S 1714 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'I'INO BUILDING-ELP.CI'RICAI, 1714
RUII.nING DIVISION APPLICA'1'ION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECTIDENL'IF'ICATHIN'
BUILDING ADDRESS SANI'T'ARY NO. APPLICATION SUBMDTAL DRIB
gkiooD �R , c u dicT��o sol
OWti NghY 1 / YI ON CONI'RACTOR:S NAM LI
NF , CN
tPSJ� L NIC CONTRfILp
t ARCHH IiCI'IENGINI?Llt LI(O'N ADDRESS ❑ 1
coNT PHONE: BUILDING PERMIT INFO
CyZ¢D �/l�, Z'z�/' ❑ Consultant Pecs Paid by Applicant(Initial) I B� ELr PL7 MECH -
1ACINSI )CONTRAC I OR S DLCIARAI'ION QTY. -�. ELL'CIRIC PP.RMD'. PEh VrJA ILEI
1 hereby arrm,m I licensed 1 p f Chapter 9 Cori riming JOB DESCRIPTION
��Z an Senior ptN]fO ur D' ilm Jmr Ne Boa u:l and Pmfe.. nn G,de.rid my Te .cis RESIDENTIAL;
CW n full raw and r[Ei 4J .3 PERMITISSUANCE ❑SIVWI- ❑KITCHEN REMODEL
aUU License Chas fJ hie.# APPLIANCES-RESIDENTIAL 11nADI'I ION El PLUMBING BIT PIPE
Ful Date
ARCHITECT'S DEChARAT N Cunamnur
y d MULTI-UNIT OSTRUC'tURAI.
ZOyZ I understand my plans 111.11 be.wdas puhlienemNs PANELS MODII7CA'fION
OZ�M- UP TO 200 AMPS ❑INTFRIOR OCHI.h1NHYREPAIR
F 4Lw Licensed Professional 2 I AI fIfNIAMPS IMPROVEMENT OSWIMMINGPOOLS
OWNER-BUILDER DECLARATION OVER 1000gM1'S O BATH REMODEWREPAIR [IDEMOLI'I ION
uu11 1 hereby;Irrrm hal 1 m, .empt l all Ino eomraitaA Licen.e loss fa me
rmlluwin s 0111 LS�Businels and Pmfnsiom Cale:An I t OODIER '
K 3 g tcason.Sec inn y City 11r County SIGNS ELECT RICAL
�LLOywhich y ' pe II t dl p demolish, p y:a tcmre
< rimm as issuance.alk. y me applWanr h pennion,file a,i,,wd,mcnwrl SPIiCIALCIRCIII'1'/MISG
thath I' dp . u th p .... n: if do,Contractors License To
(Chapmr9
ao�o (co g with ]000) fD 1i l lh Basine.. IP f C+ 1)or IEM11METERORPOLEINST COMMERCIAL'
I1"p�oa Ihm h pr'Ncrcf I thetr sis I halleged exemption Any �lui of O NEW BLDG/ADDITION O DEMOLITION
iCm Y. Sec, 11DI56y any 111 If peri I. lj t mc',I II ','Ipaallynr POWER DEVICES
WtiyOTENANI' ❑FOOD SI:RVICI'.
0t more than five hundred dollars($SW).
H Z} Ih1PROVIiMENT
�Sp �1,as uwncrnf the progeny,1.r 1.Y empinyre>wilh wages mtheir sole rompenutinn. SWIMMING POfll.ELECTRIC
will do me work,and the slmcmlc is not intended or offered for sale(Sec. iimin --Zms
� / ODTHIiR
w
W0.3 and Professions Code:'I'he Contractuf%License law Nos not apply to an owner of OUTLETS-SW ITCHES-FIXTURES
property who builds or inyvuves thereon,and who does such work htmleBur Nmngh
hie own eanplmyees,provided that..ch Ioym venaals are moa Incaand a 01lbral lin NEW RESIDENT'I Ah i.i.EC5'R SQ p1'
,a],,If,I scverNe bailding11rimpaseowliewld within uricyear of comp letiun.In SQ.PE FLOOR AREA vSQ,ET.
cder will hacc Inc nuNeO of proving IM1ut he did mol hlulJ or improve for Pur- �-2
pox m ris.mle,).
co L m owner nr the See 70y,,Ba,inc,it I contmeting witn licensed connaann m T AL:
metmct Nc pmiem(Sec.IIIJ4,ensinesl wul Prates siom Code.)."he Cnnm¢ma's Li- .
1u Laawdncl nm apply ea an ownernfprnlwny whohuil+L Orimprmes lhercma.:m<I QTY. 'PLUMBING-PERMIT ` PEE
woe amin¢'Ie ti+nucn pnajccll with a contn+angll nccnsctl pnrnuum m the Cnntrnnor'1
License Law. 1'13 1' SUA is
O lam elemplunder Sec. ,Li h P C for this reason
ACI - R & ;NT-WA'I'IiR(EA) VALUATION
Owner Ilam I �
WORKER) COMPRNSAI'ION DECLARNI'ION LACK FLOW lI?CT.DEVICE \ \ d11
Ihm,bffi
yaran un Jcfponaltyofpcjurryoneof the following JecWmtlmns: '- P-en
O l navetad will maintain.Cenificalcof Consentmsclf-inmre Pim W'orker's Campcn- DRAINS-FLOOR.R F.ARHA.COND.
salon,,ns provided for by Section 3700 of the Labor Cale,for the pednrmnn<c of the STORIES TYPE CON5'fRICfIDN
lo
work for which This gamut is issued, I[STORES-PER AP Z
❑ 1 heve;md will maintain Workers Con+pe-ati m Insurance,as m,n d by Section
h1YmWnfrth
e Luna1P nurJ. OAS-EA.SYS'I'iMINC.AatlI'LIiTS r OCC.CROUP APN
k nIn, aandpolicy
s . OAS-EA.SYS'I'IM-OVFRJI(EA) M
CERTIFICATEOF l9' FROM K
COMPENSATION INSURANCE I GRF,ASEINDUSTRL,WASTE INTERCEPTOR
I1 VISION h1iE5
(rTh'i1 xntimn need 1.+l hu rompleanl il'ahe permit it rnr atehundlW dollars($IINI)
nr le-)1 GItIiER-SAP PLANCIII?CK FIT!1-- /,
Icenify thin in NeperGnmuneeof she work!which Nlywrmil isilsuel.Llhall SIIWER-SANI'IANY-STORM IiA.?TIO F4.
ria
employ.,pcon.inm,onamersoas b+becomembjec,to he Workers Cnm wn- 1:NERGY IBiC V
z satin Law1of California.One WATER HEATER WNENT/ELECPR
Applicant GRADING PIAT
BUT ICH'11)APPLICANT:ILaftermaking this CrIme.eof iixroi,dmn,y+mshould WATER SY5TEMOREATING
her ua 1W+'iec1 m the Wake,Cmnpensulien 1;0111111111 of Labo,C adc,you mull - 5011 S FIFE
LM burb id,corody olh sahpm,,omsorthiepennit shall hedecrmdrevoked, WAI'IiR SERVICE
a
CONS TRUCf10NLENDING AGENCY NEW kFSiDISN9lA1,1'LMB. SQ,FI'. PAID
L) I for O loch thi iliac there is ed Sec 30 lending agency for the perfmrnuna of Dale ccipl#
Ne work for which this permit is issued(See 1119].Civ.C)
I--a LenJn's N:nneO'fAl.:
Wens Lder' Address ( 'I
1 ccr if,mal 1 have team mis ap,hcaxm and lmte Nal me above Information i1 HUILDING �N
F' N correct.I agree to comply with all city and county ovlintncesmad state Inns relating to QTY, MECHANICAL PERMIT FEE
8
V z building construction,and hereby mthorim representatives of this city to enter upmNc I SEISMI PIAT
r above-incntioned mTcay for inspection purposes, PIT R MIT ISSUA NCP' //--��
(We)agree n+mwe,indemnify and kery+harries,Nm(Toy of CuNi inu national 13LECr I
linhllilicajudgmenls,elsta and expemms whl¢hnuty in any way...me a,ah,llI iCoy ALI IR OR ADD'DI MECH.
in c of the granting of Ihi1 permit. PLUM
APP 11CA !T UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO I0,000 CPhp
h F.CHA�'IC PEE
<CI' PLG
AIR HANDLING UNIT(OVER 10j)(10 CONSTIC N'I'AX t
u+ ppicant/ConlrucNr I D e HXHAUSTHOOD(W/DUC) G 1 IATION FEE
HAZARDOUS MATERIALS DISCLOSURE r
Will[lie applicant or frim¢building occupant store or handle hauMmua malarial HHAIANG Ust 1'00100,0100 BTIA t
as defined by the Cupertino Municipal Code.Chapter 212,and the Health and Safety
Cede,Section 25532(.)1 I]EAT'ING UNIT(OVER Ig1.gX111'TU)
❑Ycsv ❑Nm - PAID -
VI3N'DLA'1'IDN PAN(SING LIT RESID)
it Receipt q
Will the app coni arson;a building by he Bl ase ea Air cidQu or JMana whish c 1
t:vil nueunlous air emmminants as JeOneJ by the Bay Area Air Quality Management IiO1LER-COMP 11HP OR IB(I,INNI RTU)
Dfvtda!
O Yes ON. 1301LER-COM P(OVER 100,000 HT(j)
AIR CONDITIONER
1 nava rod Nc huntnlns lams 255 5.25533 ma orderChapter695 cit at euro SSrUANCIi )AT�
fomia IlcaOh&Safely l,fa Swoons 25led i 8513 and 255)1 I i understand tn:n if the NEN'RFSIDEN'1'IAI.MECH. SQ.FT.
buildingdosriats whicyhave a MCIPheard,lbaloismylesOf a Cdifimnotify(C aeupaot ✓�/J�
of the myuirenten¢which most he mel pdnnn insumce ora Cenificae of(kcup+nep.
Owner ar aolorictil opera Dao, O' 1- ISSUED By:
OFFICE