S 2190APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD SG - ELECTRICAL
1,03BI
BUILDING DIVISION APPLICATION/PERMIT NG-MECIIANICAL
BUILDING PRIIIECI IDENTIFICATION
PESIT NO
2190
BUILDINGADDRPSS:
e
IX ;v.c�,be. 21 Cr Lk-
SANITARY NO
APPLICATION SUBMl'PI'AL DATE,
O BRS NAMI': �'l1U r'
O 06" � I �e �
6-Z
CONTRACTOR'S NAMF LIC NO
NIC
❑
COYIROLM`_
ANCIII'IT,C'1'IRAGINCI!R: LIC NO
ADDRESS'.
CQNfnc11 191)
N
6
❑ Coraultant Fees Paid by Applicant (InllW)
BUILDING PERMIT INFO
BLDG EII CT PLUMB MI:CH
❑ ❑ ❑
LICENSED CONMtACTOR S IA TCIARAHON
Aialonr
1 lereby drone Nal 1 am Iv,ud anlur prt of Chapter 9 cca iltg
with Sceti.70BO) nHHvisWn J of the BreSM'. and Pmf¢�Mrrs Cods. and mylcccme is
in furlass effect.
Date Clue Cone
Der Cl'S
QTY
ELECTRIC PERMIT
FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWI. ❑ KffCHEN REMODEL
❑ADDITION ❑ PLUMBING BE PIPE
❑MUL'fl -UNIT ❑STRUCTURAL
MODIFICATION
INTERIOR ❑ CHIMNEY Rl OLL
Ih1PR0VEh1E \T SWIMMING POOLS
❑ RATA RINODIHAEPNR 11 DEMOLITION
❑ QTHI:R
P`HkMI'I ISSUANCE
APPLIANCES - RF_SID4NTIAL
ARCHITECT'S Us uhherI'IUN
DFCL
I uexlvsurd my Mv^s Juli be oval u pWhe raWS
1
IJCCnsed l'mfomitnei
OWNER- BUILDIBZ DECLARATION
Le¢hy ue you Om I vat eemmpl from Ne Commner's Gcanrc Lnw for the
follow ng reanon. (SUtion 10315. Business and Profca imlz CodW Any coy or deny
which rcquina a (crow to coxistmct, abet. imepnnc, dcnwli,ro or repair any 4beclum
Eniot In its i .... ...lm ocel the vpplirvtt hrwah pcmtiu) file .signed slacmcN
than he is licemed!pursuant to lfhe rovkiom of the Comlcacto ✓s License Law (CTarym9
j Icvxnnmm:illgwlh tialinn llXXBof lliv sire Juflde! business vnd lTtfmninm Crdcpa
that Ile a escmpt Ihercfmm and the tuna IM the allegeB rarm,iom. Any viribro n of
Senioo 1031.5 by anyapplkem for a pemlit subjects the applicator to a civil penalty of
man then five hundred dogan 135!X8.
' El I.uowrcr of the pnryedY mmy empkym wiN wages. Norwle carpemuidn.
1 will do the worLund rlmemmme is nr nmrdcdoroUcrcd for sole (Se, 7U ,Bminns
i zrd 11 rnfe"em, Grk: Tic Contractor'• License Law Asa o vpply to on m ner'of
Parycny wito builds or improves tarreen, arul who does such work himself m Ihmugh
den own canploycc , Provided Ih'ut noel, iun,.. nunrs am nor iii orinl nr oHCrtd fir
sak.11;lu»esv. the building m improrsement is sold within me year ManBXctian. the
owner builder will lure Ile harden of proving that he did net build or improve: fur pur-
P"* ofs le.).
I, us owocr of dhe prvgeny, .m eadusivdy ninlffiling wiN IicemeJ conrrrcsm In
twruci lha projecl (se, 1B44, IIm and 14r(c.. mC «IeJ ThC Comoixutr'x
cemclawdoesnotapplymonownerofEr s,er, who huids or imprvm thereon. art!
who counsc s fee such pnrject, won v cimoemr(q licensed pmsuanr ro the Conlmcus'
Liccn¢ Taw�,�� acaaan
❑ lam cscian / 1. , B & P C for this
PANELS
Of' T011X)AMPS
]Ill- IflUll A11P5
OVER IIXXIAMPS
SIGNS FLEC RICAN
SPECIALCIRCUU^IISC.
P
THM P. M I'TR OR POIAH INS' 1'.
C 1
❑ NEW BLDG /ADDITION ❑ DEMOLITION
[_1 TENANT ❑FR)OD SERVICE
IMPROVEMENT
❑OTT HER
POWER DEVICES
SWIMMING PRIL ELECTRIC
OUT.ER- SWITCHP_S- FXTURES
NI ?W RESIDENTIAL CI.LCIA SQ YI�
WET FLOOR AREA
SOsQ. FT
YT
�f�
k_J V
QTY. PLUMBING PERMIT
FEE
%!NMIT ISSUANCE
ACIP.R - DRAINA VENT - WA PER (HA)
pis
VALUATION
Rnder COMPENSATION DECLARATION
I hereby ell irm unkr pnlNlly of Icrjury.ne of the fnlhwing dalamtinm:
IMrcand willrwiomineCmificem of COmmnosdf- inwrtlm Wmkcr's Conger
.moon, az prnvidal for by Sudan 31(X1 of the Inter Codc, fur IhC µAmmame o(nc�
weak for whkh Nisry It is iswtd.
❑ I have and will maintain Worker's Comipcnwtrcm W.uumee, es oeyuired by Ssdom
3700oft he la Mr Cedc, A, hc, domme- ode e, work for which his perout manned.
A!y Wtnke /x Cmnfencvien Imunrce curler •rd Policy number arc:
Carrier. Policy M,
CBRI'TFICA'IR 01; EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
1Thise Ihoeoc,t om hemmlpkmd if Nclernilh frrore hunlnd dollom(S 100)
a kav)
Icenifythw in perfmmanee ofdw wml, for whichrhi, Vromi, is iunc+l. I shall
employ any,"" in any mare, ro use m M1c'ontc. subject In the Wmkvi C'onepnr
wine Laws tt California. Date
Applicant t
HACK FLOW 1'R(TILLT DEVICE
DRAINS - FIDOOR. ROOB ARIBA, CONE.
ST(IHIF_S
'll'I9i CUNSTHUCfI11N
FIXTURES - PER TRAP
GAS- 13A -I INC.4OUII.IiIS
OCC. GROUP
APN
GAS -EA. SYSTEM-OVER i (EA)
GREASEI NDUSTRL WAsTIa, INTERCEPTOR
BUILDING DI VISION FEES
GHIASETRAP
%ANCFII!CK FEE
SFW ER- SANITARY - STORM 1A. 11X) IT.
ENERGY FEE
Wn'IT.R IIPATER WNRJTOEI.I.CIR
GRADING ILE
NOTICE DO APPLICANT: IL alter making this Cer if le of E.c"liun, you hmud
bri subject to the Work is Compensation provision, Mlle IaMr Code, you must
ochwnh...Uplywirhsuc11'111 imt zm lhizpvnnl(shall he deemed mvokN.
CONSTRUCTION LENDING AGENCY
I hereby irm that !here is construction resting agency hr the perfsmuntt of
the onrk fee which Bli. Permit is issued (Sec. 3097. Ci, C.)
Lender's Neme
WATER SYSIE\VfRFATING
SAILS FEE
Wn'1'BR SERVICE
PAID
Ic
ciprY
NEW RFSIDINTIAL PLVHL SQ. II'.
TOTAL:
Lender's Adhess
TOTAL:
,
LDIN
1 certify thin I have reed ,his a,hcauiotn std vast tlw the above information is
met. 1 nprce m emmply wish au city anal arrtnty oNinmam ow dam Wws relating td
W ilding ronwuc .. and thereby vanhorirc repescntativcn of Nix 61, ,, enter aprm his
ars ve- nwtuunml pnbq : y fm inspection Prri .
v
IWO•remsarc.iMemnily d keep turminstM City of Cupeniru aguq
Irbil itic,judgments,coxed,and e.,usc,. rich may in any way ueme vg a, mo said City
I¢yucnce of the grunrin8 of thl .permit.
APPLICA. tNDERSTANDS AND WILL COMPLY WITH ALI. NON.P)IN'T
SOUR - 'C 'PIONS.
QTY
MECHANIC
4
K
C.
MIC FEE
PENMII'ISSUANCE
CTRIC E
l' D0
AUITR OH ADII TTI MECII.
BI
AIR IfANDI_IN. UNIT OT 11 X
MIiCHANICA Flit
AIR HANDLING UNIT(OVER 10.000 CFM)
CIINSTRUC1ON'I'AX
Sign A,fie.1/Conl mcmr, Dulc
HAZARDOUS MATVRIALS DISCLOSURE
Will the ap,licmtsrman, tmildinguccepanl smmorhvMlchwurdous numA:d
res dcl'med by the CuWaint Municipal Code. ChVivi-9.11, amt Ile Heoth and Safety
Cock, Seetkn 2553210?
0Yuw E] No
W ill the applicant m fumte twit hng occulram use equipment m devices which
emit huWUu.v air contatninnnh us defined by the Bay Area Air Quality hl t cmenr
DiuriwO
[I Yes [_1 No
I love read led hvurtkeu manrisl, qi irement• modev Chri 695 of de Cali
fora o I IvdN & Safety Code, Seniom 25505, 25533 and 25531. I aMmlmd that if de
building dosros cunrndy lave a term. Nan it i. my te.pmibility w notify the occurrent
of the rtgai ociewnt, winch must be del prior lot ionanee of a Ccn l fie -atc of Occu,mcy.
EX IIAUST' 11001)(wmucf)
HOUSING MITIGATION FEE
HEANNG LINIT(TU 100,10X) BTU)
HIA'I'ING UNIT ((OVER 1811,0110 BTU)
PAID
VENTILATION FAN (SINGLE RFSID)
Bar, RnciPY
BOILER- C'11MP (JILT ON IIXkIXXI B'IV)
TOT L:
ROILER- COMP (OVER 100,DxO BTU)
AIR CONDI'fIONIR
ISSUANCE D -fu.
—
ISSUED BY:
NEW RESIDFNTAL MECH. SQ.
Tuner m eon o -Ind agent Dom
TOTAL:
OFFICE