S 2385 (2) - APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINNO BUILDING-ELECTRICA I. Pl:kn+lr rva.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2385
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRP_SS:CJ L� SANITARY NO. APPLICAI ION SUBMITTAL DAIS
OWNEERS NAN41 E: CON'IRAC ' 'S 11F: LIC N(1:
_ NIC CONTRrII.p
ARC I'Trc1/ENGINEER: Lrr NII: AJDR ISS' ' r .S• ❑ /
CONTACT f PHONE: - HIJILDING PERMIT INFO
\ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MESsCI�I/
LI:I? SED CC N'I' ACI'Olt'S DI?ChARA'II(1N QTY. C,i 'ELECTRICPERMIT a: .FELE
I berchy affirm that I ant licensed under provisions or chapter 9 heommcndng - - JOB DESCRIPTION ;I
DetZ with Sermon J(Xl1 Division 3ofthe Business and Professions Cad,maT license is RESIDENTIAL: t
WOO PERMIT ISSUANCE
F W.. in lull force uhd ell' ❑SFDWI. ❑KfrCHB REh10DF:L
QUU Liccio fluty _ 0 Lic. APPLIANCIiS-RESIUI!NTIAL ❑ADDITION ❑PLUMBING R17-pi r,
E Z ul pate Commnor i
❑S
FSH ARCI IITECT'S DECLARAI'I N PANELS ❑MULTI-UNIT' TRUCTURAL
m I understand m lads shut l he used as public records MODIFICATION i
o v
z' �� ❑I'r0211f1AMPS -
OZ O ❑INTF;It1012 ❑CHIMNIiY REPAIR ;
1-�F-al licensed Prorcuieral 201-10NAMPS IMPROVEMENT []SWIMMING POOLS `
OWNER BUILDER DECLARATION OVER IIXNIAMPS (3U
HATH REMODFREPAIR ❑DEMOLITION
W W0
3CLuO-UF I 1 hcrchy nfmn that 1 m exempt rodt the Contractor's License law for the
Mlowng (Section 70 Buinesxand Proensimn Code:An tY c��ntY SIGNS P1IF_
RICAI.
[:1 OTHER
y which I scrinfil toconsider, her.intense,ded li,nor visa, Y.masure
E" m
poura,its:. Iso mquires the applicantf h unnit tofile a signed vertical SI'I CIAI CIRCULI/MI ..
y hathlicensedp s tt the 1 TII C t t 1 1 (Claptcr9
(eommeu ,gwmSea na 7000)ofDivisi n3oDflm Bu.n s ate Proms aC l,)or 'I EMP,MEI'I?RO OLI3INS'P, COMMERCIAL;
E E:c C that he is exempt therefrom and the fiesis for the alleged exemption.Any violation of - ❑NEW BL UG/ADDLTION ❑DEMOLITION
X m ns Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty ofPOWER DIiV P.S
W�r� nam Bum Evc huddresl ill $500). ❑TENANT ❑FOODSERVICE
nia
( IMPROVI:MEN'I'
~=Q� on hmowner [[lie nraPenrorm em to seswimwawmcir hole cons wnanin , SWIMM GPO0.ELECTRIC -
y�F- d Prof a sions and the a Contractor's
tots License Love dos net apply to a own',of ❑OTHER
w�M lino Professions Culc:The Cnmrucmrl License haw Aces net apply m un owner of DV'.. S-SWITCHES-PI%9URP.S
pmpedy who huilds or nnpmvcs thereon,ode who does such work himsslt or I......
his own employem,provided that such improvements am not intended sr offeree for aW BESIDES 11AL ELP.CTR SQ FT.
sale.If,however the building or improvement is sold within one year ofcumpletiun.the SQ,Er.FLOOR AREA EISQ.1'1'.
cr-hui dcr will have the badlen of proving that he did not huild or improve I,),pur-
rnx I - I ).
L]1 as f tl p ,cry lu: ly r i g th l e eaJ t t t, 101A1.: -
n�w t the p j t(Sce.9tW4 Boards, d Professions Coded'Ibe Contracts . - - ,
L t-rl lyt fl lmr,who mild,,,improve, Indecu,nal QTY. !,PLUMBING ' MITJ FEE
wh t us lora Jtp J '.won ueunt mr(a)luuulp unuo ere Gmtmetnre
Law. P1?RMlr ISSUANCE
del an,axemvt ander Sec. .n&Pefor his
ALTER-DRAIN (17, VAIAAll ION
Owner mole U
WORKER S COMI'ENSAT N DIiCLARA'I'ION If PLO\l'PROI IiCI'.DE / �J J
I lmalay ufiin i under pcnnlry of perjury one of the following dwelumtlnns: +
❑16uee and will dmintin a Can lfene of mooch maelf-hour,lar Wnrkair Ganpnt- DRAINS-DOOR,RODE,AREA,CONI . SIORIES TY PECl1NSTRUC'IIOA
avtion,as provided for by Sociian 3700of the Iahnr Card,for the pe,ftlmunce of the
work for which This pc find is issued. FIXTURES-PER TRAP
gentoe ane will maintain Worker's Cmapensatien hvolum,:as reycircd by Section
3700ol The labor Galc,lit,theperfinul ce of the work for which mis permit is iasmsl. GAS-17A.SYSTEM-1 INC.40U1/.TS OCG GROUP APN
My Worke' Comrensatinn 11pnuf�nc ,`tier ane Policy n% t �a ��}'�
Carrier: G Jf�.E7HL €P ,.he,Na/C��� CAS-EA.SY.STEM OVER4 A)
Cliff IICATE OF EXEMPTION FROM WORKERS'
COMPIINSAIION INSURANCE GREASHIINUUSTRI.WA.' iINTERCI?I40R
BUILDING DIVISION IT IS
(Thisneetinn owed not becompleed ifthepennit is Torose hundreedollars($100) - -- —
nr lesal GRF.A561'RAP PLANCHECK FEE
I certify that in line perfitromnce nfine work lin which,liklwrmit is I....cd,Nadi SEWER-.ANIT tY-STORM EA.list FF. -
nat employ any person in any manner so as to became subject In me Wal keri Comlwn- ENERGY FEE
Z sateen Laws sfcaliforma.Date WATER EP ERW/VENT/ELRCTR
0 Applicant I OR
NOTICE'I0 APPLICAN'C 11,aIle,staking this Ccnifiete it Exemption,you should WATER SYSTEMflW ATING
(•-' > lacome.subject to the Worker's Cnmperoala d pmvio'sus of the labs Calc,you mu.a SOILS FEE
W ..
formal complywi,h.mch pmskions or Itis permitshall Mdeenunl revoked. WATER SERVICE
P A
CONS11CICTION
scone I.ENDINGAGENCY NEW ltd?91mF.NTIAI.PLMB. SQ PP. I' Ili
L)O IM1crebY nffinn that is aconametion lendin&agencY forme perlimnancc of JU In lis If
III... F the work for which this permit is issued(Sats 30PI7,Civ.C.)
Leader's Name TOTAL
U' Leader',AAdreca 'POTA L:
1 certify mat 1 nave read mis arplieation and stale mat ore aMrve inlitmatinn i. .. 1111.D1 '
,F. 11rail Iagree'.comply wins all cit,and v.entyordinatcealnasone laws relatingm QTY. MECHANICAI.PERMIT .E '
C.J P handing.sacelion,andherell... ercpre.senunivesofmis ciyu,,rmrupan.he - E
"
7 11
above memlou'd,iny lin inspection purposes. ` I'ERMH ISSUANCE
(we)agree to save,indemnify and keep hani less the City of Cupertino againstIZ—hEL[CI'Ric FEE
habiliticsjudgments,cos¢and expenses which may inanywvy accruaagainxt said City ALTER OR ADDTO MECII.
segnanw.1 tire graming of mis peduo. PLUMBING[:[;I.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING ON I'r(TO I tI,hacFm
SOL' EREGUTATIONS. � MECHANICAL FEE L17- ��
zlerl�'L, set AIR HANDLING UNIT(OVER Bill CFM) CONSTRUCT ION'1'A%
Sigmnurc of ApplicanVCommmor V 1) a EXHA LISP BUD,(WIDUC'P) I LOUSINGMITIGAION FEE
HAZARDOUS MATER IS DISCLOSURE
Will the applicant orfuturcbuilding occupant ameor handle hazardous mxterlul / 1 LEAPING UNIT(1011X),000 BTU) ,
Q
as deliocd by the Cupertino MuCndc,Gtuptcr 9.12,and me H.111,H.111,and Sufcty
Code,Section 25532(loc - HEATING UNIT(OVER 100,000 HI 0)
❑Yo' BIT. VENTILATION FA N(SINGLE RES ID) PAID
Date Reeaim
Will the apPlicmn or lidure building uccuptm nae ttryipmenl ar devices whidt 1
IWemit h/caskus air contaminants as defined by the Bury Area Air Quality Management BOILER-COMP(3HP OR IIXlfNXI ITT 0) 'TOTAL: �-
Distriat'1
0Yes mR BOILER-COMP(OVER HiddenBTU)
ONDIT
AIR RESIDENTIAL
N
I have rcan Jr.tRevision,materials rryamental s under Chapter 6.95 of the Oji- ISSUANCE DATE /]y
n,mia Health&Safety Cndc,S¢tions 255115,25513 lino 25331.I uneemanJ mm if tnc NEW k1iSIUF;NT1Al.MF.CH. SQ.14.
bailie ug doe nota yhuumnum, unit Ls my cup ity In notify thu,scupunt
of We rcywhich mist ora,i f.Ccnificatc of(kp
Owner tar aIDhnrmce agent ' Date TOTAL: a O ISSUED BY.-71'0- e-
• "�/"1� ��Ll
OFFICE