S2898 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC9'RICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICALS 2898
RUILDING I'ROJECTIDENNI'IFICVI'ION'
IHJILDINGAUDRF?SS' SANITARY, API' ICA'HONSUBMI'1'1'ALDATE
I VALLco rAPYWA
OWNER'S NAM H: PHONE CONTRACIORSN ME: LIC NO:
•G J. L. N/G GON RGLN
ARC l"I''/I:N INF.E ' utijow �lv���� ADDRESS; ❑ ? '/ /
CONJTAC'I: PHONE: BUILDING PERMIT INFO _
51 22t� 11oz ❑ COnsullanl Fees Paid by Applicant(Initial) BLDG ELSE]CTT PLUMB MECCH/
L� LK ❑ C�1
LICENSED CONI RACTOR S DECLARATION QTY. ELECTRIC PERMIT FEE
I 1 y 1 to m t l licensed e p t Chapter 9( g _ JOB DESCRIPTION
0Z wins i 21XXU fU mOnfteBm and Piles:� :Code,ual by le ase is RESIDENTIAL,
OQ I'KNIT ISSUANCE
Fly_ it failf rand Cada. ❑Spim. O KITCHEN REMODEL
'C V I- License ClassLie.N
Q U AI'I'LIANCF_S-RESIDENTIAI. ❑AUDITION ❑PLUMIRING RE-PIPE,y ,6 C Mae Contractor
F.]y CIIITECTSDECLARATION PANELS ❑MULTI-UNIT OSTRUcrURAI.
z,pHZ Iuad-,,coir :public revvnds MODIFICATION
O UP'10200AMPS L1 INTERIOR El CHIMNEY REPAIR
LL. Lice . 201-1000AMPS IMPROVEMENTE]SWIMMING POOLS
� NER-BUII.DEkDECLAI<A'I'ION UVGItI(NN)AMYS ❑RATE{REMODEIIREPAIR ❑DEMOLITION
1 C W Q 1 hemby anima that I Ant venapi loom the Como ants License law lin the
X3=WLUsF following reewn.(Section 7031.5.Business and Professimre Code:Any city oc county SIGNS F,LECfkICAI. C3 OTHER
0
m which requires a permit to construct,cher,Improve,demolish.or repair any nauaure
F'� <
CV
prior to t also 4 the ppli t for suchps ict in rile a signedstatement SI'ICIALCIRCUIT/MISC.
tbuth I Ip n Ill p n If'he Contractor, 1' ((.I prer9
WapO leonrnou tawlh Seclon]IHID)tl Dimki Sol the Ilmia.an WPmfes:' hs CwleJrr 1'I:MR METER OR POI.I!IN COMMERCIAL
d a e C that he is esrnml merefmm and the h;"is for IM1c allrgnl IXnhTNinn.Any vinhuion of 00- NI?W BLIIG/ADDITION ❑DEMOLITION
LL-w Section 7031.5 by am applicant for a permit subjects the applicant to a civil penalty If 1v)WER DEVICES
nrn more than five hundred d011nn ISSIXq. ENAN'P [I FOOD SERVICI?
�=6 has owner of the norm lovers with woes as their ndr cote tion. SWINAMING POOL I!LECTR IC MPROVI?M1FaNT
A F D ❑ profanity. Y emp 6 penes
C"w will ta 0 , dI, t tt t' l dd ff reef MIS oan K ss Ll OTHER
63 andP t 'C ]I,The C l l I L I tapply t of, "OUTLETS SWITCIIGS
property T Id, p II d hdoes.t k h ll lougln
his ply ,pr d d In,(. i poen t a' tinternal D red for NEW RESIDENTIAL 1'1 l CI R SQ IT.
sale lfhw ce the hu ld gorimprovcm rolls colt w'th nomyenrofe)nplut lythe SQ,FT FLOOR ARIA SISQ,IeI'.
ow rrbuilderwill have the bafden of pnn'ing tum he did not build ter improve for par- /�n
pouofsalc.). / ,9A
L as owner of the property,am exclusively contracting with licensed aontravocs n, T4 ,-
msaum the project(See.7(94,Bnsines and professions Code:)The Comracua' Li-
cause Law does not rtplyloan owncror property Winn hailds or impmvcahcreon,and QTY.. PLUMBING PERMIT FEE
wM1m rontrauYn for such orI arm a cnntrarmf(n)I lceacd pa...con n.Ota Cnmmelor'e
tirense Ww. FIiRMI'1'ISSUANCE
I am exempt under Sec. .B&P C for This reran
ALTER-DRAIN&VENT-WATER(IIA) VALUATION
caner Mae I Z 2 Do 0
WORKER'S COMPENSATION DECLARATIONBACK FLOW PR(llTCl'.DEVICE
i M1awill �iul'lmo undo penally of perjury one of Ibe Inlh wing dedarmiuns:
�Ih nd I m Ccoill,alcotL cau,cf-in,loci Worlo,r,C'n pet DRAINS Il,pOk,It00I;Ak1A,CONU' STORIES 'I'YPB CONSIHUC'1'[ON
surium,asp ded for h,Section 37N)of,he Lidar,Cn,la.I m dalliance ol'the 2
work for h I Ill.pe t J I'IXTURL$ PCR'1'RAI'
LJ I have and will maintain W k :Compensation Insurance.as Occumd by Section
3700 ofh Labor Codc.for the performance of the work lot h h this pernot issued. GAS IA SYSTEN111NC.4OUTLETS (JCC.GROUP ANN
My W k r.Comiscroatim Imuccure mm d Policy nun be are
Cam Policy No GAS FA SYSTEMd)VER 4(EA) Ditto
CI.RI'IFICATI OI INEMII ION FROM WORKERS' Gltl!ASUINDUS'TRI,WASTE INTERCI?IsfOk
COMPENSSI ION INSURANCE BUILDING])]VISION FEES
(ILixneclinn need not he cnanpleted if he permit in I....me hundreddollas is l No GRL'ASETRAP
or less.) PLANCIII!CK FEE
I reality that in the pcmormance oftbe work for which Nis permit is issued,l shall SEWER-SANITARY-STORM EA.200 17.
per
,on employ any pean in any manner sat as to became subject to the Workers Compen- EN 'YFEE. 0
Z dinn Laws all'C'allunnia.Data WATERHEATER WNI!NPELECTR
zQ Applicant \UI. I hili
rN-r
NOTICE 10 AVVIJCAN I`11L alter making this Cendleate of Exemption,you.should WAI'EIZ SYS]E14fl'R17NFING SOI i!1!
F , become ah ce,o,the Woders Cumpenmdan pmvi-sion of the Wbor Cn I,you must
forthwith comply with such pr.,i,i...I,or this peroon,mll he Jeemcd revoked. NATER SI!RVICE
Q
Z
CONSTRUCTIONisaom LENDINGAGENCYagony NISN'RESIDENTIAL III-1,1B. SQ.17. PAI
U all
pe, Ireissued(See lNOlenJing agency for the prrfonnanrc of Dam keaiptN
W Fy rust h l Lich Illi p 1 rxmcJ(Su.1119] C v C)
O U 1,r,d N T(lfN.:
} ]UTA
L:land Adl '
6. Icrfy that lh ad this application nd:nt d M flat information is
ILMINCII!E L
F y onceel l.,meto trump], h InIcity J emany N'...ec,unufame low,rcFf ngm QTY MECI IANICAL PERMIT FEF: / 2
rore
UZ building constclon.and nearby authorize repmscninven of this city trapnn the SLIM. ICIIE f0
obuvementinned property for inspection purposes PERMIT ISSUANCE
(We)agree
Q SO
mxuvr.indanni l y and keep hamil—the City of Cuponi no land all ELECT .FEE
families,judgm.nts,v is and exp.."c.which may In any way ucrmeagninnt suit City ALTER OR ADD P)MEC H. Q PLUNKING IEII
in n.....eme of me".,I, snfnn
Illi,penult.APPLICANT APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNH try 10,UO)CFM) MECHANICAL FEE
soil Cr,RE"In'A Fe
AIR HANDLING UNIT(OVER 10.0001 CFM) CONST RUCTION TAF
Slgnuwr mnnclor ibnc I!XIIPI1ST 11000[W/DUCT) HOUSINGNIOGATIONIEE
IIAZARaDtJS MATERIALS DISCLOSURE
Will the applicant ter f calm hullJing umupum store m M1andle by colo,mnlerial I H!AI INC,UNIT'('l l h 1I1(,00(111I TO
as defined by the Cupertino Municipal Cade.Chapter 9,12,cad the HcalOn and Sofety
Cadq Section 25532(a)". IMAGING UNIT IOVIeR 100.0010 BTU)
0Yen x10VENTILATION VAN(SINGLE RESID) PAID Dar Receipt
Will the applicant or room huilding occupou use equipment or devices which [to[[. 0HP OR 1001.00X1 R'TIf)
1 emit haronlous air ,accountants I ictmin!by the Hay Arca Air Quulip,Ylamrgcmenn TOTAL:
Di,m,r? /r BOILER-COMP(OVER IIX),IIIH)1,11,J)
C) '/T"Ew
I have read the hsmNous mommal,¢quiremen"under Chapter 695"l the Cali- AIR CONDITIONER ISSIL CIE DATE
bomla Health.@ Safely Cel,Sections 25505.25533 and 25534.1 undcrswnd that if the NEW RESIDENTIAL MITCH, SQ.FT /3---
building rose,na trocndylrncar.- that It isnty msponsibilily to notify thccecupand ( a ( J
of them ren"m Inch must bey remoalfa Cenifica cola arpancy.
•cut Uat 'IYT(Il.: ISSUED BY'.
OFFICE -ec —