S 2354APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL- ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT rING PROJECT IDENTIFICATION
BUILDING PROJECT IrDENTIFICATION
PERMINO.
T'DING
S 2354
NUILDINGGADDRESS: �Me
lkrlrl
C t/61
SANITARY NII.
APPLICATION SUBMITTAL DATE
O /
OWN R'S NAME: I'110NE:
C( 1' A k.' N E: L
C
NIC
❑
s.
CON'1'ROLa
CI 'I'iCr/1: GINIiER: LIC NO:
:
AUI ESSIS
HUILDINU PERMIT INFO
ONTAC : PHONE:
VyNes
O ✓ ,n
er,
❑ Consultant Fees Paid by Applicant (Initial)
HLDc IiL1iCT PLUMB MECH i
r4cLt /
0aZ
W00
Fy'��
LICCEENSED CON 'IBACTOk:S DECLARATION
1 hereby affirm that 1 ma licensed under provisions of Chapter 9 (commencing
with Sibeion 7(XIB)of Dicean 3of the Huxincssaced Profession, Cade.znd my license is
_ �^
in toll form and e0mn. J
QTY ELECTRIC PI7RMIT FEE
JOB DESCRIPTION
RESIDENTIAL
❑SI'DWL ❑ KITCHHNRF,M OPEL
�`
PERMI'I'ISSUANCE S S
APPLIANCES- RES I DIN I' IN I.
6V0
W
Cleanse Chux Lic'N
Data �.(.+i-L�f� Cnnwcror �n /
❑ADDITION ❑ PLUMBING RE PIPE
❑AfULTI- ON] T ❑STRUCTURAh
AfODIFICA'rION
❑INTERIOR ❑CHIMNEY REPAIR
E] SWIMMING POOLS
Z0wZ
0240
/AICCUITECPS UIiCLA(lA'1_'If.IN
spublicnfds
Itentergaodmyplans sinliseuxnlare
NAAFIS
UP*10200 AMPS
F,4 W
limnsrd Pofiselonal
201-1g)0AMPS
dyg 3'
C Q
=014 C, O
W LL h
�<prior
pr
dF'(e+
a a c 0Oy
NSection
[[..
❑zO
�3w
OWNER" BUILDER DFCLARA'1'ION
I hereby affirm that 1 am exanpt from the Contractor's License law fur the
following reason. (Section 7031.5, Business end Professions Civic: Any city or county
which requires a pemtit m construct cher, improve, demolish, m mpair any suucmre
t':. q the l such tl file b d:ntement
1hot it, is iiptfisuaanl the p t i, "Ifie, Con,in,fer, beemeta Chapter
c tg with Seen IIXXB fD is ':I i fm e Business and I . ' Cellar
Ibut he is encmpt henchman and the hams fur the alleged axe npuon. Any viola inn of
7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($5(10).
I, us owner of the pniprny, or my employees with wages as their soleronipcnsntine.
dmbiwork, andthe sb,Corcinnnts License[.a d(sli,r eole(Sec.]Oi4, Buanc'
and I'ntl'ccst
heb Cndr,ard, Contestant's License Lawdos nm apply man owners
progeny whit builds or improves thereon, and who docs Bitch tine himself or throng
:MPROVFM1zN'F
❑13A'I'H REMODE JREPAIR ❑DjiM01.1rION
OTHER
OVER IIXIfInMPS
SIGNS ELECT RICA].
SPECIALCIRCUITIMISC. aiii
TEMP ME'112 ORPOLEINS'lt
L;
COMMERCIAL
❑ NF. BLDG/ADDITION ElDEMOLITION
IJANT ❑ FOOD SERVICE
IMPROVEMENT
EITHER
POWER DEVICES
SWIMMING POOL ELECTRIC
��. OUTLHIS-SWITCHES-IzTxTURHS `
/
his own employees, building that such mentis old w ..act intended or offered for
sale. IL however the building or improvement is sold within one year of completion.the
NEW RLSIDENTIAI. F.LIiCfR SQ Fr.
SQ. Ff. FLOOR ARRA
SISQ. FT.
rrwfirr-haildcr will have the harden of proving that he did nut huild or lmpravc for par-
"
p0sc of ad,).
❑ I, uv owner of the pnrpcny, um exdunivcly conuoeing with licensed canm¢mry to
%f[ AL.
construct the project (See. 70Tq Business and Puifecsions Ceamj The Cnmramnr's Li-
-
crowLawdeesactapplytoanow'nerofpmpeny who builds or improves thereon,and
QTY, PLUMB ING PERMIT FF,E
who umtmets for such projects with it nunraaor(s)licensed p nelson to the Contreetor's
PCRMI'1ISSUANCE
Litacom law.
F1 lume.aempnunder See ,13&PCfnrthisrntsou
ALTER- DRAIN & VEN"1' - WATER HHA)
Owner Dem
DECLARATION
WinuZerSnalty
VALUATION
Y QQ
BACK IaI.[lW I`ROTECf. DEVICE
oCOMPENSATION
�I I hereby affirm ander penahy of perjury one of the following dedumtions:
!,
❑Ibuvu nnA will muintuin eCeniOatlenf Consent to eolhlnuure far Wmkrr'e Compen-
smion, as provided for by Section 3700,,t the Labor Code, for the penlunmnec of the
work lir which this pcouil is issued
DRAINS -HLOO CONDI.
FEWITRES - PER A' Q
•TORIES
'TYPE CONS' I'RUCT10N
❑ 1 have and will mainesin Wallace, Cmnpomation Insurance, as requited by Section
3700 ofthe labor Code, for the acrobatof the work for which this profit is issued.
OCC. GROUP
AI'N
GAS -EA. SYS
NC 4011T1.FT5
Cr Wo��rr¢¢���, C��om a Linn lnsum dPolicy nun c m f•Z
Canicr: � Policy (�---
GAS-IiA. SYST VI
'5 19
I_1 CEHI'119CA Ie.M PIIONPROM WOIt F.RS'
ROM
COMPENSATION INSURANCE
stir
GREASIYINDUS' L WAS'IEINTF.RCEP If OR
BUILDING DIVISION FF m
('Ibis section need not be emnpined Hits, permit is for nine hundred dollars (SIM)
or less[
GREASEI'RAP
PLANCHECK IaHH
cenify thin inthclxrfonnamenf lire ,,,it for whidide permit is issued,[shall
not nubby any person lit any annotations to becomesob,jert m the Wnrkme'Compen-
SEWER -SANT
2
HNl
I3BOV FEE
OZ satins laws of California. Date
Z O ApPlicam
.N. NMIC12 TO APPLICAN"P IL it,, marking this Cenifcate of C•xemption, you should
a, becamexobject to the Worker's Compeneation provisions of the Labor Cuda you must
fEl fablevih seuply with stmh pmvi..oneor this permit shall be decmedovuked
CONSTRUC PION LENDING AMINCY
UO
I hereby affirm that hem is a construction lending agency forth, porfnrmmnce ofLl.
the work for which this ,.it is iiond (Sec. 3M7, Cr,C.)
C) F" Lender's Nome
Lender's Acidness
1 certify thin I have read Otis it,heab000 and arm thin the above in uoullit n is
Ncornet. l agree to comply with all city and county ordinances and state laws relmingm
UZ building construction. and hereby authorize representatives of this city it) enter upon the
WATER I HATER WNEN HELECTR
GRADING EEC
WATER SYSTENUTRHA'I'ING
SOILS IEEE
WATER SERVICE
PAID
I m Re¢iptp
NEW RESIDENHALPLMH, SQ. Ef.
ITy1'AL:
'DOTAL:
IRALDIN 3f 22 r o
QTY MECHANICAL PERMIT FEE
SEISMIC FE
7
PERMIT T ISSUANCE z
z /
ELECTRIC TE
starve-mmotioned pmperty for inspection purposes.
f We) agree to save. indemnily and keop bane the City or Cupertino uguind
ALI1iR OR A DD'fO MECH.
PLUMIR FEE
Iiahllilirs,j... arnk.....te'anA expcnxcc which may in:my way accmc ugxiusl naidC
to wachirmeof the ganon, of this permit
AIR HANDLING UNIT (TO It1,(MCPND
MECHANIC A ITE
APPLICANT DERS'I'ANDS AND WILL C 1PLY W ALL NON -POINT
SOURCF,1 :G' AT IONS
AIR HANDLING UNIT (OVER 10.000 CPM)
CONS'rRUC1'10 TAX
0
pplicunt/ abal-' D'o
A RDOUS MATERIALS DISCLOSURE
17XHAUSI'HOOD(W/DUCT)
HOUSING MFDGA')'ION ITH
HEATING UNI T(TO 100.0( BTU)
Will the applican mare building occupaloom ar handle hairdo.,mmerial
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Calc. Section 25532(a)'f
❑Yes BNo -
Wi11 the air conlnt in future a building occupant use equipment or devices which
�emithavrdnus air conwtninams as defined by the Pay Area Air Quality Management
DistdcR
Yrs a[}N'o
HEAP INC, UNI 'f(OVER 11X).101) BTU)
EAU)
Data "T"-
VENT LAI' ION PAN REMDI
BOILER -GDNTP (31I11 OR IW,(100 Br ]'(I)
T'OT
BOILER - GGMP(QVIIR IfXl.lpB BTU)
AIR CION DI'I IONE R
have read the intensities materiule reprirememx under Chapter h.95 of the Coli-
I ISSIJA/N IJA
NEW RIS IDENT1AL MSCI I. SQ. ET.
tomia Safety Code, Sections 25505, 25533 and ^3534. 1..&,, ad than if the
That &
building does not currently have a tenant, that it is my mspmsibilay to notify the oecupin
/ O f
h J
of the mqulrcntems which must be met prior w Issuance ora Cenift vat of fkcupancy.
ISSUED BY: ton
'PTTAL:
Owner m:mthori.1:ge.( Ilam
OFFICE