31122 APPLIUAN 1IU FILL IN INI-UHMAI IUN VVI I MIN MtU LINES-USt BALL FUIN 1 YEN UNLY
CITY OF CUPERTINO BUILDING-F.LP.CRRICAL 1'IiRMIT NO. apt ^/�
BUILDING DIVISION APPLICATION/PERMIT PL.UMBINC,-MECHANICAL 3 LL
EUILnING PROJECT IDENTIFICATION
BUILOINC.ADDRP_SS: YI V • 3 SANITARY NO. APPLIC'AfION St H MITI'ALDAIF.
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CHITCLTI-NGINEE LIC NO: ADDRESS: ElD11 C 1Ot�R M Lf `/5 Y, W c r
COONQNT11ACT.:gfL�� PIIDN/f:: BUILDING PERMIT INF
J W 1�1`c POO/-,9 - `''9q3 ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUM MEC"
E3IJO ❑
LICENSED CONTRACTOR'S DECLARATION QTY - ELF.CfRIC PERMIT FEE I hereby affirm than I nn licenced under provisions of Cimpw 9(commencing 'OB DESCRIPTION
�Z wide Section 7000)ofDivisionnofthe ninilLeomal Profeesions Cork,,oad my Ecenm is
��1+00 in full facet • PERMIT ISSIIANCT:
`-u1❑ ]I-I SPDWIL ❑KITCHEN REMODEL
U lUil License Ins m.g
�•7�- Dlne C[mwata (!� ,'�A1 _.e APPLIANCES-RFSIUENTIAL OADDITIDN OPI,UMEING RE-PIPF.
1.'M ARCHITECTS DT:CI.ARATION 0MULTI-UNIT ❑STRUCTURAL.
p 0 1 urtdenond my plan,shell beused xPublic records PANELS MODIFICATION
TO 20 AMPS
�yUP
` OIMPROVR OCHIMNF.Y REPAIR
ISFSjs LicrnsN Rofcuionel ]IH-IIMMIAMPS IMPROVEMENT
Xd OWNERexempt frDECe Contractors
OVER HXXIAMPS 0 BATH REMODEURT:PAIR 0DEMOLITION
U F I hereby affirm that I nm exempt from the Cnmmcloin License Low for the
BOJ Which requir s a Section 711nL0.Buaitc aimp rve,Prodemolish.
Code:Any cityof manrY SIGNS ELECTRICAL. ❑OTHER
3 W Which ngnires a permit m 0311. 1,cher.improve.demolish m mpah any almemm ��.(/j Lren+Tll[Jp2l
yI prior to iIx borrow.also requires the applicant for such Permit o fileesignW slmemem SPEC1 A1.Cl RCUITIMISC.
} that he in licensed Immoral In the provisions of the Contractor a License Law(Chapter 9.
CO (commencing with Seelion 1000OfDi.ision3afthe Theiressaml PmfexsinnsCdelo, 'I[SMP.MBfI!R OR PDLL!INSL COMMERCIAL:
Ihm he is e[cmpr Iberef on arid the Iasis fur the allegerl am plion.Any violatin.of 0 NEW DLDG/ADDITION 0 DEMOLITION
$ �
Section 70nl.5 by any applicant for a permit subjects the pidbum his civil penoby of POWER DEVICES
Ilse more than give hundred dollars(S5(%)). 0IMPROT ❑FOOD SF.RVICF.
aC ❑Les owner of the pmpeny,nr my employee with w....enhelr sole compenmtinn, SWIMMING P001.ELECTRIC IMPROVFAIF.NT
will do the work,and the structure is not intended or offered ler mie(See.II44,Business 0OTIIER
and Pndesslons Cole:The Cnngaonrs License Law docs sen apply In an owner of OOTIJGS-SW rtjDLS-FIXTURUS
R' property who builds or dmprovm Thereon,and who docs such work himself or through
his own employees,provided thin such in,rowtva t on,no,intemled oI offered for NEW BESIDE .ELE SQ FT.
sole.IL bnwevFe the building or improvement Ls sold within Lore yearof completion,Ihe SQ.FT.1r)BNRf:AD LSQ,Fr.
w
oner-builder will have the harden of proving that he did not build or improve for put- gi
pane of soil). IAL:
�1 2
01,"owner of property.am exclusively conlexcling with licensedennlmelma'sla
doe MICR ^1 RECconstconstructflue D
construct project(SerIll.7144,holiness and Co—T CnnuomnrLi-
eenseLawdoesnotapplyloanorneruf property who builds or improves thereon,end QTY, PLUMBIN - FEE
who commels for such projects with a contorctotO licensed pusm to the Convector's
License Law. PERMIT 196,VA CII f VI- vvf Cfil Ill
O l em exempt under Sec. ,B A,PC for this reason
ALTER-DR V -WAT[R ICAI VALUATION
netDate
WORKER'S COMPENSATION DECLARATION ` BACK FLOW PROTI . ICC
I hereby elfin maker Family of perjury one of the following okde.....
I`, I have end will maintain a Cenifcale of Consent to mllimure fm Worker's Cumprn. DRAINS-FL .R F. .CO ). STORIES TYI'ECONSTRUCrION
xation,as provided for by Section 3700 of the Labor Codc,for die performance of the
work for which this pelmil is ismd. FIXTURES- '. T P
O 1 have and will maintain Workers Compensation Insurance,as required by Section
T!Wm the labor Code,for theperfrmmittof the work for whidthispe.it is Issued. OAS-EA.SYS76 RE
4 UX13vat OC'CGROUP APN
My Worker' q 'wtI antt ce ironA Policy.nu r
Eerier: 'TP XEMMI iN itO P'! - yr GAS-CA.SYSTEM-OV d
C RTIFlC OMPE SATIONII N PRAM ORXERS'
COMPENSATION INSURANCE ORIiASPI1N1lLIST RL WASTE INT; ft ,
BUILDING DIVISION FEES s
(This section needmir N completed if the permit is fame hundred dollnm(9100) GREASETRAP
a Ies+J H.ANGIIEGK FEC
I candy that in the perforans of he work for which this permh Ls issued,Ishdl SP.WER-SANITARY-STORM EA.210 FT.
nm employ any peram in any manna Imemb' O I Wnrkm'Cmnprn- ENERGY FEE
Iz satin.law}u Tomlin.D)I + WAI ER 111iATCR WNENTICLECTR jo
7� Applicant-1 A1'f^"_EpeA- ��+e ,/� GRADING FEE
q p%1 N07 ICE TO APPLICANT.If._o�.king this Canifcmc of Esunpib 1,You should I WATER SYSTEM?REATINO so
CGI becmme sobject o the W..ker'a Cmu,m nliaa ro,likinims of the Labor Code,you matt SOILS FEE
forthwith en n ply with such provisions or this permit shell be okemcd revoked. WA'T'ER SERVICE
_d
CONSI G(1NLENDINGAGENCY NEW NECIUIiN 115E PLM.. SUIT, PAID
VZ Ihaehy affirm that them is
a construction lending agency for he perfonnemx of Data ReceipN
ltr•'ll the work far which[his permit is iaued(Sec.)(191,Civ.CA
Lendme er's NaTOTAL:
WLemler+AJdress TOTAL:
I certify that I have read this application and state that the shove infmmolinn Ls BUILDING FEF.
14 .mea.l agree te comply with all city and caumy mJinoncee enA stem lawn mlelin6 to QTY MECHAMCALPERIli - FEE
V 17Z building constmetion.aM hereby enthoNu representatives of this city to enter trivia the SEISMIC FEE
aMrve-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)aline to save,indemnify and keep hnrmlee,the City of Cupeninm against ELECTRIC ITE
liabilities,judgments,costs end expenses which may inany way accrue against mid City ALTERORADDTOMECIL
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT(TO 10.00 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR DANDLING UNIT(OVER 10.0001 CFM) CONSTRUCfIONTAX
Signature of AMlicansCorihacmr Data EXI I RUST DOUG I WIDUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will rheapplicant or furore buildingoccupnt care or handle h...Mo.,material HEAT INC.GNP'T(To I IXI.DO FIT'U)
as defined by the C'upe into Municipal Cale,Oxide,9.12,and the Health told Safety
Code,Soudan 255]21.)! 1 I1CAI ING UNIT(OVER 1110,000 B I'U)
❑Yen ON. VCN TILAI'ION FAN I SINGLE EMIG) PAID
Dam Reoei,,N
Will the applicant or lumm building oecupml use equipmcnl err devises which
it haeerdans cif r mordir is es daftned by the Bay Art.Air Quality Mammose m HOILER-COMP(31 IF OR 10171.000 BTU) TOTAL: 'y 0
,oriel?
0 Y 0 N BOILER-COMP(OVER 100.000B'TU)
I how resodthe hnnrdo.,materiels aumenenn nide,Chapter 6950(lox C.H.- AIR CONGO IONER ISSUANCE.DAIS �
fomia Heald,R Safety Ode.Sections 25515,25533 and 25534.1 undamtmd Ilmt if the NEW RESIDENTIAL MECTI. SQ.IT.
lailding dies no,currently have a lemon,that it is Illy responsibility In nosily he m'l'op:on
a IIIC IrelM.lt IIIe11111 IlY reel prhtt In issuance nfa l.enlBenleaf 0, M
¢ � 3-7J— '
(Ixarm emMniierl ngcm Una TOTAL: ISSUED BY:
OFFICE