S2830 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-FLEC'IRICAI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2830
Q
BUILDING PROIF,LTIDENIFIF'IC\TION J
BUILDING ADDRESS: SANfI'ARY N(1. APPLICATION SUBMITTAL DAP IT
Cu PP -
OWNER SSNAME 1' PITONS CON'IRACFOR'S NAME: LIC NO�.
OS Sets e- I .Wo ABA. V1.
NIC CONIRGLN
ARCIII'I EC'i'/ENGINEBK: LIC NO. ADDRESS: / El
3 Du L. S N 1?A al-
CONTACT PHONE. BUILDING PERMIT INFO
ElCDindri and Fees Paid by Applicant(Initial) SLUG ELEC I' PLUMB MECH
❑ ❑ ❑ 0�
LICENSED CONTRACTORS DECLARADON Q'FY ELECTRIC PERMIT PEE
1 hereby afrrm that F am licensed under provisions of chapter v(commencing JOB DFSCRIPTION
an with Section7(X)O)off)ivisian3ofthu B.,iness and Profe,,iu is Code,andnry license is RESIDENTIAL:
won I'I!RMI'I'ISSUANCE
It l� Lice.. C1L,1 Be 5058c ❑SFDWL El KITCHEN RIiM10UEl.
Q,UV License Cla- - Cmuc APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RI:PIPE
y Q G Il;ec Cnnme'or 1`111017117 I&k"5
F.�m ARCHITECT S DECLARATION PANELS ❑MULTI-UNIT ❑S'fRUCI'URAL
ZC)z I understand my plans shall lre uvnl as public recoils MODIFICATION
O 2.-+-a UP TO 20()AMPS 0INTERIOR ❑CHIMN17Y REPAIR
F
4 t W Licensed poll...tion 201-1(MNJAMPS IMPROVEMENT CjSWIMMING POOLS
Q ,�.] ONVNER-BIJILD17R DECLARATION
5 S5�'Q booby altirm that I vat exempt liam the Contractor's Guensu Low 1'or the OVER 1000 AMPS C1 BATH RF.MOUEfIREPAIR DEMOLITION
'K 3 c.E- following mosnn.(Socio..]031.5,Business and Pu fe.dons Code.Any city err county SIGNS I!LECFRICAL Cl OTHER L r�
4: LL y which repine v permit m construct,ober,improve,demolish,tri mpar a
iny s ureame Kill �pocg
FI='.Q Troon t e.ads '
no TM1 plic t
pf hpermit, fl g d,tternam SPECIAL CIRCUI UNIISC.
a,� 'bar hc,,licensed pai u fficinuokilisol th C oration's L , Lov(Cl:pter9
W5 ;V (commencing with Section 9000)of Division 3 of the Business and Professions Code)or TEMP.MEIER OR POLEINST.. COMMERCIAL:
n e.. that he is exempt themfmon and The basis for the alleged exemption.Any violation of L1NEW BLDG/ADDITION [IDEMOLITION
Section 9031.5 by any applicant fur a lsubjects the applicant to it civil pcnuhy of JIDWP.R D17VICES ❑TENANT ❑1-001)SERVICE
FZ} nil more than frvr hunJmJ dollars(1500). IMPROVEMENT
=Q ❑ Las owner nRhn propcny.or my employees with x'oges a.their role compcnm'inn, SWIMMINGPOOLELECIRIC ❑OTHER
p. .01do the work.t vid a 000,lmaI,not In'ended aralicmd fnrsale(See 7(clL Business
LLand Pmfes.inns CndC'The Cmdracwr's License Law dues fill apply do an omarof oil H-1,I S-SWITCHES-ITS'1 URES
a 3 propcny who builds nr improves thereon,and who dues such work himsslf or through
his own employees,provided shat such improvement,are our imeadnl nr o0'cred fur NEW RESIDENTIAL P,LFC R SQ FT.
sale.If.however,the building or Improvement is sold within one year complelien,Ihc SQ.FI' IAOR ARCA $ISfJ.Irl'.
owner-builder will have the burden of proving that he did not build or improve for pur-
p-L'nfsale.).
wit
It
❑I,as awner of the progeny,am exd.,isely contracting h lut,nsed rio rxcmons Ill)IAL:
construct the project(Sec.]BW,Business and Punfessions Code:)The Contractor's Li-
cerise Law does nor apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who a duet,fin such projects with a c m.a.1 s)licenced Tullman do the Cnmammr's
License Lw. PERMIT ISSUANCE
❑ I amoxempt under See. ,B AT P C formis re...n
AUFER-DRAIN Ti VENT-WAI'ER(EA) _ VALUATION
Owner Date
O
WOkKER'SCOMPENSATION DECLARATION BACK FLOW'I`ROIECT.DEVICE �/� I I
hereby vl mai under penalty to of Con enc ll WC fn oat fi gWorknnnv l
❑ .have and
monde maintain e3700of Consent Codi for
the Worker's.ofh- DRAINS-FLOOR.ROOI'.AREA,COND.- STO1 TYPE CONS'fRUCI'[ON
sotto p mooded f by Sector 3]W f dh Labor Cod f the M1 I c of the
work) h i II ' er IIXTIIRES PER TRAP
I h J IIlmaintain Workers Compensation Insurance,as captured by Section F1
3]fMl of the huMr Gdc,for the Performance of the work for which thispe/mni�t xnsnsfsueJ. GAS I:A SYSTEM-I INCAOUTLETS ` OCC. AYN
My Cam raked.' n n n.a nuaam�Poi Y 1,m•7
G/S-HA.SYS'I'E,M-OVER J(IiA)
CFRTIPIC TEi OI'EXEMIT'ION FROM WORKERS'
COMPENSATION INSURANCE GREASIIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FRES
a,svevion occur.,be completed if mepcmu is Insane hundred doll. CREASE:TRAP
or Inst(TPLANCIIECK PEE
I certify that in the performance oflhework for which this penin isi,ssued,I shall SEWER-SANT IARY-S'IORM EA.200 FF.
nploY any pe non in any'mmntty, vs)ntrec_ �ubjcct to The Worker:Camgn- ENERGY FP-E
Z nation laws of California.Date WATERHBATI:R N'NENT/L•LECI H
z Applicam - GRADING FEE
NOT ICE'U)API' ANT:If.aims makingNill Ccnifieenof Exmfp'i....yon should WATER SYS"I EMO REA'I'INC,
beconc abjca ser the Worker's Compensation Prov cions of the Lit Code.You moa SOILS FEF,
LaSI fanhwimumtply wLlh.such sokicaso,this permit shall bcdeemed reveaed. WATER SERVICE
0
6. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI.MB. SQ Q FI. PAID
UO (hereby aftirm than there is conduction lending agency for the performance of Oec - IM
(-' the work fm which Thix pcmnit i.v L.ucA(Sec.3fy»,Civ.C.1
OU Lender's Name 'I(TfAI.:
} U Isacler's Address TOTAL:
Cw I cefily tent 1 lwve rend mis appi'Lai ami ane road me A...c infor.nvdnn:x aun.nlnc Fns
.`�., 0 correct.I agree to comply with all city and county ordlmanav and stun laws relating in QTY. MSCI IANICAL PERMIT FEE
UZ building constrvction,and hereby antler a representatives of this City To enter upon the SLISMIC4LE
nbuveendemio led property ,for inxpectinn al ow,. I'ERMI'1'ISSl1ANCE
(We)agree n xi,e.indca illy and keep Imrn less dbe City of Cupertino against Ii1,F.C1'KIC PI!H
Iiddlities,judgmenu,costs and expenses which shay in any way acme against said City ALTER OR ADD*10 MITCH.
YhIJMBING PGF
nICANI cofroc RSIAN SThispermit.
APPLICANT UNDHRS'PANDS AND WILL COMPLY WITH AEI.NON-I'OIN'I' pIR IIANDhING I]NI'T('FO IQI)(IfI CFMI MECHANICAL n3E
SOURCE R[GULA'I'IONS
.
_ 1-viQ AIR HANDLING UNIT(OVER 10,00ICITD CONS'fRUCT10N'TAX
Wr( II�-Fl^'{ l
Sdg ature of APPlicaHAZA DO Il:nc EXHAU.STHWO(W/IIIJCT) HOUSING MI'I'[CATION ELF:
HAZARDOUS h MATERIALS DISCLOSURE O
Will lhu uppnc:nu ur fulnrehulding necupand afro nrlmndlc hnvuNonsnnteri;dl HEA'T'ING UNIT(TO IIN1.IXq R'R1)
a dented by the Cupertino Municipal Code,Chapter 9.12,and the ucahh and Safety
Code,Section 255321x1' HEATING ON]It'(OVER 100.000 BTU)
❑Yes ❑NaPAID
VEN'T'ILATION IAN(SINGLE ItES1U) Date k�cul p
Will the applicant or frit re building neeupam um cyaipme t or devices which 601LIIK-COMP(3Hp(lk IW.IMXI ITTU)
01cm l bump mdN an nimnmin:mux us dclineA by din Bay Arca AT,Quality Management TOA ;
Diaric0 BOILER-COMP(OVER W.00(HAL)
E]Via, Fl No
Ihuve Head the hvnrJmdn dnmerial.m t,under Chu rte 695 of lbs Celi AIR CONDITIONER ISSUANCE DATE;
mrcn¢n
fnmia Health h Safety CWt Sections 25505.25533 and 25.5.}1.I aMcnnnd That if the NEW RIiSIDIiNI'IAI,MECH.
building dcesnomunemly havuu¢mtm.tha Tt is my renrymvihilirymneify thctneupmt -
oftile rey" men which must he met prior to issuance Lit a Camille w c�,xv'1yFay,
�=R t—t c b nt (+- Dec/Y-,i "OTAI_ ISSUED BY:
OFFICE