PERMITISSUANCE
�'2'� 6233Sy ❑$FOWL El KITCHEN RI:MODI:1.
U Licen Lic'M
APPLIANCES-RESIDENT'IAT, ❑ADDITION [3 PLUMBING Rl%PlPE
rF 6 Dine _zs�� Comnn rr Gp/J (}f 0/.xY 1
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑sTRUCTURAI,
p.0 y PANELS
Zor�J,?, lummrswna ter nmoa snau rte a,ed as panhc reamma MODIFICATION
OZ-0 UI'T020(lAMPS ❑INTERIOR EklIMNEY R17PAIR
Fey. ul Licensed l4nfesaianal 201-I(XOAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION
OVER Rod AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
�C4 w nerehy uffinn that ten cacmpo frmn the CnmmuunLe License Law foram,the
S 6 U following reason.(Semon 7031.5,Business and Professions Code:Any city 2r county SIGNS ELECTRICAL (]OTHLR
au13 a h which requires a Tenant to construct,cher,improve.demolish,at repair any structure
F'.,y�J prior m it,ixmance,also recruits me applicmn for such permit to file aligned.statement SPECIAL Cl RCUIT/ht I SC.
RUp. that he is licensed pursuant the provi.uions of me Contractors License Law(Chapter 9
W'2y Dommencing widt Section 7000)nf Division 3 f,he Business and Prefessionx Cnac)or '[EMP.MITFHR OR POLL INST COMMERCIAL:
L Xm 4 thin he is et t therefrom and the had,at,me alleged esemptien.Any Anlminn of ❑NEW BLDGIADDITION ❑DEMOLITION
�•„y Section 7031.5 by any applicam for apemasusiects the applicant b a civil penalty of POW17R DEVICES ❑TENANT ❑FOODSERVICE
FZi• 't mom than five hundred dollar l55(NB. IMPROVEMENT 1
Q ❑1.its owner of the property,or my cimployaxs with wages as mei,cle nt2gmneanor, SWIMMINGPOOLELF RIC
will do the work,and the sanction is not lntendedoroQered for sale(Sec.TAA.Business []OTHER
L
"'m and 1'mfessions Coda The Contractor's License Law docs not apply m all owner of OUD.G'1'S-$WIT -IIXTURFIS
O'3 property who builds Or improves ihereen,and who does such work himself or through
his awn aupl,src,provided tbm such imprnvmn mos ore not intended or offered for NEW RESIDEWIVI-17fSQ F1'.
sale.IL however.the building or improvement is uld within one year ofeomplction.the SQ.FT.Fl.(K)R AREA SISQ,FT.
cr-heilder will have the harden of Towing than hedld urn build or impress,tor,m-
pose of sale.).
❑L as owner of the property,ant eaclmively Comracdng with Ilccocil contractors so DIAL'
construct the pn;j.I(Sec.7(W.Business and Perfexsionx Cede:)'Ibe Comnctors Li-
sense Lawdo..not apply m an owner ofpngsCry who bond,or hmTroves tncreon,and QTY. PLUMBING PERMIT FEE
who contracts for such Projects with a comraaod9 licensed pursuanuo file Contractors
License Law. PERMIT ISSUANCE
❑I nm exempt under Sec ,B&P C loggias..,,at
ALTER-DRAIN&VENT-WATER(EA) VALUA'T'ION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE! 5-t) /V1
I hereby aifed under penaltyof perjury one of the following declas:ration
I have and will maintain a Certificate of Consent o self-insure for Workers Compcn- DRAINS-FLOOR.ROOF.AREA,GOND. -DRIES TYPE CONSTRUCTION
nation as provided for by Section 37(X1 of the Labor Cate,for the performance Of The
work lin which this permit is issued FIXTURES-PER'TRAP '
❑I have:ted will maintain Workers Compensation Insurance,as squired by Section
3700ofohe LoMr Cade,Jordan perl'orme2c,ofthe work forwhich this permit is issued. GAS-PA.SYSTEM-]INCA OUTLEfS OCC.GROUT' AI'N
My Werke' ogadio sun 1Pole,i n GAS-FLA.SYSTGAI-OVERJ(EA)
Comer. 4t{ V nncg carne l'Miey Na:
CEERTIFICNIE OF EGXEMM ION FROM
WOkKEItS' GREASIIINDUSTRI. :INTIiRC iIOR
COMPF:NSAI'[ON INSURANCE NUILDING DIVISION FEBS
1'ILix section nucd ono be Completed if the Tannic is foum.e hundreddriums($11X0 GREASE RAP
Or less,) PLANCHPAK FEE
I certify thin in the per fanuance of the work for which This permit is issued,lshall SEWER- ANY-STORM ' 1
not employ any Person in any manner m as to become subject to the Worker!Compcn- ENERGY ITE
z ,� Iniad Laws w California.Date WATER fl N' .LE 'N
Applicant GRADING FEE
` NOTICE TO APPLICANT:11,after making this Cri iliene of Exemption,you should WATER SYS I/TREATING
become subject in the Workers Compenmtion provisions of the Labor Cale,year must 2E SOTLB HE
Q
lorthwim comply with such provisions rr this permit said be deemed Occulted. WATER SER
7z CONSONLENDINGAGENCY NEW RI!SIDG I SQ.FEPAID
V 0 Thereby affmuhm them
!saconmaon leningngenay fr theperfonnunce of Date Receipt#
the work for which this permit is;.,sued(Sec.3(9],Civ.C.)
CF L;mder'x Name (DIAL:
V Lender's ABdress TOTAL:
�+ 04 BUILDING PGI!
[..t 1 certify mat E bine it:m acusty and coup dna xtato mm me anaet iws mining i.
N cones,CoPemsnmply with all city and mmntygc;dim ufdhf,state laws mining QTY. MIECIIANICAL.PERMIT FEE ^
UZ building emtxwetinn,and hereby nnohorim repmxntuoivcx ofthis city m5nter npnn The SEISMIC PIH! V
above-mentioned property for inspection professes. PERMIT ISSUANCE
(Wc)e,mi,m M
cave,innmflu
y rota keep hrmles,tiro City 51 Cupcdine against GLEC'I'RIC PEE
Ilabilities.jud,grund enntsandespenses which may in any w.yacciveagairel.aid City ALI ER OR ADD TO MECH.
in a;mcquarce of m5 grunting of this permit. PLUMBING PGI!
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 110111,(1(111 CFM)
ETE
SOURCE REGULATIONS, 10.000MECII CA NT
AIR HANDLING UNIT TONER IB, CIM) CONSTRUANCTION TAX
Signature of ApplicaMCmmmacmr Date 1?XI IAUSTHOOD(WMUCT I IDUs I NO M ITIGATiON FEE
HAZARDOUS MAA HRIAfS DISCLOSURE
Will one applicant or(rote building Occupant Bettor handle lmzonleusneamn.l HEATING UNIT(TO I Ou NMI ITU)
as defined by the Cupertino Municipal Gyle,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING HNI'T(OVER I 00,m)B'IU)
❑Yes 0 N VENTILATION PAN(SINGLE TIES[])) PAID
Date kceeip M
Will the applicant or ec building occupant equipment or devices which
fumnt m
. emit nouoidous our Contaminants m defined by the Buy Arca Air Quality Manager cm BOILI;R-COMP(311P OR 1011,00 RTU) 1Ze
7, m
District?
r L: V
F�Yca F7No BOILER-COMP(OVER 100,0(D BTU)
NR CONDITIONER
lalth mad the h odeSsnmes 25s5.25535ms12553Cnapteroundfd®Cyli- ISSUANCE DATE
lomia Health&safety Cale,Sxtions 25505,255]3 and 2553J.1 undersand than if the NEW RESIDIlNTIAI.M1ffCl{. SQ,1.7
building does Bat aarendy catenate mit 1.my respmdbility uuumify me oeuupam
tents whit n be e ns,m i.soon of a Cenificute of(kempancy.
Owner ns,aumorizc agent Uam TOTAL: ISSUEDBY:
OFFICE