S 2215/ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEKFINO BUILDING-ELECTRICAL PER ftp No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL J 2215
BUILDING PROJECT IDEN'I'IF'ICA'1'ION
BUILDING ADDRESS: SANITARY NO. APPLICA'T'ION SUBMITTAL USE
21 Co no CA - 956 14- /2-fid
OWE :k'"NAMIJ PHO ' CON'r...TO Sj•1AME: IC NO'
1 / NUC CONI ROLA
.� ARC TF:CI'/: LIC NO: All ESS: ❑
CONTACT: PHONE: BUILDING PERMI'I'INPD
('l the t e 3��(�3 ❑ Consultant Fees Paid by Applicant(initial) BLU ELEcr PLUMB MECU
LICENSEDCONTRACIOR'S DECLARATION QTY. 13LECI'RICPERMIT El:E
1 hereby affirm Ihm 1 ant licensed under provisions of Chapter 9 b"m n e"ing JOB DESCRIPTION
Z Air Section VIXXIpdDi,oiU113ofdMBuvirre,mlPrnfes.'ons ode.arl mylirunmis RESIDENTIAL:
u c c �� PERMIT ISSUANCE
FU.. li;ll tinct nnA cOac' d. ❑SFDWL ❑KITCHEN REMODEL
aUF' T.iec Tote ac o hie.b
6 U APPLIANCES-RESIDEN'I'IAI. ❑ADD]TION ❑I'IAMRING RF-PIPE
I—Zt� nam canlmrla
r2 CIIFFECIESDECLARATION ❑MUI-TFUNIT ❑STRUCTURAL
'- v, I undmumd m h ll be used as hint records PANELS MODIFICATION
CZ-= YPn^ssO Pu UPT0200AMP5
❑INTERIOR ❑CIIIMNEV RIiI'r\IR
14F-W Liumscd P..leSoul 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
Cse OWNER-BUILDER DF.CLARAIION OVER 1000 AMPS [I BATH RIiMODEf/REPAIR [I DEMOLITION
W a 1 hereby uftirm Ihm I tun exempt from the Cnmmemrs License Law for the
O e.V I'ollowln Snnlon]0315,Bunions and Pmle,nonv Code:An T O �DTHER
g twntm e Y ci Y or Gunn Y SIGNS EhIiCI81CAl.
3LLy whirl itsisssupermit it)re mre%the aper.nt for suhpermitt ore a sig any structure
FLLq�a pout he shuctoedpartalso re It)the theapplicantConatinninuicense Law
Nhancirt SPECIAL CIRCUIT/MISC.
mons iNlim,,fi,Section anhepravisiansof orecBu,imorNLicenw Law(Chapmr9
Ia1�00 (c°nnmencing with Seedion]1XNq of Divininn3 of 0e ltn.vinms and Pndusaions Code)or TEMP.METER OR PULE:INS). COMMERCIAL,
m e. C thin re is uxennpO Inerclinm and aha basis for the alleged exe;npllnn.Any viohnion of ❑NFW BLDG/ADDITION ❑DEMOLITION
I., Ah,
Section 7031.5 by anyapplicanl I, if s.bjcaslnc npplicanl uoa evil prrudy of POWIik DIiVICEl
rZ I more loam rise hundred dollars ESSEX)). ❑TENANT ❑FOOD SERVICE
~?a [D Las owner of the property,or my employees with wages as their sale compunction, Sw'IMMING WH)1.[LECfRIC IM ROVIi\1EN'r
=tO will do Thewnrk,and tncdmctw'a is nm lnnenJedomlfend for culclSw.]fUJ,IPnxiness HER
tC mal Pndasions Code:The Comnwour'x I.ieemt Law Joe,nm apply to an owner of Ou11.17'1'S-SWI'1CI IES-NI%'I'U RES
fes property who buiWsofimprovesthereat.end who does.such work himself ar through
his own employees.provided dna,such improvement,are not intended or offered fnr NEN'RESIDENTIAL EL Ht
sale.If,however,the building or mpnwem nmis sold within one year nrcompletion.the SQ.14.FLOOR AREA $/SQ.FT
er-lboldur w ill have the student A noviagThalbedid not build orHaproveliorpur-
pnenf vale.). TO'T'AL:
1,as owner of the pmpen,am exclusively tommeding with licensed conmemors do
nconstruct the project(Sec.70sb1.Business and Professions uwc:j IFre Conlmcuds-
cease Law due tut apply n owner est of propemY who buildsor in,roves thereon.and lorry. PLUMBING PERMIT FEE
who contracts fnrsuch projects with ucunwutorO llnnscU pit nuanuuthe CnnlntClm'x
License Use PERMITISSUANCE,
1 am exempt under Sec. .B&P C for this reason
AI.TF,R-DRAIN&VENT-WAI'HR(EA) VALUATION
I leaner Date
WORKERS COMPENSA'T'ION DECLARATION BACK FLOW PRUI EGI',DEVICE
1 hereby affirm under penalty of perjury one of the following declaration.,
Ihase and will maintain a Certificate of Consent n Self-insure for Workers Compen- DRAINS-FLOOR.ROOF AREA.CON
STORIES TYPECONSTRUC710
.Nation,to,provided for by Section 3701 n1'the LutunC de.far Ina pcifotmunm of the
wrk for whlun Iu,Permit is issued, FIXTURES-Ili RAP
I nave and will maintain Workers Comi,ruseiou Insurance,as required by Section
39 fine Labso�Gecode.for p�eRaarymaneccof Ne work for which this permit is issued. GAS-EA.SY, t ZINC OUTLETS OCC.GROUP N'N
My W� �!/Ln Ta uJYT N'/Ilt 7� �dieym a!5I��'q GAS-EA.Sy"', t./OV• ' 1
Curds
EBTIPICAI'E OP Ii%IiMI'1'10' ROMWORKERS'
COMPENSATION INSURANCE GREASIYINDU " L WASTE INTGRCEPION
BUILDING DIVISION FEES
(Thisnecdion need nal he completed Bite permit is forone hundred dollar,($1000 GREASETRAP
or leas.l pp PLANCHIiCK FEE
I ecnil'y Junin the pcdomeanctnfthe work for which this pennilm moored, SEWER-SANI'1 I(lf
not employ any person many manner so as to become.subject m the Worker,'Cnmpcn- ENERGY ITE
Z section Laws of Califomla.Date WATER HEATER WNEN-UELECrk
C) O ArNicanl GRADING PEE
NOTICE 10 APPLICAN'1:If tor,making this Cer ilicare A EXe;npuon. should WA'I'17R SYSTF-MTI REATING
a > bccomt subject Tribe Worker',Cn n,,t,.Tlou provixianx of the Lubar Code,you omst SOILS PITH
EmhwiOh comply wiles tech pnrvisinns ar this pennil shall be leaned mvokcd, WATER SERVICE
a �
CONS]RUM[ON LENDING AGENCY NEW RESIDENTIAL PLMR. SQ.F1. R\IU
1)O Date NcceipTp
1 hereby al'lirm that thurc is u aonNtnnnlon lending agency for the perli,nnunecof
the work for which this permit is i....d(See RAG,Ci,CJ
0 U lender's Name 'Itil'AL:
CLI I.enderc AJdre, TOTAL
I ecuiry that I have read this application and state diel the above infonoatlon is BUIL G EE
.F.N cones.)agree to cmplywBhall city and county urdhtanees end Mate laws relating bo QTY. MECHANICAL PHRMIT FEE
V z thinking c , ed and nercby autnorir<tepresenWliveS o(Ihi.a city to enter upon the S: ' IC Eli
shave-mentionedpurpose.PmNny lin inspection purse. PERMIT ISSUANCE ^
(We)agree to cave,maturmily turd keep harmless the City or Cupertino.,am,,
1J EL IC FEE
Iiabllitie,juigtumn,cnxbandcxpnwswhicn nary In any cavy untrue vgninST.endd Ciry ALTERORADD'rOMCCH.
In ennaequena of the granting of tnia Nnnid. 1'Lll HUNG FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WE III A 1.NON-POINT AIN 1{ANULING UNIT(TO IU.000CFM) ri\
. IURCE REGUL. 'TIONS. �\ ///yyy yY CHANICAL FEE �/
v { //I�• // ///]\, AIRHANDLINC.UNIT(OVER10.007ICFMI C(l 'l'RUCTION"TAX
S:42ignature opAApplicanV�r /l/C/ f Dam E, EXHAUST HOOD fW/DUCT) HOUSI .MITIGATION FEE
HAS.ARDOUS MATERIALS DISCLOSURE:
Will the applicant or future building occupant some or handle fir-mousmmenvl HEAT TNG UNIT CEO 100.000 RTU)
as deGmvl try life Cupertino Munldpal Cndc.Cmgner,9.12,and the HeAh and S;dcly
Code.Section 25532(x):' HEA'T'ING UNIT(OVER I rX%hop BTU)
[:3 yes C]Nor VENTILATION CAN(SINGLE BESIDE PAID
e Will The a ream m home btiddin,ooca t use c tar desires wraith Date Receipt e
pp g pun Area
BOILER-COMP(3HPOR 101).(X)p BTU)
mit huraNnus mir ttntlanununts as delinN by The 11ay Area Alr Qu;JityManagement
D...fic, 'TR'I'AL:
E3 yes DiBOILIiR-COMPIOVF.R 100.000 BTU) O
I restored the hamrdouv mmrriulxre tx under Chute,E95or the Cull- AIR C(1NDITIONER ISSUAN EDATE
quiremm� p
lomia Health&Safety C«la soon,25505,25513 and 25534.1 undasmad than it an, NEW RESIDENT[A].MECIL SQ.Fr,
building ducx not currently have a ranant.Ihat it is my responsibility bO notify the occupant
of IM requiretteats which must be met prior to issuance of a Certificate of Occupancy.
Owner nr vmhorierd agent IlamA.:'1O rISSUED BY:
OFFICE