S 2422 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL �X ^ A ^
IIUILUING PRONELY IIH?NTIFICATION J 2 4 2
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
`r (R
OWNEN'S NAMIi: / �^ PHONE'' CONTRA Ok'S NAME S LIC NO
V sw `! NIC CONTROL#
G
ARCHITECIDENGINEER: LIC NO: ADDRESS: ❑
CDNTnCl': PxONE: BUILDING PERMIT INFO
.�� ❑ Consultant FcCS Paid by Applicant(Initial) BLDG tiLECr PLUMB MECH
LICENSIiD COMBACTOR;S DECLARATION ❑ ❑
I hereby affirm mm
In.,I am licensed under previsions of Chapter 9(cumencin. QTY ELECTRIC PERMIT FEE 70B DESCRIP-f
❑0Z. wire Sttdan70o0eo'Divislnn 3 rune Holnee,sac
od Prafaxsiona .eard nay licenseb
�ly� in lull force and elTea. PERMIT ISSUANCE RESIDENTIAL:
FVZ Li cense Class c-if) Lic.N ❑SFDWL ❑KITCHEN REMODEL.
NQS :)ate /•'/'c-'�_Coatmnnr illAPPLIANCES-RESIDF.N9'IAL []ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION
zoI underoand my plans shall accused..,public records PANELS ❑MULTI-UNIT ❑S'PRUCTURAL
OZ4-
I1PT0200 AMPS MODIFICATION
F, ;W Lmmned l'mfesslanal ❑INTERIOR ❑Cf1IMNEY REPAIR
Q .� 201-1000AMPS IMPROVEMENT
yrY�� OWNER BUILDER DECLARATION El SWIMMING POOLS
QI hereby affirm ohm 1 am exempt from the Cornmcror's License Law for the OVER IgM)AMPS El BATH REMODEVREPAIR [I DEMOLITION
3 m F fallowing reason.(Scetion 731.5,Ifte"I'ss and Preficeiunx Code:Any city m manly SIGNS ELECTRICAL ❑IYfHEk
F LL O y which requires a permit m cnnstmn.also.improve,Jcmnlish,or repair any structure
r� pdono its issuance,also requires the applicant fnrsoch Peril'afile.lignN smtemem
that he in licensed nil the SYF.CIAI.CIRCIJI'f/MISC.
Q� pursuant prnvixions unM Cnnwcmrs License Law(Chapter
(m,he I,l montheclirran ad of Divisionl theheetand vocand Pm[nyvisCode)or TEMP.ML'fER ON POE. COMMERCIAL
a L M the he 7 exempt therefrom and the basis for the allege,mmrm m Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�H nout Serum,7031.5byally hundrdicomn($5gomit suhjects the npplicam ma civil penalty of POWER DEVICES
Fzy rnmore than frvv hundred:tillers l$SIXO. ❑TENANT ❑FOOD SERVICE
f=QO ❑ Las owner of me prrpeny,nr my cnnployces with wageusthcir sole mmpcnsatinn, SWIMMINGPDCELECTRIC IMPROVEMENT
will do the work,and the structure is not intended nraffcrcd for sale(Sm.7019,Business []OTHER
3 and Professions Once:The Comranor's Gurnee Law does not apply to un owner of OUI'LIU-s-SWI"TCHES-FIX NP .�y1
progeny who builds er improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intender!or offered for NEW RESIDENTIAL ELLCIR 'VP
sale.If,hnweverJhe building or improvement is snldwithin one year ufcompletion,'he 5 .FT.FL JORARfiA $ISQ.FT
ervbuilder will have Wr burden al'proving IM1m he did nm buJJ or improve I'nr pur-
of
que of sale.).
❑I.as ural of the Pruned,,am aclinowely contracting with licensed n raftwo rs to TOI'A
o..tract the project(Sea.0149,B.Inner s and Polfeseions Code,.T.Gmtrnaors...
cense Law rices not apply In an owner of pmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a comrdnm(s)licensed pursram m the Comracmfs
License Law. -
❑ I am exempt under Sec. ,B&P C funhin reason PURMI'I'ISSUANCH
Owner Date ALTER-DRAIN&VENT-WATER IEA) VALUATION
WORKER'S COMPENSATION DECLA RAI[ON BACK FLAW PROTECT.DI?VICH
I hereby alBnn under fertility of perjury ane of Ne following dalarmmi
❑ I have and will maintain a Certificate ofConsent to self-insure for Workers Compact- DRAINS-FLOOR,ROOF A R EA,GOND.
sails,ns provided fill by Section 37(X1 of the label Cal.,for the performance of the STORIES TYPP.CONSTRUCTION
work for which Nis permit is issue. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37110 of the Labor Cale,tor the performance of the work tiu which this peril is issued. GAS-Lit SYST13M-I INC.9 OIITLITS OCC.GROUP APN
My Won Insumncc emricrand Vol'lp't�%nF{
Cartier Policy Dlp]L/r�� GAS-IiA.SYSTEM-OVER 4I[iA)
CERTIFICATE OF Fi%EMF'r10N�J A tj'(wlrr/ ;— GREASE/INDUST RL WASTE INTERCEPTOR
CObe MA Pa A Mrr/J
(This section need not Mrnmplmed if the peril is Torose hundred dollars 151001 HULLOING DIVISION flips
orless.) OREASCTRAP
CHECK
I crnl(y Thal in the prrfnnnnnee of thewnrk for which this permit is isxueJ,1 shall '
SEWER InSANI'1'AR
or employ any pennon in any manner so m to become subject to rhe WorkerFCompen- - Y_S'IfJNM EA.21X1 F'f. ENEN YPIiF. A
sation Laws of California.Dam
O� O Applicant WATER 11ETEN W/VEN'T/ELECTR ,H D '
G h NOI'ICE'IO APPLICANT'
:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
a ; httome subjcet m the Workers Compenmfinn pmvisionz of the Labor Cash,you must SOUS M.
forthwith comply with such pmvisiom.,,his permit eem
shall he dominant revoked.
W� Q WATER SERVICE
Oz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PMIH. SQ,FT. PAID
Ll O I hereby vffr fl ache.is a comtmctim,lending agency far the perforanev or rift
LL the work for which this permit is issued(Sec.3097,Civ,C.)
LenName
O der's LU Lucas Address TOTAL: TOTAL:
ty 1 really that 1 have mud this application and state that the above inlmmation is BUILDING FEE CA
y correct.[agree to comply wire all rhyand county ordinances and state law,,rclming ,, QTY, MECHANICAL PERMIT FEE
L) z building conswcdnn.and hereby amnoriu representatives of this city to enter upon the SEISMIC 1TH
ahuve-mrntmaed ormeny rat inspection purpose.,.
(WO agree a save,i ilearmly and keep hnnnlcsx the City of Cupenhm against III:RMIT ISSUANCE ELECTRIC F
lisbildicooptlgmems,cosh,and expenses which may imany way rccmc again.n said City gLTER ON ADD TO MECII.
in
consequence of the graming of this peril PLUMBING FEE
APPLI CANT UNDE RSLONDS AN D WILL COMPLY WITH A LI.NON-POIN9' AIR HANDLING 11N1T(TO Io,tNNICFM)
SOURCE.kEGULAT S. MECHANICA EE
AIR HANDLING UNIT(OVER 10.(00CFM) CONSTRUCTIO TAX
.'ignat o ApplicnnVCnnt ctrl , Fall, IXHAUST HOLD(W/DUC'1)
HAZARDOUS MATERIAE S DISCLOSURE HOUSING MITIGA'ON FEE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cost Municipal Code.Chapter 9.12,and he IlealtM1 and Safety
Cade,Section 25532(a)9 / HEATING UNIT LOVER 100.IXNI BTU)
❑Yes lw
VENTILATION FA N(SINGLE RESI D) PAID Data Rttxipt#
Will the npplicom or I'uwre building occupant me c popmcnt m devices which
emit haeardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP UHP OR 100,0011 BTU)
District,
❑Yes HOLLER-COMP(OVER 100,0I0 BTU) A off)
I have and the h. trdoa ear Jx uiremcnts umtir Chap¢•r695 rf the Cali- AIRCONDITIONER ISSUANCE, TF.
fnmid Health&Sufe Je,S tions 3. 255J1 anA 2551;InndcrsunA that if the NEWHESIDENTIALMECIL SQ.IT. / a/r(' �I
bvlldlagdtrsn�l yhar amu I. it is my respomsibility m notify the occupant sJa�' 7 7\n
Anne requirennyne. en crt
OwneraDate TOTAL: ISSUEDBY:
OFFICE