S 2585L-,11
C -
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPFRTINO
BUILDING DIVISION APPLICATION/PERMIT
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IIU I LDING - ELECTRICAL
PLUMBING - MECHANICAL
BUILDING PROJECT' IDENTIFICATION
PERMI l' NO.
S 2585
BUILDING ADDRESS
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SANITARY NO,
APPI.ICAI ION SUIIMIPI'AL UN' 1:
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OWN(! 'S NAME : PIIUNE:
✓�i!!0N 4116/Yen .25-////
CO 'I'Rq CTOR:S NAME I.IC No.
7SUS Bui'L1�E2s 7/Z/S'
❑
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>RCIII'I'IiCT/ENGINIiIiH; LIC NO; ADDjtlo2 e,eoy�oNf}YE• s -J.95
/�'
CON'I'AC'r PHONE:
BUILDING PERMIT INFO
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❑ Consultant Fees Paid by Applicant (Initial)
BLDG El ECI' PLUMB MECH
� � ❑ ❑
LICENSED CON' I'RACfOH:S DECLARATION
I hereby efran that I aall Balt,ed ander pnwi.tion, of Ch:)ncr v ¢ boublee„ l
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
with Seelion7f)[NIor Divislon3ol lhclleinc%sand l'roIv,,iom Code. and my l lcvnsc in
in full force and efcel. B 7,
1'IeRMIq'ISSl1ANCE
RESIDENTIAL'
❑SIUWI. ❑KLI-CIII!N REMODEL.
One Class 20- Canko
One ^ - E�
��an,
APPLIANCES - RESIDENTIAL
❑ADDITION ❑PLUNUUNGRE.PI E
❑MUIThl1NIT []STRUCTURAL
MODIFICATION
❑INTIiRIOR ❑CHIMNhY RETAIN
IMPROVEMENT E)SWEMMINGFOOLS
I S DEmr
fall emw DECLARNiON PANELS
nnJastnnA my plans ,hull be mcd es puMiu rounds
kill LO 211f1AMP5
Licensed Profc.%ianal 201-1"AAIPS
OWNER -BUILDER DECLARATION
I hereby alhrnl thal I can cscnlpt from Ihn Contractor's Liccnsc Law lar the
follnwiag lemon. (Section 7031.5. BuJnc„ call I'n frome, Crxlu: Any city or anamy
OVER RXXIAMPS
SIGNS ELECTRICAL
RESIOUFI/NEPAIR ❑DEMOL.ITION
(YPIIHR
which requires a permit to conswel, alley, improve, demolish or repair any nwclurc
,mano its i,woma,.alen recrireslheepplicam Rnstwh pc.it In file v signed statement
that he is licensed pursuantto IM1e pnrvisiomuf the Contractor'% License Law (Chapmr Y
boor ening with Sect lan 90X0ol Dlvi,ion 3of0c Husinc%s and PromrsiorsCdc)or
Thin he is csca", thenl'mm vnd the basis for the alleged c,, nplion. Any violation of
Section 7031.5 by any applicant lin a pemtit suhjec,s IM1e applicant to a civil penalty of
SPECIAL CIRCUIT'/MISC.
TEMP. MINER OR POLE INST.
POWER DEVICES
COMMERCIAL'
❑ NEW Ii I.DG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOODSERVICE
not marc than five hundred dollars (551X).
❑ Lmosenerof the propanyornty employees with wages., bri-ole conlpemation,
will Jo the wod., vnd thea ware oral intended ondfend lar sale (Sec. ]0W, liusinms
and Prolession.v Code, 'lite Cnrtmlan', Licenw Lam dtxs nal upl'ly m un own, rel'
proped, who kronor), improve, Ihenum, end who dw, wch work hitrnelf or through
his own employees, provided that such intprovemmats ere not invaded or offend for
sale. If. however. the building or impmvernemi, sold within one yearofrompletautdc
SWI MMI NO K )OL ELECT'
OUTLET S - SWITCII K 9X"PURE
NEW RESIDEN'U 'L.IiCrR S
ISiPNOVIiMENT
❑ OTHER
Sp. PL'. 1'IAOR AMID
S/SV. Irf.
owner -builder will have the burden of proving that he did not build or improve tin Our
E] I I' %ole). M the pmpcny, a xduµivd......farting on Ilcv'nncJ aenlmcmm m
( O
cnnxlna:l the unt cct (See 9044. Business and Prom,ion, Cadc:)'ITe Ca em"ll,'I Li-
censel ov does net apply m an owher (if properly who build% or improve, meson, and
Q'I'Y. PLUMBING PERMIT FEE
who contracts for such projects with a contracmrfs) licensed pursuant the Contractor's
Uwe— Law.
PERMIT ISSUANCE
❑ I :an exeupl under Sec. , It sa P C for th'd tenon
VALUATION
A D O
ALLER - DRAIN E VENL'- WATER 1EA)
Dam
WORKER S HACK FLOW' I'HOTECI'. DEVICE
IOwner
hereby ntfinn under penalty rel Iwrjury nnc rel IM1e following Actium
❑Ihocarld will Inuinlaina Cenilicamel'Consenunsell-Insureo woulk ion.e
�3700of
UI<AINS - Il (TOR, ROOI(AI111A.CllND.
S'IY)i11iS
TVI'IiCONSIRU('IION
once of the
InimtIts he Lad, Care, hn the pedormnC ,he
w omudcd ar bylSolana
ark l'ur i
� 0
I)Xl'UHES-PI3R TRAPL/
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❑ 1 have and will maintain Wader% Compensation Inwmnce, as required by Section
-le -fine said, far bell this it is i,cvncd.
he Labor Calle. for 'he
pa
m1 cn I' In,ul'nnce 1.111111andPolicy^Y�%J5`01=
Cnrricrh� 'iUA/i� I'nhcy No:
MyWvki%III rXf?Mf9lONIrROhi
GAS IYSFEM-IINCJ)UTLI TS
CAS_BA, SVITEM•GVleli 13ACFKI )
O GROUP
APN
Wv✓ o
IIan1!'I W(IHKI'.R.S'On
T.
COMPENSKLION INSURANCE.
GRGSI%INUl1STJtL 1
BUILDING DIVISION FRIES
[Thissectinn need not fe,onplaN ifthe p:mtit is for one h parbidellms(EIIX)
lir Icv,,l
OREAS 1
I'LANCIIIiCK I�I!li
Trendy that In dtc �nrfoonataccul the wank lbrwhich lhivpanntit b omed, Island
not employ any perssm in any mvnnvr w m Io hunne whjea to the Wnrkcrs' Contpcm
YzWER-SANITARY-S'InRMEA.2(X)171.
ENERGY FEE
GRADING hili
cation Irw%of California. Dae WATER BRA'IER WNL'
Applicam ^"moi
NOTICE TO N'PLICAN'I''.11,alicnnaking this Cenilil'ar of Etctnpnar, yax,beam
became subject to the Wader's Compensation pmvUion, Ili 'he Labor Code, you must
WNIER SYSIENICTEAI'ING
SUB.SFEE
Ionlecohennply with such junsworsor this pe Iran shall Ac declined tn'oked. WAIER SERVICE
CONSTRUCT ION LENDI NO AGENCY
( hereby atfinn neat there is a consrttctionlending agency let he pmfofotenee of
NEW REST UESrr1AL PLM Ii. SQ. FE
PAID
Inc Receimx
T(H'Ah:
thu work, nwmch This pcnnn is issued (Scc.3099. Co. CJ
Lenders Name
L.emdcr's AJdnI
1 T
L cenity that I have read this application and Ovate that the above information is
correct. I agree to comply with all city and county ordinances; dManelawsmia ingm
construction, laid hcrchy nal crepe¢%mannumv-1thi, city la rel npml liepra,l for im,nlinn purpo%c,.
agreea, cask, indannify and keep hxrndcss the City of Cupertino againstI imilitien.judgments. costs and expenses which pay in any way accre almost said City
QTY. MECHANICAL PERMIT FEE
P13RNIIT ISSUANCE?(We)
ATTER OR ADD TO MIiCH.
OzhuBJing
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.. ma.vc of the grunting of his perrel.
API'1.1 CANT UNDIi BS".ANUS AND WILT. COMPY WI'I II AL1, NONH'OI N'I'
AIR HANDLING UNIT TIO 0,0IXt CFM)
FEL'
S N1RCIiRW"J{,NS.
AIR HANDLING UNIT (OVER 100)(CFM1
CONSTRUM]ON TAX
Signamre Ili Amicam/Conowl Date
I IAY,ARDOIIS MATERIALS DISCLOSURE
Will the -apphc4 n or rump buiIdur, ucmgmnt %lore or handl, haeerdou,... a nal
no defined by the Cupcnino Mmalyal Code. Chapter 9.12, and the Health and Safety
Calle, Station 25572(x)'!
EXHAUST HOOD(W/DUCT)
1117ATING UNIT (TO 10130011 II'TU)
Hl'ATINC UNIT (OVER ❑X1,0100.000 BTU)
HOUSING MI'I[CATION FEE
Ya[�NJ
VI!NTILATION I'AN (SI NGLIi RESIDI
PAID
Date Receld#
Will the updlir murrehuildin. occupnm use equipment on device,which
iamt
mit haeardou.s air contaminant%us defined by the Bay Arca Air Quality Management
100,00IT
BOILI!R-COMP(31U'OR 100,0
1
District'! 1
❑Yes JL
BOILER- COMP (OVER 101.010 BTU)
ISSUANCN. DATE
2 -3-1 9
I have tendtlue homrdovx materiaN Iv under Chune6.95 n1 Ibv Cali- AIR CONDI'I'ION1iH
n.15513n
h,mla Health & Safety Cada Sections 25505, 2s and 255311 ndcmmnh that if the NEW RIiSIDIiN11AL h11iC11. SQ. FC
I
huilJinb Jnex nolo fly have amnam. that it is my resryrnsihil'ny In dually the w�cupam
my
cit +tcquimns moa be ntetprrNr it) uunce of Certificate of (km:pancy.
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ISSUED IIY:
uuthnrirtAu � nnc IGLAhI
bErget
orrlut