S 2663 -APPLICANTTO-FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING,ELEC'T'RICAL PERsdi
BUILDING DIVISION APPLICATION/Pli IT PLUMBING-MECIIANICALS 2663
BUILDING PROJECT IDI?NI'IF'ICATION
BUILDINGADDRIiSS: . SANITARY NO. APPLICATION SUBMIITALDATE
/1 17 kexi 0oAve - ho 5a 3- 23�?
O ' S NAME r wit,
,/t. y 1 '' O RACr)R'S MC: LIC NO,
/g p 11 NIC CONTROL#
�IA CHITECUENGINEER: LIC NO: R' Waf7Q� ❑
CONTACT: PHONE: sok .BUILDING PERMIT INTO
❑ CDngultant Fees Paid by Applicant(Initial) BLDG HLECIPLUMB MHCH
owq
i EJ ElX 1:1LICE SED CONTRACTOR'S DEC AR 'PION Ila QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DWX thSatinn]1XNq El Division]ofthe llusinens and l4nfaeinn.r Crrk,and m}licenseis RESIDENTIAL,
{v00 � PERMIT ISSUANCE
n full farce and elle
0�u1 F, ❑SPD ITL ❑KITCHEN RF_PI EL
6VyyU Linntm LIc'# pppLIANCES-RESIDHN'flAl. ❑ADDITION ❑PLUMPING kC-PIPE
o<LL late Canlmctnr
p.0rn ARCHITECT'S DELL ATION PANELS El MULTI ❑STRUCTURAL
Z 0 rn X 1 understand my plans shall he uxd as public ranrJx MODIFICATION
OZ=O UP TO 20()AMPS I El INTERIOR El CHIMNEY REPAIR
F4f:El Licenser)Pot..ional 201-1000AMI'S IMPROVEMENT C)SWIMMING POOLS
yam,
OWNER-BUILDER DECLARATION OVER IINIIIAh11'S ❑PA'I'R RIiMODIiI/RGpA1R ❑DILMOLDHON
0.' a I hereby It Bat 1 11 1h C I . I' L for the
O UJU
a wg ( ti ]031 5 H : d P C y - ent SIGNS : :C'IItICAL
❑OTIR
Wyhich requires a Permit
e m t to construct, h improve,deroullsh,or repair
nY merre
� �Tu�'�/Y I1lLW�l/•
E'�0q
prior to its'.. once.also requiresme applicantf h permitt file a signed suatimanni SPECIAL CIRCUIT/M ISC. 1`42 CAWM �
Y� mru
at he is licensed to the pvnitmns
ns of the CEncons License Lmw,(Chapter 9 �
W y'p0 (commencingwirh Scction'10001of DivisfoI3 oOhe Businessand Professions Cale). I'GMP.MIaER OR POLE INST. COMMERCIAL.
6 e mat he is exempt 0terefrnm end the basis(or the oltefod caemption.Any violation of ❑NEW HI.DG/AUDITION ❑DEMOLITION
x Scnion]E,3 L5 M1y any applicdm tins a permit subject.'the applic:mt to a civil pcneby of POWER DEVICES ❑'TENANT ❑FOOD SERVICE,
>. n n mans man flvc it Bird dollars 55010),
d O I,asowncrnfmcprnpwty,ortn n i(aeswilhwa•csnsihcirsulcmm orlon, SWIMMING POOL PLP.C'IRIC IMPROVEMENT'
Yor P Y' 6 puns
Fand Jo thework.Code
Its, mmisrnat;Licausc U.
do l'm':II apply(See am Brair os ❑O'1'111iR
mand Professions Cnlc'Ihe Conmacmr's Licenx Luw m,es ore apply to an Iwner of OUTLETS-SWITCHES-FI%'I'UHLS
property who builds or imposes menton,and who does such work himrelf or though
his own employees,provided rho such improvemt are ennot imm�deJ Er EBereJ for NEW RIRIDIiNTIAL ELBQR SQ FT.
sale.IL however.the building or improvement is sold within one year of compichat the SQ.FT.FLOOR AREA SISQ.I'I'.
er-bueldcr will have lire h rr of proving that he dad nor huild or improve fm pur-
e.o 01 role.).
1,os owner of the pen
mpy,and eselusevely contrud' gmwith Oil eonmn
tor'm - TOIAId
cnnsmcr the project(Ser.9041 Business and Professions Cmuap I Im Commewr's Li- - -
cnsa Law does not npplyio an owner E(pmpeny who build nn improves meram and PI;UMBING PERMIT PEE
whsramanew(orsuch pmjems with aennm hnI)licensed pursuant to the Commnnrs
License Law. PERMIT ISSUANCE 3
❑1 am exempt under Sec. .H AF 1'C for this ran...0
N.TER-IIRAIN&VENT-WArHR(EA) VALUATION
Ownor Ilam - (^�
WORKER'S COMPENSATION DECLARATION BACK Iy,OW PROTECT.DEVICC
I herebyafurn under Penally of perjury one of the fallowing declarations:
❑I have and will maintain.Camicmeof Condom to self-insure lin Worker's Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
smion,as hick the for mi is
issued.
3]11(1 of the labor Crvle,(or the perfnnnancc of rhe
wo fur and this lwnnai is issued. Fl%TURFS-1'1iR TRAP
1 have and will maintain Worker's Contpensotion Insurance,as his can by Section
My Won Ix'^+"inn a P�gncc e' Tic JI'nHcy 'I Ie.this l+enniusixnuetl, OAS-I?A.SYS'I'CM-I INC.40I]'1'Lii l'S OCC.GROUP AI's
1200 of thel.alrnr CnJq[or l'a l nose anfthe work fnrw
s .um COE OF
FEXEMPTION
AMPTINSURANCE h• a ' _
Cartier: Policy sh, . GAS-HA.SYS THM-OVIR4(HA)
ER'UIl EOE SKIT NI NPROM kKL'RS'
GRF.ASPIINDUS'Bh WASTIi INTERCEPTOR
BUILDING DIVISION IT1S
(This satinnneN not be completed ifthe.emnn
ir is fnnme hhoolddiarr ltgq GREASE'I'RAI'
nr
les")Olds
FEE
lenifythm inmeperformmearfthe work forwhlch HNpennil kianeJ,Is1B.11 SEWER-SANITARY-STORM E.A.20H FT.
ma employ any persn in any manner so ns ser become suhjen to the Workers CEmove. F,NBROY FEE
O z o...lion Luw'n1 CldiGnnin.Data WATER III?ATI?Ii W/VENTII?LIiC'Ill CRADING FEE
Z Applicant
NODCE TO APPI.ICANT.If,okcr making this Cenilie..m n(17sempriun,you should WATER SYSTENUTREATING
a > haome subject In the Workers 13rmpensation provisions of the Labor Cade,you moa SOILS PEG -
W forthwith comply with such provisions Enhis permit shall attenuated revoked. WATER SERVICE
6 La
U0 CONSTRUCITON LENDINGAGCNCY NEW RESIDI?NI'IALPLMB, SQ.FT. PAID
ihttehy n0inn that mn
ere i' cnnsrmnlon lending agency for the Pmlannnmnof Dal;,, Receipt#
4.U . the work for which dues permit is issuwl(Sa,3097,Co.C)
C) Lender's Name TOTAL:
Lender's Address T
W 1 cartery that I have read this application send lam mar the above information is BUILDING
FIn cormet l agree to comply with all city and county onhnaaces and stare laws relating to QTY. MECHANICAL PERMIT FEE
U ,Z building construction,and hereby authorize representatives of this at ty to enter npntthe SCISMICFEE
alli ancurnmel prnpeny for inspection Impn+es. PERMIT ISSUANCP.
(We)agree In xav rdb Ill,mW kap harmless the City III Cupeneno against ELCC'I'Rlf:FEE
aiabiaities.judgmcns,c node +cv whlehmr,mon,waynameag.enm said Cay ALDER OIt A DD'1'O MP,GIi.
in ar,iolance oflh 1111 o! is pe PLUMBING FEE D
APPLICANT U :R - U. ANTI PLY WITH ALI-NON POINT AIR HANDLING UNIT(TO 10,1) CIM)
SOURCE .AT MGCIIANICAL
Z / AIRIIANDLING UNIT(01ER BI.Bro CEND CONORUCIONTA%
Si re a(Applman Conan r I e EXHAUST HOOD(WMUCT)
I IA3ARDOUS MAI IiRIALS DISCI,OSURI? HOUSING MITICA'I'lON PI?E
Willmcuppllcunlnr famm I ildingaccupam'anenr handac haemolm,material HEATING IINI'I'TCO I(a).,n)1,'1'UI
as defined by @e Cupcnmo Municipal Lobe,Chapter 9.11,and the Health and Safcry
Coda.Section 255]2(.)? J HPAtiNG llNI'P(OVER 100,000IITU)
❑Yes WNO VEND H,ATION FAN(SINGLE RESN) PAID -
Dare Receipts
ar—
Will me app lic.nt,orfurore refinedding by the By A equipment or devices which
emir hmrNou.vair cunmminam'as ec0ncd by the Bay Arco Air Quality Managcmcnl BOILER-COMP OUT OR IIN),IN10 B'I'U) TOT
Dinner?
❑Yes nth 'BOILI?k-GOMP(GYER IINkINN1II'HD
I have mixt the haeaNuux materialsrequirements under Chapter 6.95 of me AIR CONDITIONER C.li- ISSUANCE DATE
moria Health&Safety Cole,Seefum,25505,23573 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.
building Jeesna arm mlemle haveamount,rent it is my respombil'ay In notify the occupant
oI the reyuircmeryy7m.n/I Farm,prior to issuance of a Certificate of Occupancy.
I✓ v
(YG//
Owner nr uullmr'I lagan Dhm TOTAL; 1551]1!11 BY:
OFFICE'