S 2021 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIIAING-ELECTRICAL Pfl IT NO. 1
BUILDING DIVISION APPLICATION/PERMIT PEUMISING-MECIIANIUAL 2021
IIUIED(NA PROJECT MEN'I'EF•ICATION
BUILDING ADURE55: L SANITARY NO. APPLICATION SUBM1f ICI'IAL DATIi
-72, W rtt.. W T1Y/ S�iue 5 �.P6 . 1 ✓—l g ( 0
OW EIf:N le..r yION[: CON'IRAM'ul<'S NAME:f LIC NO
y
NIC CONIkOLp
.ARCO]I'ECTIENGINrEIR I.IC NO: ADDRESS: / ❑
IL-/Lim / ei"li
[CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG I3I.EC1' 1'I.UMB MECII
,�; 26� 2 -2Z ❑ ❑ r� ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PIJRMIT FEE
m
1 hereby affirthat 1 am licensed under prowisions of Chapter 9(commencing JOB DESCRIPTION
aceZ with Secniun]aXR ofDivisinnJnfthe lsusircss and Prnfe..inm Cole,and my license is RESIDENTIAL:
WOO p PERMIT ISSUANCE
in fu 11 force and effmt.e � bO �' / ❑SPDWL [I KITCHEN REMODEL.
aUU L¢cnse 'Ess L¢.« O r APPLIANCLS-RESIDF,NTIAL ❑ADDITION ❑PLUMBING RE-PIPE
yQ4 Dxte .�-'-. ICTy Conrad.
DECildm o mals PANELS ❑MULTI-UNIT ❑MODIFTURAL
ZO4Z IanJemanJ my plans shall heated as public rwoMs CHIMNICA'RION
EPA
OZ..0 111'T021X)AM)'S ❑INffiRIOR ❑CHIMNEY REPAIR
f=4F'LLI LianxJ Prole..innal 201-1000AMRS IMPROVEMENT 0SWIMMING POOLS
W •.1 OWN13R.BUIIAER DECLARATION OVER IOIXIAMPS [I HATH REMODEUREPAIR 0DEMOLIT[ON
9 W� 1 hereby affirm that 1 ten exempt frothe
m Contractor's License Low for the
xL�(O a U following neon.(Second 7031.5,Business and Trunnion,Code Any city or county SIGNS FEECTRICA), El OTHERifR
my which regniros a neem(to amawma,alter,Improve,dennllah,a npa1.any ormume /
ft-
1".1�Og prior to its issuance,also requirciaoicppliamo for such permit to fileasigned owement SPECIAL CIRCUTEMISC.
thin he is licensed paccnam a)the provi.inns of the Convenors License l.ow(Chapter 9
� d (commencing with Section 9000)of Division Jolthe ll.vinessandPmfession,Cedr)nr T'EMP.METERORPULEINST. COMMERCIAL,
d c.o C that he is exempt therefrom and the basis for the alleged exemption.Any violation of Cl NEW BLDG/ADDITION ElDEMOUTION
xSee.nn 911.11.5 M1y any appl'manl tin a permit subjects the applicant m a civil penalty of POWER DEVICES
nonnorc than rive hundred dollars(SSgB. El TENANT [I FOOL)SERVICE
IMPROVEMENT
< D I,asawnerof the pmPery,.r my employees with wages us their sale compensation, SW IMMI NO POOL HTE IC
F� willdn lheak,andmen
e structure is not imdedoedtot ❑O'1'IIER
w
as 3 m and Padessinns Code:The Connector's Lirenw law does not apply to an owner of OUTLET'S-SWI -TEXTURES
property who builds or improves thereon,and who dies such work hlnEell or through
his ,on employee......into that such improvements are not intended counted far NEW RESIDENT! SQ FT.
sale.If.hossxevet.the building or improvement is sold within one year of completion,rhe SQ.FE FLOOR AREA $/SQ.FE
.ovacrouilihi-Mil hove the bunter of proving that Outdid not buildor improve far,.,
Rose
orpur-
Rose of sate.).
❑ I,ascr of the.moony,oat esrlosivcly cnntrucing whh bemtscd counar oa h, AL'
construct theprojcct(Sec.7044.Business and Professions Con)The Convectors E.i-
ccnse Low does out apply m anoonernf property who Wildsor imposes there on.and QTY PI.UMBINGPERMIT FEE
who contracts for such projects with a comecun(s)Neelsen pursuant m the Contractor's t
Lmama law. PERMIT ISSUANCE fo
❑ tom escradr Jim Seo. .B&I-C for this m.son
ALTER-DRAIN&VENT-WATER EA) VALUATION
Owner Elate
WORKERS COMPENSATION DECLAkRFION BACK IT.(IW PROTECT.DE ICE
I hereby often under penalty of perjory one of the following declarations:
❑I have and will maintain a Cenifcmenf Conon)noel(-metee for Worker's Cnmpam DRAINS-FLOOR,R(IOF,AlkFA,C(1ND' STORIES 'TYPE CONS'TRUCTEON
salion,as pmwlded for by Section 3900 of the labor Cale,for the performance of the O
work for which Otis permit is issued. FIXTURES-PER TRAP
❑ I have and will nmintain Waders C.....pensatlnn Insurance,as required M1y Section
3700 of the labor Code,for the Esdormove ofne work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AI-N
My Workcr's QQ yy�so i.iA a'+li ,1zr d I'.lisy n b r leu Q�(
Curicr: SfrYCPolicy No.: f"�_ GAS-EA.SYS'rBM-OVER4(EA)
CERTIFICATE 01 EXEMPTION FROM WORKF. b' GRI3ASIlINUUSTRE.WAST'Ii INTIi12CEPlfIR
COMPENSAI ION INSURANCE BUILDING DI SIGN FEES
(This section neN urn be mmplacd if the ptmdt is for one hutWma dollars($11X1) GREASETRAP
or Icns.) 1'1,ANCIIECK PEE
I cenify that in me pemmumnce more work tar which this Fervor is issued,I shall SEWER-SANITARY-STORM EA.200 FI'.
not employ any person in any manner so as in become subject to the Workers'Compan- 13NERGY FEB
Z wtinn laws of Callfnrnio.U;°e WATER HEATER W/VENT/ELECfR
2 O Applicant
NOTICE TO APPLICANT:If,alta making an,Certilicote of 13senquion,yen should WATER SYSTL'M/TREATING
a > Wrome subject to the Workers Compensation provisions.f the Lahr Cale,you muss Zn ITS IT E
LSI forthwith comply an such provisions.,,his pemtit shut)he deemed revoked. WATER SERVICE
0. 0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PTMB. SQ.F
U PA
Z «
U O In.reby affirm that titere is wnsutitntt. le.eittg ag.nny formH
e pe .nn:mt...r le Receipt
U. the work for which this permit is issued(Sec.LW],Civ.C.)
I" I<nJers Name TOTAL:
0
O LJ [,cock,',Address ]OT
�r fa1 i DING FTiIi
1 cenify that I have read this application and store nor the above information aclaunn is
tF-t f0./) buildingiagnroion.niplyand with all airysoul roomyoratives of ono stem lawsr up.te QTY MF.CIIANICAI.PERMIT PF.Ii
U z building construction.and hereby numorixe representatives of this city ut enter up.the !ISMIC PEE
above-racroonal property for inspection pu pow, PERMIT ISSUANCE
fWm agree m save, nnemmfy and keep lan.leea the City of Cu unino against H HCI RIC PER
liabionics,judgmenu.cnsl mJ expenses which may in anyway accrvc against said City pCIER OR AUD TO MGCH. 1
I
n consequence ve ring of mis pr h. I'1. BING PEG I
APPLICAN" DP STANDS ILL CU. LY WI'1-H AI.E NON-POINT AIR HANDLING UNIT('10 IOA1ICFM) MEC I \NICALFEE
SOURCE I S.
AIR IIANDLINGUNI'I'(OVER 10,000CFh) CONSTUCHON TAX
Si nnt.m.f Applicant/Cnntmem. Dote EXIIAUS'IHOOD(W/DUCT) HOUSING MIT'IGA'TION OTE
HAZARDOUS MAI ERIA1 S DISCLOSURE
Will rte applicant n,future building oecupamsmreor handle hamrdam material HEATINO ON]'1'(TO 1110,000 BT U)
ns defnad 1,the Cuperm Manieipal Code,Chapter 9.12,and the I lealh and Safety
Calc.Section 25532mo? HEATING UNIT(OVER 100,010 BTU)
❑Yes f�Ntt VENOMEAI'ION PAN(SINGEE RRSID) PAID
e �S Uma ktreipt«
Winne air conmsnfumrc NuiWied occupby
nt use Bay
Air Qul.rdwicagement pp11.ER-COMP QHP OR isfow B'IU)
1 mit haanrdoux air ennmminums its defined by Ih.Euy Area Air Qnallty Management TO L.
Ir
Union,
C]Yes Nu Ill-COME(OVER I00,IN10 Bi L)1
I have mad rtv
e Woodouuaterials m
requitames under Chapter 6.95 of the Calm AIR CONDITIONER ISSUANCE DATE
forma Ilcahh&Sof•ty C c.Seri 255 5,25533 and 25534.1 underma d that if the NEW RESIDENTIAL MFCH. SQ.FT. I?
buiWingdapu
s rte yh:rceann at it is my reslemsibility t.notify etc n I(f I
of the hast uli I of a Cmcnm df s
Ow o roan.gem Dam TOTAL: ISSIJI3U 13Y: 1/ /- �`I �✓
OFFICE