S 1663 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull DING-1'ILIIO'I RICA], 1'III 1'1'No.
nUII,DING DIR9SIDN APPI,ICATION/PIiRMIT PLUBIBING NIECE,\NIG\I. 1663
BUILDING 1'ROJECI'u nNPIFEOA'TION
BUILDINGADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
Is -// X5 • r Li, S _/1/- 9B
I OW EHSNAME: PHONE: NA'TOR:S NAME
NIC CONTROL p
`IP L1(` y9O$
ARCI11 rD7 ENGINP,ER:- I,IC NO. ADDRLSS: �/� ED
CON'I'AC'I': I' PHONE, 11 , nUILDING PERMITINFO
NAS �53��� Y 8 ❑ Consultant Fees Paid by Applicant(Initial) BOG ELECT PLUMB MECH
El F-1
LICENSED CONTRACTORS DECLARATION QTY (ELECTRIC PERMIT FEE
Lhereny arerm thmlant Bremad amaer prm-iamarr nr enamer9(commencing JOB DESCRIPTION
qaZ wh�9eerna 70001oONvislon3a0he[I to,and PmfevxiomC 11,andmyliccnsc is RESIDENTIAL:
1+10 0 PIiRMIT ISSUANCIi'
FU_
Infall Class etfret. ❑SFDWI. (I KIT 0.F:MODEI.
azo License Class I,iaM APPLIAFCIiS-RESIDENI'I Al, ❑ADDITION PLUMBING RE PIPIT
h4L Dnlc Gmvmcet
ARCI{ITECI':S DECLARATION ❑MULTI-UNIT ❑STRUCTURAI.
Z O`�Z l mah aand my plans,hal be used as pahlic records PANELS MODIFICATION
Oil 10 AMPS
OZ ❑IN'1ROR ❑CHIMNEY REPAIR
[accusedOL
[accused Pmfcssiunal 201-IINIOAMPS IMPROVEMENT (]SWIMMING POOLS
CY ; OWNEHrecall iRlt DECLARATION OVIiR 1000 AMPS ❑PATH REMODEURHPAIR DEMOLITION
C Q herby a(rma that I um exempt I'mm the Conlrnrmr'a license Late for the
OW followingSection]031.5.Business anti Profession%Coda:An I t ❑f7fHIiR
mason ( Y city or coon Y SIGNS F.LF.CI'HICAI.
3 c y which myuims a pennil m constmm,al¢q improve.demolish,nr repair any stmcuarc
y� prior m its ianuanca nAu reyuircx the a,dfiwam lna'xuchpernai ted IIIc asignwlxunatenl SPI:CIAI,CHRCUTDMISC.
?N'� (hal he is licensed pursoann theproonvof
visithe Cmueminr'r License Law(Chapter
�m uASO (commencing with Seainn700(yofDivision3 ofthe Business and professions Cool 'TEMP..METER OR POLE INS'C COMMERCIAJ,;
6 oa tont he is exempt Reel}om and she basis for We alleged exemption.Any violation of ❑NEW BLDGIADDTI'ION [_]DEMOLITION
Section 70315 by any applicant lit a permit subjects the applicant it)a civil penalty of POWER DEVICES ❑'I' NT ❑FOODSERVICE
not nmre tlmn Eve hundred dollar(ES(I0),
~ C [� Lns owner of the prapcny,or my employees wish wugar us their rule nmgtnsntion, SWIMMING POOL EI.ECIRIC PR EVENTX
' p�. writ Jo the work.and the-slrocmrc is not imm�deJoroffemdl'orsnlc(Sec.96H,Business ❑OTHER
6 3 m and Pmrrslons Calc:The Cnmmcmr's Licanse Law does not apply to an owner of CHI'LETS-SWITCHES-FIXTURES
prapcny who hullds nr ina,m,es therum,and who dor'such work himself or through
his own employee:,provided duct such intprovemcnn am not intended or onbred lar NEW RESIDIINTIAI.ELECT SQ FC.
sale.If.howcva,the budding or improvement is sold within one year ofcontpleuon,tire ,OOR AREA SISQ.IT.
cnhrh
ailder will have o barren ofpnwing tom he did not nada or iumbou for p rr'
posof sale).
[1I,as owner of the pmpeny,am exclusively contracting with licensed conme ors to TOTAL:
ro..mmm We project(Sec.7194,Business and Pml'<sxions Cork:)The Cnn racta,IJ-
muse Low does not apply to an neutral property who builds
J-museLowdocsnotapplytoanneutralpropertywhobuilds(ir improves thereon lord QTY. I'LUMnING P17RMIT FEE
who commits for such projects with a nsntramon%)licensed pursuant to the Cnntmno's
License Law. PHRMI'IISSUANCE
E] 1amwsenptunder Sec ,B&PCtarthisreason
ACf13R-DRAIN&VENT-WATER(1!A) VALUATION
Owner Lose
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
Ihereh,affrm under pantry of perjuryoneof the following declarations:
❑ I have and will mainmina CcniOcate nfCrnwo,mselGinsnre for Warkcr's Compeo- DRAINS-FLOOR,ROOF,ARFA,COND' S'TOItIIiS TYPE CONST RUCTION
cru n,as provided far by Section 3900 of the lahnr Cock,far the performance or the
work far which this permit is issncd, FIX'T'URES-E'ER TRAP to
1 have and will mmbason Worker's Compensation Insurance,as mynacd by Saetion
3900ol he Labor Code.lin the lacdionsuacofthe work for which Ibis pennil is issued GAS-EA.SYSTEM-I INC.4 OU'ILINS OCC GROUP Al
My Wrk�try.Cpni r9i, sur nee anic'O il`olicy
Carrier:ADC*''µ Policy No.: Go/ GAS-EA.SYSTEM-OVER 4(EA)
CEWI'I IICATH OI'E% PTION I'RONI WORKERS'
COMI'ENS PION INSURANCE GREASEANDUSTRLWASTE INTERCEPTOR
BUILDING DIVISION FEES
(Thisscninnneedmm he coardthiddic,peon is fortune hundred dollars($100) GREASETHAI'
or Inn.) 1'LANC{IIiCK FEE
I certify that
person
in perfomtance a,t work far w hicao,,he tidcmedlshml SEWER-SANITARY-STORM EA.NNI FT.
not mnploy any person in any manner sn aHn httnane subject m the Warkcri Compeo- I'NERGY ITB
Zz sari....Laws nI Culititnia.Date WATI7R HEAd ITR W/VIiNTXLIiCTR
0 Applicant GRADING FEF.
y NOTICR TO APPLICANT:IL ager making Ibis Ceni iece of Esantption,you should WATER SYS]IMG RHA'TING SOILS THE
abecome wbjecl m the Workeds Compenvmion provisions al the Lahor Core,You lona
GJ forthwith comply w,Ih,.ch pmvisionsm this pennil shallM deemed revoked. WATER SERVICE
d A
'J z CONSTRUCTION LENDING ngaerAGENCY NEW R[SIDIiN'1'IA1.11I.MIL SQ.I°T. - PAID Date ttc'u#
V l lot by which this
that issued(See.30 lending agency Tonle perlisrmanm of
the work for wM1ieh this permit is issued(Sea 3099,Civ.Cd
u" H LenJcrs Nuanc I(YfAi,:
C.J Lender's Address TOl'AL
a1 certify thnl I hove real thin application onJ slam that the nhnve in[nrmmion is v/ r BUILDING ITE
.Hih unreel lagreemconaply with ml cityunJe�unty nnlinanccvand sntmlaws mlwingm QTY. MECHANICAL PERMIT FEE
V Z bmildingconsauctiomanJ hereby adiarizu repreutnmivevofthis cquircnterupunthe SEISMIC
aha"-amntirm"I pmpeny for m"welion purposes. PERMIT ISSUANCE -
(We)agree to xnvc,mole any and keep Iwnnless Ila City it Cupertino against 10.001C ITE
liabilities.judgments,costs and expenses which may in anywayaccme against said City ALTER OR ADD TO MECH.
cnn.w,rearrofthe grunting at this permit. 1'Ll1Mo .F
APPLICANT IINDERS'IANDS A )WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNG(TO IB,IN)OCIM(
SOURCE R .LATI 'S. et H I AL PER 1
r!51G A11E HANDLING UNIT(OVHR IB.fxxICPM) CONSITRUCTONTAX
Si of App can,conlarefor T C[))are EXHAUST HOOD(WIDUCf) \1"MiNG MITIGATION ITE
HAZARDOUS MATFRIALS DISCLOSURE
Will the applicant or form building necupam smm or handle hnmrdnusmatcnal HEATING UN I'T(TO I(NLU(N)II'I'U)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Sermon 25532(.)9 HEATING UNIT(OVER III(JSX)BTU)
❑Yes 0N VENTILATION I AN(SINGLE R ESID) PAID -
Date Hismiplx
Will the applicant or future building by the Ht ma s Air nn or Manna which
`mil haauNnur rut cnmm�ainmus us duOneJ by lou i{uy Aruu Air UnWity Munegammat BOIL(?R-COMP(3HI'OR 10g11W BTU) '
TOTAL
District"
❑Yes F1 No BOILUR-COMP(OVER 100,000 BTU)
I have read the hmatdoun brourial.0 requimmems under Chaptar h95of the Cali- AIR CONDI'I TONER ISSUANCE DATE
fomia Braila&Safary Cal Sections 25505,25533 and 25534.I andemanJ that is the NEW RIISIDIIN'IIAL MICH. SQ.FL
buildiatgJcee nal currently huvcamnan Leal oyat"noodalityton...dy the"cupanl /\ TwT ,
of the requirement,
eyuiremc iswhich must fee prim ear^C�iRca�e Anp,tncy. l/ Imo//Ca'�p 191/(J�
I)
isiI n t)ulu TOTAL: ISSUED HY: �_` 1 `v
OFFICE.,,