S 0317 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUIaERTINO BUILDING.ELBC'I R1C1L PERMIT NO.
BUII,UING DI VISION AIaPLic/mON/PERMIT BUILDING
PLUMBRNG OJECT 1CHAI1F[C S 0317
HULLOING PROJECT IDEA"1'It1CA'1'10E'
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE!
IOS07Z 96nnISOA.) Ale
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO'.
/1� y_ L / NIC CONI ROha
.ARCHITECT/lo GINECR: a G LIC NO. ADDRESS: O4/ J' ��� ❑
FS.6.p
PHONE: N BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(InitiaH ELEc' PLO E hIPc1
LICENSED CON'IAACFOR'S DECLARA'f ION QTY ELFCIRIC PERMIT FEE
y alar malChapter 9(eonttnendag JOB DESCRIPTION
000lof Division 3ofthe Holiness and P fesaiam Code.and my lirema,i. RESIDENTIAL;I'F.RMIT ISSl1ANCLnJvfa,mi ❑SPDWL Kf1CHEN REMODE1.
QU —�3NAPPLIANCES—RESIDENTIAL )DITION ❑P1.OMBING REdEpr,hte Cnmmaor
ARCHITFCFS DE!CI.ARA'I'[ON ❑JIJLTI-I1NiT ❑S'I'RUCFUItAh
I'AN131'S MODIIECATION
ZOHZ lundarsnnJ my plana xhallMuse]vc public rttorJc
—M UP 10 200AMPS El INTERIOR El CHIMNEY REPAIR
W Licensed PrnbeWun:J 201-10SMAMPS IMPROVI!MEN'1SWIMMING POOLS
CCG 1 hereby alBnn
OWNER
BUIbveLDER
mo the C room roe's License Law forme OVER 1(100 AMPS ❑HATH RIiAfODFIIREPAIR U6\fOLIT10N
dU Iirlluwine r r-o(Seamon 9131.5.Business z I Prufe..Par,Cndo.Any city or manly SIGNS ELECT ❑O'1J1ER
LL y which requires a permit m amnrct,alter,improve,demolish,or repair any Immo e
LLO
Qpn t Iissuance.ol. req .thapplicantf M1pmmO fl . gad statement SPECIAL. T/h .0
E IyY�
(commencing
dpum t 0 p tam I'of C tucm an onsCodrer0
WfLQ� (colo g Nth Section JgNll of Division l fm Bines ml Professions ioru Calu)nr TEAtI'.MEI'[ R INS'1'. COMMERCIAL: p (�
A.Xe K that he n exempt therefrom and the basis for me alleged exemption.Any violnaon of ❑NIiW BLDG/ADDITION 171iMypLITION
W_m Section 90.31.5 by any applicant for u permit subjects the uppllcvn,m u roll penally til' POWIER DEVICE. [I TENANT ❑FOOD SERVICE
nut more than Eve hundred dollars 185( L
F. nor I)I HER h1Et•�,I/
Q 01,vsowncrofthc propenytemycinployces with wage.ua,thcirsnlccompcnmtion, SWIMMINGFOOLEIJiCTRIC
�t=.O will do the work,and the structure is nth'mtendedoroll,Aal limsale(See 71-4,13 � ❑Olt{ER
ZLL�'3 we and Professions Code The Contractor'.License Law does not apply m an owner of OUTLETS—SWITCHES—FI TURES C/)i•
prepvny whin builds in improves thereon,and who does such work himself or through ,� E'r Uut`
his awn empinycex,provided That web improvements are urn intended or nlYcrW far NEW RESIDENTIAL I!LLC SQ Ff.
sale.IL how bob,the buildingor imprveorm is sold within one yam ofromplainn.the SQ.IT.FLOOR AREA 4/SQ.IT.
ow,ra-builder is itIhave the burden f provingtlrtM1 did no,b Id or i uproml pt-
po uct ) V67FA
�.
1 o f the progeny. exclusively contracting w ' ds tm with la
LJ
construct tn project p Loan B :' s II whoharCN imp C trot -1
1' d t apply t o1 p nn(s h build' improves and QTY. PLUMBING PERMIT FEC
who contracts for such projects with a amaacu'gM becnud pursuml In the Commnor's
License Law. PERM I'1'ISSUANCE
❑ I um eacmpt under Sec .E3&P C fortis reason
ALTIER—DRAIN&VIENT—WATER(IEA) VALUATION
Owner Date
WOR KERS COMPENSATION DIECLARAI'ION BACK FLOW PROTEGE DEVICE
1 hereby uWrm under penalty of facdrr y ane of the following d sdirra ur, `ll
❑ IM1mmmJ will mnimninu CcrmLnne nfCnnxcnlln vd4insumfur WodrY'xCumpcn- DRAINS—FLOOR.ROOF,AREA.COND. STORIES '1'YPECONSTRUC'I'ION
cation,as provided file by Section 3700 of the Labor Cale,for the performance of the .
work for which his permit is issued. FIXTURES—PER TRAP
❑ I have and will num nim Worker's CumEP..n Insurance,as required by Section
390)of the labor Coce,for perfonnarea o1 he work for x'hich this permit is issued. GAS—FA.SYS"1'EM-I INCA OUTLETS OCC. a' AP3
eskers Compensation Insurance carrier and Policy number arc:
race. Policy No.: GAS—EA.SYSTEMOVER4(EA)
CERTIFICA'I'IE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASH:INTERCEPTOR
B ILD GDI VISIO IYIiS
GHn,wGionnecdnot Ewenmplelyd if mt,riorlls tome,M1undned dullars($HXB GREASRTRAP
ur Ilio.) PLANCI -C E
cenlfy that nhe performancmdthr workfur which his permit is issued,Is hall SEWER—SANITARY—STORM EA,200 ML
noLrmu'b"a y person In any tau n. u n emmne yt icer""he
Workers'Compel ENENG
zZ caiman laws a lifomis.Date WATER HF.AI LER W'IVENTIIELECTR
Zo Applicant �'�_LdMW'2�1 GRA FEE
N NOUL
'I'O APPhI'ANT: L attar m.king this Cean"am of I se WATER SYSTEM1VIREATING SOIL.,
a ? became subject to me W'orker's.Compenmtion provisions of the e r u s, st
[anhwlth mnmply with such pmmsnnsur his permh shall he Acmncd r<voked. WATI!R SERVICE
a0
CONSTRUCTION LENDING AGENCY NEW RI3IDIEN'f1A1.PLMB. SQ,FT. PAID
z Ihemh 1[mahatthere is a mnsmefooleniin < hathc fonnuncenf D:o Hcecipta
N)n OP
V Ya 6ugcn y per
the work for which his permit Is ismed(Sec.30G.Cie.C.)
F"
Lender's Name TOTAL:
{Utl Leona'.,Address TOTAL: BUILDING iIi
y 1 canny that I have mud this application and state that the above information i.
fA ,correct.I agree to comply with all city and county orJinunecs and.nn lawssdutingto QTY. MECHANICAL PERMIT FEE
U Z bung,oarvunion.and hereny ualh...im mpres..ralve,of this uity In role,upondm SEISM IC F11i
a6me-memioned property for insisted—purposes. PERMIT ISSUANCE
(We)agree Io save,indemnify and keep harmless'he City of Cupertino against I..LECI RIC Ff:E
linhilitics.judgnnms ceras mW expenses which may in any way uwmc ngninnxtiiJ City AI,TERORADDTOMECH.
in consequence of the graining of this permit. PLO III '•FEE
APPLICANT UNDERSTANDS AND WIL 0MPLY WITH ALL NON-POINT AIR HANDLING ON[[0-0 I(I,IXNICFM) MECIIA CAI.FEE
SOURCEREG ' TIO S.
AIR HANDLING UNIT(OVER 10.000 CPM) CONSI'E 'CI'ION TAX
Siganm oNdeplicatit/Conti-PiMM ate LXHAUS"f HOOD(W/DUCT) HOUSIN ON FEE
HAZARDOUS MATERIALS DISCLOSURE
W511 the applicant nr fnure building occupant more o handle ham,Jous ar,'O al I ELATING UNIT(B)II0k1NN1 BTU)
as defined by doe Cupertino Municipal Cale.Chapter 9.12.and the Health and Safety
Cade Section 25532(a)' HEATING UNIT(OVER l0q(NNI BTU)
E]Yee, 0N
VEN"f ELATION FAN(SINGLE RP_SID) PAID
Will the applicant nr future building by the Bt y A equipment n,devices which ): Retti1 M
emit hamrdmn air ummmimnnn its defined by the Itny Arca Air Quality Mun:mgummn BOILER—COMP(LHP OR IIX).lNX11T'EU)
T(YI'A L:
Dinvcfl BOILER—COMP(OVER I00.off0 BTU)
E]Yes F1 No
1 I have read the hanNous material,requimmems under Chaprcr,6.95 idme,Cali- AIR CONDITIONER ISSUANCE DATE
forma Hathb&Safety Code.Section,25505.25533 and 25534.1 understand the if the NEW RIES IDENTI AI,MECH. SQ.PT
buildingdue mol cumch hove a,aero,Ihuto ivmyelu Ceritifcanotifythefron,arn
of the r,doe-enc ren,l must bemetpoor ta,,by,cofaCent,tooof Occupancy.
Owner or umJaPn ,d agent One 'IOIAL: ISSUED BY:
OFFICE