S 2332APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
C II•4FIlYIOPINCUIE WH NO r,rr. HUI LDNC - ELEC'I'RICA IPERMIT NO
51\IMECHANICAL
CDPVISION APPLICATION/PERMIT till1.r.. rnr.ur-„rr.v .
1 S 2332
N
OFFICE
FEE
FEE
BUILDING PERMIT INFO
CON'I'ACI: I-GONe!
PLUMB MI'❑/
O
i ANrf,, trltRD rzl0.''I/c6 90
° Consultant Fees Paid by Applicant (Initial)
LICENSED CONI RAMOR'S DECLARATION
I hereby unarm amt I sen licensed rude, pruvi.Jnnx of Chapter, 9 (comurencar,
wise Seaio.700fgnflno,,ion 3ofthcBusinessand l' rnftw,un-CWe.and my lieense is
in full lorcc ul /
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License Clan. Licp
nand Cnnv car -
Q'PY. ELECTRIC PERMI'E
WOO
WOO
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PCRh11TCES-
ES
API'LIANCIiS-RCSIDENI'IAL
ARCI,ITECI-S DECLARXI'ION
Iundeotandmy plum ,hall be used as puhlic tcond,
PANI!IS
UPI 0200 AMPS
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LicmuW Profv-i al
OWNER- BUILDER DUCLARNI'[ON
1 hereby affirm that I am exempt from the Contain, nr'n I,icaoc law hu In,
Inlluwing reuwn. (Section 91131,5. Il uvincvv and ]',,)lesions Code: Any city or county
which requires a pens., to consent, alter, ilnpmve, demolish, or repair any structure1-
prior to its isvtrance,also requires the applicant for such perm.,, )b—,nsardxl:ncmnn
Incl Ile is licensed Primum mall pmvlxionv-yjl6aE deer',Iw.tp -u '(Chrai,r9
x'ith&aioll L%IN1rRfJn'iliun}pf Ne Rueine�`y chit Pit(r�i mGvle)or
That Ito is exempt Ihcref ere and the bav fon IlcgM %Intption 1 'inlaunn al
Seen 7031.5 by any ap�iicvn1fm a)Peon wlrje 1, the ... Errand, c 'redyal'
not more than Eve hundred dolLvs (551X).
I, asovirmofthe }t Ism tovihcyt„tFilQi�xu retail I,
❑ p^'Pc. )'.S Yclltp 'V k VOW
��i�s��L//
will do the work. mWthc strbilule is o��'y' tap dt I of le(Sen 0mines,
and Purfics.las C,Ac,; Th1elty l- gA-Li ns law does nen apply an weer of
pro, en 'h F dd 0 1 ' d on I r l ,bait k hi stir the nal
his ply ,. p d I h i p t' are o f I J d end for
201-1000AMPS
100DAMPS
SIGNS ELECTRICAL
SPECIA,CIRCIB'1'/MISC.
TEMP. I'll,HORPOLEINST
POWIiR DEVICES
SWIMMING 11001, 13,F,Cl1
OUTLITS-SN'ITCHf3-IIXTURfS
NEW RESIDENTIAL ELECI'R SQ
vle If h hen ,d p 'em I IJ 'IM1i Inn rhe
'l, tl 1 '�i u""y m J ptonclbrpu-
h ld box
paw if ).
I, as owner of the torten, am exclusively contracting with licensed ean,mefarF m
fOTAI''
onstmcLtet, profcw(Scu. ?(U4, Rslncss and ,'ndsxin e,Cour:,'ne C'nnm,cNe Li -
ns Law Arte, nor apply it) an owner of property who hui,ds or improves thereon. and
QTY PLUMBING PERMIT
who routers for such pnrjeas with a contortions) licensed pursuant n die Qmmmcor's
PERMIT ISSUANCE
Limon Law.
1 am exempt trader Sec. . B & P C for Ihis recon
ALI Pit - TRAIN & V,!NT- WATER (HA)
Owner Dm,
WORKERS COMPEbISAI'ION DECLARATION
RACK FLOW Plc”! ECT DEVICE
Ihereby 'rl' 1 dl, ofP Yone tittl falo, r,dr,1,mdf
❑ I have and will nuoureare a Certificate of Consent toE' W A C pen
DRAINS FLOOR. RI RDF, A RIA. COND.
sation. as providell for by Section 3710 of the Labor CoilCoile. lot the performance of the
sen din,mrol I, issued.FIX
I UIt FS - PER TRAP
I I 'l, mu t Workers Comte r 1. y d by Section
:41, or
the Lahr Code, far the p.r6 nn mccrfthe ',I for whcM1ffim,.rmn is issued,
GAS EA SYS Itt1-I INC. J OOIl.1FS
My Work peu.mi n nee tc II'dicyit I
Carrier: i 'nm e1Pnliry Nm: Ad L�V':QD16
GAS - EA. SYS TEM-OVAR a(EA)
GREASIVINDUSTRI, WASTH INTERCEPTOR
CER'IIFICATI3 OPE NPI' ION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
(This section need not M completed ifthe permit is foram, hundreddoltm, lS 10a
or lest)
SEWER -SANITARY- STORM P.A. Zan FT.
I oerl i fy that in are per5mnenceofthc work for w hichthls,mrn.it'n„use,, Ishan
not employ any person in any manner m as to become subject m the Wotkeri Compen-
WAI PH I IEA'I12R W/VCNI'ATI-ITC 'IR
Z,z'min
O
i Law, of Cal llirmiu Dore
Apptmnnl
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rf”
Pan ICE TO APPLICANT: If, after making This Certificate of Exemption. you should
hennne subject m are Worker's Cu'ogteneainn pm sins if 11'. Limor Coda you must
fonhwirh cunnp,y with such pmv:' n. tr this permit vhall re deeneJ revoked.
CONS] smis. 1ION on,me,NDIN'GAGENCYng amen
Ihere,hifGrm lhm isisisued(wen30lerWit. agency lidthe perinnnune, of
Ire dark for which IM1i, permit is ivwcJ (Sec. 1119). Civ. C.)
WA'l I7R SYSI EMOR E\TING
WATER SERVICE
NE\V ItIiSIDIiNT1A1, I'L.MB. S(7 IT
F P.
V)
UZ
Isndds Nmnu
Under', Atldrss.
TOTAL
1 otedy that 1 have read this apphe,ann and acne that he trove in9tmunhtn is
con rcl.I agree to contdY with ad mtyvnd mra.,yordi Land rune Dw, elfang In
huilJmg rummerion, and hereby arthndm reprewntmivcs of this titym enter v,m the
aMrvcmenrioned pmpeny for irepection purpose,
(We) agree Ise sive, indemnify unit keep hann,csx the City of Cupertino agnin,t
Q'I'Y. MECHANICAL PERMIT
PERMIT ISSUA NCI' 3
ALTER OR ADD TOM ECH.
Iiabi,itics,judgmenls, cox a unit expcns h nmyin.reway acme agsi.,t did City
n nuquatre mfr 6rundng n( sprtrmif.
AIR IIANDLING UNI'1'('IO III,INXICIM)
PrI,ICAN'1'llNll 'RSTAND ANU WIL. COMPLY WI'1'II ALL NON -POINT
SO CiREIiULAI )NS.
1 �/ /`I/4
I
AIR HANDLING UN,'P(OVCR 0.000CFMI
e arc oLSpplicnnt/ Dm,
EXHAISTHO)DGGLUC)
HAZARDOUS MAI ER1A,S DISCLOSURE
Will the applicant or fume, huddingncupent store or handle hamNau, material
THEAI'INGUNI'f(TO 100.000E'1"u) �
m defined by the Co,sminn Municipal Code, Chapter 9.12, and the I lcallh and Safety
0.1r. Seen 1255121.0
IIEAI'INC UNIT(OVI!R 1(111.000 BTU)
C3 Yet 0 N
VENTILATION PAN ISI\GLI: RF'_SID)
Will the.,,liven...A mare hudding nca.pam ave egtdpmrm nrdevias which
emit hms ardoair contaminant, as Jvlined by the Hay Area Air Quality Management
BOILER -COMP pHl' OR IIXLUW If1'U)
1301LER-COMP (OVER 100.00013'111)
Dinria7
Ely" ❑Na
AIR CONDITIONER
I have red the haeardnns materials requirements lender Chapter b 95 of the Cal.
NEW RESIDENT Ud. MECH. SQ. IT.
V
Imnia Ilealth & Safety Calc Sections 25505.25533 chit 25534. 1 undeevund mut if me
building docs not currently have a tenant. Iran it is my rexprooda ly to notity the+ccupant
of rhe myui nuns wnicb mu.1lN: mal p�ormismunce nfn Ccnifu,m ofomtp:mry.
OFFICE
FEE
FEE
BUILDING PERMIT INFO
ItL❑DO Ii1C❑Cl'
PLUMB MI'❑/
O
1711 C]'RIC FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SPDWI,
❑ KITCHEN RPMODEI,
❑ADDITION
OPLUMRINGRE-PIPE
❑MULTI-UN'IT
❑STRUCI'URAI,
MODIFICATION
El INTERIOR
El CHIMNEY REPAIR
INIPROV17MFN'I
[DSWIMMING POOLS
❑ BATH REMODEIBEPAIR
[I DEMOLITION
❑ OIHER
COMMERCIAL:
❑NI?W It1AG/ADDITION
❑'1'ENANI'
IMPROVEMENT
❑OTHER
SQ.
S'IORIF'_S
❑ DEMOLITION
[I FOOD SERVICE
BUILDING DIVISION TINS
PLANCHECK FEE
ENERGY FEE
GRADING FITE
SOII.S FEI!
PAID
udte Ro,epla
IOIAI,:
FEE
BUILDING ME
SEISMIC FIAT
O
1711 C]'RIC FEE
PLUMBING IEE
MECHANICAL FEE
CONST RUC'I'ION'I'AX
HOUSING MITIGADON FEE
PAID
Date Receipt#
ar
ISSUANCE DATE
ISSUE[)BY:
$/SQ, FE