S2124 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO [lull.DINC.-CLb:M RICAL PL8 IT NO.
BUILDING DIVISION APPLICATIONAERhUT PLUMBING.MECHANICAL 2124
BUILDING PROJECT IDENTIFICATION
BUILDING A UDRESS: SANITARY NO. AP'IPLICAIION SUIDU'TIAL DATE,
2-16og LU Gt- � �3 --9
0WE.k:9 NA fE: a P�H)O�NE: ^ _ CON Cf( "N MG r 5/ LIC NO:
NIC CONEROL#
•ARCHITECI'IIINGINEER LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
2 �7 q! '7 q El Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB lIE❑CH
LICENSED CONTRACTORS UI CILARATION !(o C`/ QTY. ELECTRIC PERMIT FEE
I hereby afrrn thll licensed aa g n.5 of chart )( come ng JOE DESCRIPTION
CMZ with Secou.7NN)ofD . mn3,fine Bta dP fil,mr.CW d dice a RESIDENTIAL:
UOp PERMIT ISSUANCE
FU in fail
ease forceandcffcn. ❑SEUWI. ❑KITCHEN REFI E
U F License Class Lic.p
QZ U APPLIANCIiS-RESIUF.N'1'IAI. ❑AUDITION ❑PLUMBING kE-PIPE.
h d a. Date ContDECL STRUM
A I2C111IECT'S UF.CLAR,VION �M1IHLTI-UNIT ❑MODIFIUIb1O
(..P m PANELS MODIFlCA'I'ION
mZ IundcmnnJ my plana shall he used as public records
p'z--m UP 1`0 200 AMPS IEl INTERIOR ❑CHIMNEY REPAIR
Qyr/)tw Liaised Profcssio..1 201-I1N00AMPS IMPROVEMENT EISWIMMINGPOOLS a= OWNER BUILDER DECLARATION
C OVER 1010AMPS ❑BATH REMODEUREPNR ❑DEMOLEI[ON
C Q I hemhy of rem that I wm exmnpt from the Contractors License Law for the
X O a U following na...n.(Semon 7031 S,Business and II I—in u,Code.Any city er mnmy SIGNS EJ.17 DUCAL OTHER
W 3 W h which requires a perunt to consent.alter.improve,demellsh.or repair any structure
F",Opout Is %suare,also1 ' the ppI t for suchN it to fian signedstateme t SPECIAL Cl RCUIDMISC.
E } that h licensed p u it in l thepct f the C I cI License Law(Chapter 9
x y.Qa
0 (commencing with Section IINp)of Division3 ofthe Business and)utas:\m Code)or TEMP.MM- ..R OR POLE,IN ST. CQMM17RCIAL:
❑:-0
6 d e 5 that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW RLUG/ADDITIOR ❑UEA10LITION
Section 7031,5 byvny np,llelnl to,,. ,mit.subject,the appEenntmn civil'rulltyuf POWER DliVICES
t ...than live ationel dollars 1150()). ❑TENANT El FOOD SERVICE
� d nwnendtba norm roto cexwitnwn thairenleeom Jan, SWIMMINGI'OOLELEGI'RIC IMPROVEMENT
pope y ye p Y gesas penin
El OTHER
Oill do We work.and the evucmre is not intended or offered for sale l See 9044.Business
Wand Profession,Cure The C t t License Law dear,ind appilla a macul of OUTLEI3 SWITCHES-FIXTURES
II, pro,ay Is hit b ild improve,flarrelart,4nit no ell such I,k It nooff or through
his ownemployers.pr 'd I that suchimprovements I t I J offered fur NEW RESIDEN'11A1.ELECT SQ Fr.
-le,If,M1r...er.the helium,,,,improvement ssolA sv lhinomyaandummplvi onJhs SQ.IT.Fl.00RAREA 5/SQ.FT.
crbuildcr will hive Ino harden It praying lh:n be did out buIIJ ur improve(or pur-
pose m sale.).
C]1,as owr ,neof the p,,,,. am exclusively cnmracting with licensed common.u. TOTAL'
reenact the projmt(Sec.7M4.Rustle and Professions CW,:)The Co oracmr'z Li.
cense Law does not apply to an no net of progeny who builds or improves thereon.and Q'TY. PLUMBING PERMIT FEE
who contracts for such pr jects with n conmamugxl lice col pursuant ,,the Coal...le",
Lives,Law, PERMIT'ISSUANCE,
❑ lana cxcm nm Sec. .Iihl'Cfnrlhiz.oxen
ALTER-DRAIN S VENT-N'AI ER IEA) VALUATION
Owne Date '
'ORK 2:5 COMPP ATI(J. DF. .ARATION RACK PLOW PROTEGE.DEVICE(herd affirm uWer penalry�Perjury one oft e following dcdarmium.:
lE Ihnvu:md will maintain a Cenificate of Cansentm sclf,rsure for Workers Canteen- DRAINS-FLOOR.ROOF,ARIiA,CONU. S'I'ORIFS TYPE CONSTRUC'T'ION
,ebur,as provided herby Seen....3700of the Labor Code,for sm l,,lonnance of the
work for which this peralil is Issued. b XTURES-PCR l RAP
n 1 have and will maintain Workers Compensation Insurance,as required by Section
37M of the WMn Code,for the commence of the Is ork for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 CUTLETS OCC.GROUP NhN
My Wokvr`%Compensation Insurance carrier and Policy number are:
Canner: Policy No.: GAS-FA.SYS PEM OVER 4IRA)
CEK'ITFICAlE OF EXEMPTION FROM WORKERS' GRI?ABI!IINDUSTRI,WAS'll?IN'IERCIiP'IY)R
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissration meedmnl lwcon.pleted iflhelabo it isformehunJlWdollars($IBI) GREASIi'WAP
PLANCHItCK FEEor Ica.)
I easily that in the performance oflhe work for which this permit is issued.)shall SEWER-SANITARY-STORM EA.200 FE
net employ any Person many manner.so m m become subject..the Workers'Compen- //�� ENGRGY'R?li
O Z stoion Laws of California.Date WIG ER Illir\'I'IiR WNENTIELEcER s/ GRADING IgiE
Z2
Applicant '
NOTICL''la)APPLICAN'1..If ofo.undr,this Cenlficvte of INcolfion,you sleadd WATER SYSTENLTRENIINC, SOILS Flip I, become'ah",a.the Worker's Compenxvtion provisions of the Luton Carlo.you mixt
forthwith comply with such pmvisiom or this permit shall ber deemed revoked WAI ER SERVICE
CONSTRUCTION LENDING AGENCY NEN'RESIDF.NIIAL PLMB. SQ.IT. PAID
I hurehy.ffrm that them ixuconxwainn landingagency for the perfunnance of Dom ceiptp
U. @c work liar which Ois cern.il l s lxxued(Sri.309).Civ,C.1
O V LcndeG Nnnm AL: 'TOTAL'.
,r LenBUILDING FIR.
ders Addrea
1 I comfy that 1 have read this agplicatinn and sate that the above information is
Frocorrect. agree mcompb with all city and nnnly ordinances and arae In,,,reltoin&t^ QTY. CHAIN CA PER FEE
V Z building construction.and hereby authorize representatives ofthiecily a)enterupon the S
EISMIC4
above.mendnnedpmpen,l'nriu,,aucn,m,oes. RN 11'1. 'P.
(We)agree oa save,indenmify and keep harmless the Ciry ol'Coplanar,against ili
IiaM1ilitic<.judgnsnls.costs and expemes which may tunny wayaecoc u,nivasvld Ciry "RORAUDTU M_ IL EE
in oasequence of the 8confog of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH At.[.NON-POINT A HANDLING UNIT('IO IO.UW L ItiESOURCE REGULATIONSAI I (rvliic R).00CPM) ION TAXSi,rommof ApplicanVCotracmr Dam EXHAUST'I IOOD(W/DUC) ITIGATIONFlU.
HAZARDOUS MATERIALS DISCLOSURE
Will thele,ham orfature building lzcepanl....c or handle naccoll automated HEATING ON I I'(TO 100INN)131 U)
as defined by the Cupertino Municipal Can,Chapter 9.12,and the Ilealth aid Safety
Calc,Section 255320)? HEATING UNIT(OVER 110.00 BTU)
C]Y1, El No VENN ILA I I ON FAN ISI NO Jr RES I U) PAID U0(¢ It,, ale
e Will the uppli,, fir fuu.re building xcupam use Wuipincut or de.....whirl.
mit hmanlowsair, c.,..Iran,,as defined by the]toy Arc.Air Gambia,Manngemcm BOILER-COMP(31111 OR 110.0X3 B'I'U)
TUT .
District' BOILER-COMP(OYER 101.000 RTU)
E)Yes E]No
I rc,credit,h I m '1 t, low,Chaps O5'If the Cal'i AIR CONDITIONER IS'SUA/NCHDD//AAT///EE
bearic I{ 10 k Safety Code S .. 5505 25513 and25544.1 Jewoud Iba, the NEW RLSIDGNDALMI-01. SQ.EL
bold 6J ml culre lylutcnunt.rah ny rvsjpnsbllyl nvi ly Meaucupml I / —
of Ne acquirements w1.ich must fr act,noon n..mwe of a CeslGcam ief Occupancy.
Ownerorauthorircdagcm Dale TOTAL L: ISSUED BY. � �
OFFICE