S 2764 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUT LDING-ELF,CI RICA L PER III NO.
BUILDING DIVISION APPIACATIONMERMIT PLUNiBING.!YIECUANICAI. Q C A
BUILDING PROJECPIDENTIFICCI'ION S USF
BUILDING ADDRESS: SANITARY NO. APPIA (PION SUBMI]TAI.DATE
13 � M E-1 Lo ) :v D r, cu qeyt Ko c-A
OWNIiR'S NAME: P n'(�$I - 591 CON'TRACTOR'S NAME: LIC NO. NIC CON'IROI.a
..CI I II'FC`lIENG I N ITR LIC NG'. ADDRESS ❑
CON'IAC'I'. PHONE, BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
R�,� ❑ ❑ ❑
LICENSED CONT'RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby aRirrn that 1 am licenced under previsions ill Chapter 9(commencing JOB DFSCRIPTION
W pwire Scuroa 7000)nn)M,ion 3 of rale Ba,mes.orad Pmfe„ion,Code,raw ley license k REST DEN•PIAI:
ZO 1'IiRMI'I'ISSl1ANCIi
l-,- re tell a Classnd vpiet. ❑SI'DWL ❑KI'I'CIIEN REMODEL
QUU License Class Li<'N APPLIANCES-RESIDEMIAL []ADDITION ❑PLUMBING RE-I'll E.
FZW Dam Commclnr
vIQL ❑MULTI-UNIT ❑STRUCTURAL
ARCIII'I'HCI'S UEChAIIA'IlON
p w I'ANISI ti MODIFICATION
ZO =Z 1 undersmnd my plans shall he useda public records UP TO 200 AMPS
❑INTERIOR El CHIMNEY REPAIR�4)F•uCl Licensed Professional gal-IIMMIAMPS IMPROVEMENT El SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IIMMIAMIPS ❑BATH REMODEI/REPAIR ❑DEMOLITION
0.'C Q I hereby alfi +that I aciclearedfrom the Contra cmr.License Law for the
a mm U Iblluw Ing reason.(Section 9031,5,Rashness rand Ve,f,..imis Codd Any city or county SIGNS ELECT RICA], ❑OTHER
W 3 LL h which require.a Farah In construct,abet,inlpmce,daroINh,or repair any structure I, n
F-uCae�S prior In its issuance,also4 the ppb t for suchpe 'tt file a signed I t mem SPECIAL CIRCUITIMISC. /a l/ n\ /h /AIL O
CLL45len,l I paranallI theproviNlaiN rfln Ct r' I .Laccti,,I' (Chapter 1) COMMERCIAL
W (D Icon ncmgcs'th Sennn 7WRofDmi.eh i ffic Business
and dces:oo:Cde7 or II:MI'.MISTER OR INDIA;INST.
a%o C IM1m M1e is exempt IM1crefrnln and the basis for the alleged nempuoa Any vi.i.io I of ❑NEW BLDGLIUDITION EIDE OLIIION
gcmW Swtimt 011315by unY:tPPlicum fir.pcnnu,nnleatx theapplicummndrib pen:dry of POWIiH IIEVICE9 ❑'TENANT ❑FOOD SIiRVICL'
rn more than five hundred dollar(5500). IMPROVIiM13N'I'
SO �1,as owner of the propend,or illy employees with wages as Braille compc'nsmion. SWIMMINGWHl1.ELIiLTRIC
h.. tuill Aothework,and thenlrndure is not lnended or ittered for sale(See.Ja44,Business ❑OTfiER
ad 3 m and PnJe...on,Code:The Contracndx Licence Law discs not apply to an owner of OUTLISI'S-SW I'I'(TIES-IIXT'URE-
pmpeny,who hard,,,,impress,@emm,and who does such work himself or through
lik awn entployces,pmvidrd thin such improvement,one nor iracrded rar oRcrcd for NEW RESIDENTIAL ELECTR SQFT.
sale,BE hnwevee m
rile building or ileproveen,bca
old withinaneyr at tun,lbe SQ.19'.IlOOH ARIA SISQ.PI'.
owner-builder will have the burden of proving that he did not build or implore for put
p�� u of sated. TO h:
PjjL tee owner onhe property,and cadusivcly connecting will licenced mmnuchm m
amt the project INec.)B1J,Business and Professions Code:)The Conrraaors Li
-
nseLawdoes not apply mill owner of pmpeny who builds or improes thereon.and QTY. PLUMBING PERMIT FEE
who unnradslir.ueh pmjms wlthumnbxetor(.)licensed pnnuannothe C.... sr'x
License Law. PERMIT ISSUANCE
1 atn eacmpt wale,Svc. .B&P C for this Bacon
AUTI!Il-DRAIN&V IiN'I'-WAT I!R 1I:AI VAI.UA[[ON
Owner Dae -
.
'WORK 'C(IDIPENSATIDN DECLARATION f RACK MOW I'H(THiCT.DEVICE
I hereby dfmn under plan
of""dory oils rat the...lowing deulamtunlc'.
r'lne and will mmmu,n a CC;'cme ol'Gmscuti.mcb nare Gra Worker's Compen- DRAINS-(TOUR,ROUY.AREA.CONU. SIORBiy "fYl'I!CONS'fRUCI'ION
lotion,as snouted for by Section N(yd of the Aub a Coda for the performance of the
work fir which rhix l.un is ixstmd. FIXTURES-PERT RA['
C1 I have and will ncularin W'orker's Congensatinn histionce as required by Sonoran
3100 al'the laMr Care.lot the Nierinnance of the work fur which this pennil is issued, GAS-EA.SYST EM- INC.4 OUT OCC.GROUP �-S� /1I N��
MyW..set's C'nn:pcnMtion Insurance carrier and Pu
dicy nmber arc: n/L (0
Carrier; Policy No.: GAS-EA.SYS'I EM-OVER 4(EA) t
CERTIFICATE OF EXEMPT[ON FROM WORKERS' GREASIIINDUSTRL WASTE INTERCEPTOR V
COMPENSATION INSURANCE BUILDING DIVISION FEES
(I'his.emion need not he completed it pcnnu is lir one handled dollars O l(IN) GREASE TRAP
or less.) um PLANCH[CK PEE
Icenifythard the pertnnnunce ol'thewark forwhic'h this pcnnu n i..mesL[,hall SEWER-SANITARY-S'FORM 111.NMI F`E
not employ any"on in any nnnlneno ux m b"a subject"'The Worker:Compo:, E
NERGY
Z cation[,vw,of CdiRtmia.Ilam WATER UEATER MOVENT/ELECTR
z Q Appliamn
NUI'ICI!TO APPLICANT':Il:afmr nial, g this C'cnlfc:nc:d Bxcn.prin,you nhnuIT WATER SyS,0,7REA'1'ING
.tea
E” becntne.cobjea ro the Worker's Compemution prormionc of the LMr Gdu,you mux[
Forthwith enol I with cash this permit shall he deemed revoked. WATER SERVICE
n r tui nrnrkeinn.or
p C CONS'1'HUCTION LENDING AGIiNCY NLW'RLSIUIiN'TIAL]'LMIi. SQ.PIt Rer..•iptaV 0 Ihereby affml thatthere is a construction lending agency for the performarecofUlila work for which this pcmnl t.isaucd(So'.31PO,Civ.C.I TOTA VU [enders Name,
Leader',Address IOTA]:
G1 renlfy lam 1 have wd]his appbictniI nnJ slam thal the above'n@....tion U eV) contact "'rcen"' nply with all city and county ordinances and aloe laws relating to QTY. MIiCHANICAL PERMIT' FEE
V Z building conamaiun.and herchy audit ine reara,caivesof thin city to enter upon the
uhwcnncnreated progeny Iter In.paetl^n PurpeoIN. PI?HMI'1'ISSUANCE ❑LI!CTRI
(W'c)agree to are,indemnify and keep han iless tie City of Capetian against
Iiabilitics,judgments.costs and expenses which any in any way accrue against end City ALTER OR ADD TO MIECH. PLUMBING FE
netptcnauof the g,a bngof this pcnnu.
APPLICANT UNDERSTANDS AND WILL COMPLY WI'I'[I AL1.NON-POINT' AIR HANDLING UNIT TO l0,0a)0CFNB s MIiCIIANICAI,F'i
SOURCE REGULATIONS.
( AIR HANDLING UNIT(OVER 10.000 CIM) CONSTRUCTION TAX
P,ZraSignumm of app ican Commst Uwc EXHAUST]OUD(W/DUCT) HOUSING MITIGAI)ON FTE!
IIA'l,ARDI US MATERIALS DISCLOSURE
Will the applcanl or III cbuilding nmupant clam ar handle huenrdouµn'uedal BEAT ING UNIT T(1011M),1MW It IUI
as defined by the Cupertino Municipal Code,Chapter 9.12,ani the health and Safety HGTING UNIT(OVER 11M),IKK)BTU)
Code.Scclinn 2553200!
❑Ya, 4No VEN'IILAI'ION I AN 191 NGLE RES IDI ]'AID
Date 14<cipl p
Will the applicant or(order building occupant use equipment or devices which BOILER-COMP(31111 OR 1000M)BTU)
emit hovn.loux air"allaoinenl, el rad by the Bay Arca Air Quality Munugnncnr
District" BOILER-COMP(OVER 100.000 BTIII
❑Yes F1 No
I have east the Incautious..".all tc untie,Chaser b.95 of the Cali- A I R CON DI'II(INER ISSUANCE DsrP,
buret,Health&Safety Code,Santora.255115,may ani 25511.1 understand lila it Inc NEW RFSIUI!NI']AL M1IECfi. SQ.17. a r 2
building dons nor ennamly haves mmol]hut it may ceepit a Cerity to nnti(y the ucamant
ill the reyuircmems which mu.w M1e and priormissuana ofaCcnilioulc of lhcupancy.
O m ninth+ .y n Dutc TOTAL: ISSUEII I{Y:
OFFICE