S 2912 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO ROILLHNG-ELEC-1 RICA I, FERMI I NO,
RUu,DING Dn'ISR)N APPLIC.1'I'ION/PF,RM17• PLUMRING-MECUANICAL S 2912
BUILDING PROJECT IIIENI'IFICAPON
111 IJNNGADIJRH S SANITARY NO. APPLICAI ION SUBMI'1'1'AL DATE
10S QZ110� 3 -4
ER'S N'Ahlli: t H'll(INE: C( T A 1(S NAMIi LIC N
NIC CONTROL N
ARCHITECTaHNGINHER: 11T111 I LIC NO, `J )I SS: 1 11 ❑
CON'I'AC'I: PHONE: BUILDING PERMIT INFO
❑'
Consultant Fees Paid by Applicant(initial) I11.DG EIr.E—ICI PLUMB ME'H
❑ LTJ' 1LJ L�1
LICENSED CONTRACTOR DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hemny affirm that I am licensed under pmviaons of Chapter 9lcomntencing
GCZ a ful5 tinconand llnf Division3ofthcemincss and Yrnfil imu Code.and my lice.,is RESIDENTIAL
Ill Q Q PERM11'ISSUANCE
CSF _� � ❑SIT)WI, Ll KITCHEN RLh10DEl.
aUU hiccnc O�-a Licp API'hIANCIiS-Rf;SInEN'I'IAh ❑ADDHION El PLUMBING all PIPE
F-Zw Uutc Colnrueln
ad ARCHITECT'S DCC. HlN ❑M1fUEI'1-UNIT ❑MOD[FI'URAI.
ZOr=nZ I understand my plans shall hcoard,pu 'c reco'ds 1'ANEIS M1fOU11yCAT10N
O Z N- UP'1'O 200 AMPS
❑INTERIOR CHIMNIEY REPAIR
F'Tt:W Licensed Pods,bnel 201-1000AMPS IMPROVEMENT ❑SW'INIh11NG Ill
2rjLj OWNER BUILDER DECLARATION OVER IIXNIAMPg ❑BAT It RIEMODCIJRHPAW [I DEMOLITION
L C W 6 I hcrcny ulilr'that I un'es n"a Irma arc Cnmracu...License L.W Un the t
�xd O C U fallowing mason.ISmloo 9113 L5.Barites.mal i'mfe,ions Core:Any city or county SIGNS r:I.EC'I'RICAL [DO)'III?k
W 3 LL y which rcgtiim a pennll In amstree,alter,improve,deamlish.or repair any amcntre /
F'�Qg prionoitsi....ace,adomyuircs the applicant larsuch permit o life a sigiod,menerm / SPECIAL.CIRCUI"UMISC.
fly.} that he is licensed punnam ar the provisions of the Contractor's Liansc lrw'fCaraPm9
h1x00 lcammencing with Sectinn)IXq)nf Division lnf the Business and lhufessiam CWe)or TEM P.h1EfER(IR POLE INST COMMERCIAL:
a C c C that he is exempt therefrom and the M1sis for the alleged exemption.Any violmim'of ❑Nli\S'RLUG/ADDITION C]IIIEMOLI1lON
if^'LL
Section 70315 byanyapplicant fill.pemnit sabjcc's lhcapplicam or a civil paulty of
POWER DEVICES ❑TENANT ❑FOOD SERVICE
not nmrethun livuhttalmd h ilars($500).
CSO1.u,c owner of the n Iu h wn•esus their so le cpm Ilan. SWIMM INC 11001.131,ECI8IC Of HER 2 ❑ these y.mtnY crop y¢awit y ,conn ❑O'I'HEk
P.. will do the wun,and me he Co cis tors ticadedLacer- ..doesed ,of sale apply to Nn orwal Business
63 co and Professions Gde The ConmenKu Livenw Law Jess not apply m an ownergh OUTLEI:S-SWITCHES-FIX'fUHES
property who melds or vides! ithereon,and warp Joel such wnrk deed or or through 1
hiz own ten lowcs,pmviJM that wen in'smvements art not amended or offered for NEW RI!SIIIIMIAL ELECT SQ FT.
P SO Ff.FLOOR AREA WSp,IT
rule If,bowmer,the melding or impmsennat is sdd within one year of meion,the
"Wennpmer wu1 b'.a me name'rr prevn'g maarc d1d nm nrEe m approve Hbr nar-
f.ale.l' �. ��
❑ 1, lir he prupmr.n xehtnivdy a iatmaing WRh licensed epalrad....w TOTAL:
mxrucl the sroject ISe,7(44.Business and I'mfnssions Cw1e:)T1 c Contractor's Li-
crane Lawdresnot apply toanowner of property who builds or improves lneremn.and QTY. PLUMBING PERMIT FEE
who cmttnet,for wen proi n ermrecmtls)licensed pursuant m thc Comractue%
License La, PERMIT ISSUANCE STY
(D T am exempt under see, .B&P C fill'his..'a I
ALTER-DRAIN&VENT'-WATER(IEA) VALUATION
Owner U:ne
WOR KI7R'S COM PI 7N Sn'I'I ON DIECLARAI ION (SACK FLOW PROI I?CT.DEVICE
1 hereby at lira'tinder penally of perjury,line of the follow as Jealarvtirnc.
I❑ Ihave and will maintain o Cenif'eam of Coment,self-insure do Workers Compn- DRAINS-FLOOR,ROOF.AREA.COND. STORIES 'TYPE CONST R(1CHU
.ation.as provided for by Section 3700 of the Labor Code,for the fa:Ifpnnence of the
l wodforwhich thislemat isiswcd. FIXTURES-PER TRAP
have and will maintain Wake,CI tiscawaon Insurance,an repaired by Section 'l
hof the Luber Cala for the formtiace of the work for which lhi. 'is issued GAS-EA.SYSIEM-IINC.4OITII.THS OCC.GROUT' AH'N
ser permi I
MY Wr. Hurn II Policy
I'nEcy (_
My W, YLU�-1 A I'z I N, ���t L u�� CAS-lin.SYS'I'EM-OVER V ll?AI
CIERTHgCArB OF EXEMPT ION FROM WORKERS' GRE,ASF/INDUSTRL WAS'T'E IN]'IiRCEFfOR I
COMP ENSA'1'ION INSURANCE BUILDING DIVISION FENS
(ThisseetiouneednotM cnmplcraJ ifine fensit is fnrone huWreddilllars 1411X)) GREASHIRAP
lir lee..) I`LANCIIECK FEE
I certify than in the performance of the work for which this permit i.issued.I shall MIWIER-SANITARY-S1 ORM IEA.200 IT
mnploy any Penson in any'runner so as In heroine unnjc,l Io the Workers'Crnnpen, IENIERCY IYP,
O Z vans..Luw,ofCuli Rrmia.IAtc WAHIR HEAfl!R W/VENT/EL
PET is GRADING FEE
O Applicunt
'z�' = NOHCIE"Hl APPLICANT il:alter snaking thio Ccrtilicam of lExetnptou,nii.hould WAIERSYSIT: O`RIEA'FING SOILS I'IEIi
f•' hecnme sublet the WorAer.Compensminn provkin-ofthe l.uWr Code,Y.a must I
a fonhxid, ,imply with such Provisions stints perma,tralt M JecmW mvolso& WATER SERVICE
a �
CONSTRUCTION LIENDINGAGENCY NEW RESIDENTIAL PLMH, SQ,ET. IO\ID
Z I hereby utlinnthal there is a cnmull; olending agency forth¢PeTarmanaeof Data eeipla
w me work fir wbivir(I parnm t.i,urd ¢.3097,Civ.CJ
ro'h'nl:
Landers Name .QO '
U Lender's Address TOTAL: U
�•" 0. Landers
ccaiiy that I[lave read this application and state that the above information is IIUIhUING FEE
Fd
' In correct.I agree to comply with all city and county"rdinances and state laws miming to QTYMF.CI{ANICAI.PERMIT FEE SEISMIC RSG
V Z building convmetion.and hereby umnorim representatives of this city to enter upon the
aNve-memiona l property for inspection proposes. PERM11]'1ISSUANCE ,� ELECI RIC FEE D
(we)agree It,que,indmnnily and Ares harmless the Chyle!Cupenino.gafot
Iiubiline jul....ents..... Acxpcmu whfnh cony in ury Pity ucarvcreminol said Cay AUIIN OR ADD 10 MECII. PLUMBING rEE O
in mnµtcnce of de,grunting rel'This in,ouil 1 t
APPLI AN"f UNDERSTANDS AND WILL COMPLY WHIZ ALL NON-POINT ATR HANDLING UNIT HTO 10.01)(HAW) MECI IANHCAL FEET O
YOUR .I 11LA1'IONS. - I I
ss
110 AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCf10NTAX
igntare AApphema/Commelor Da¢ EXHAUST I1(10DfW/DUCT) HOUSINGMITIGATION FII!
IAZARDOUS NIAITiRHAIS DISCI.OSURIE
Will the uppIs; lir more mild....owu pmt Rhin or handle bumnlon,reluriul HEATI NG U N IT(TO I IXI,IXHI 11'I'UI
us derated by the Cupertino Municipal Cask,Chapter 9.12,and the[Icahn and Safety
CWc Scotian 25532(a)I // HEATING ON['I'(OVER I sfhX)It 1'U)
0Ies do VF,NTIL l]ON PAN(SINGLE RESI U) PAID
Date Receipt a
Nall the applicant m future building ed by the B use cyui it Qu or devices which / BOILIER-COMP(JHP OR IIXLIMN)111 U) �a.ao
toil bamrduue air applicant
r future
aching by Iuc Bay Arca Air cis or devices
chem TOTAL:
Dlsmcfl BOILER-COMP(OVER Iy)Jm I[I I U)
❑Yd /
I have mod the haamdous materials requirement.under Chapter 6.95 of Ibc Cali- AB CONDI I'IONIik ISSUANCE DATE /
farm.Health&Safety Cale.Sectio,255115,25533 and 25534.I undeomnd that If the NEW RESIDIENTIAL MECII. SQ.Ef. Q
buildingdms ten cuncntlY m bthat it is'r)'resrymziniliry emptily the rccupam /_ �- 3 (/
of me rcyuiremcnls which must arc mA�imyris.uanm ofa Ccnifcnm oftk<upa"cy. (C� J
(lwncnrz uwhnrimd ugcm 11 Date TOTAL 7,�o ISSUIED BY:
OFFICE