S 2631 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO r.: BUILDING-ELECTRICAL - P1iRn91'I'NO.
BUII.IIING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL C
BUILDING PROJECT IDENTIFICATION 2631
BUILDING ADDRESS. SANI'T'ARY NO, APIEACAI'V N SCENE MAL ONE if
10370 M imoaAk \11I,l RCI Coaper-hs no, q,50t 4i} P
O N:R'S NAME 1'IIUNIi: CONI'RACTOE'SNAME: LIC NO:
1m�J SIC CONTROL p
ARC(OHCHENGINEER: LIC No AODRHSA, ❑
CONTACT: PuoNE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG BE ECT PLUMB ME U
&, ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
DMZ with Section 7")of Division 3ofthe Businessand Professiun.s Col,andmy license is R S;IDF.NTIAL
1100 PERMIT ISSUANCE 5Q0 ES
F-_ in full folie and effect. ❑SFDWI. ❑KITCHEN REMODEL
QUV License Class Lim.p ppPL(ANC15—RES(DENTIAI. ❑ADDITION ❑I'LUhINING RI:PIPIi
hZW Dam Contractor
ARCHITECTS DECLARATION ❑MULTl-UNIT [I Sl
F.,O la PANE(ti
z p y z 1 understand my plans shall be used ms public recomin MODIFICATION
OZ-0 UPTO200AMPS [I INTERIOR ❑CHIMNEY REPAIR
W LicensW Professional 201-100AMPS IMPROVEMENT E]SWIMMING POLIS
�'1�
OWNER-BUILDER DECLARATION OVER 1000AMPS 19H1CTH RI'..MODEIJR13PA1R ❑DEMOLITION
a 1 hereby M.that 1 mm exempt fru.the Conuanor's Liermc Low,for the
KO 6 U following mrum.(Suction]031.5,Business and Professions CNC:Any City or county SIGNS ELECTRICAL ❑O'I'l1ER
v~i which requires a permit to con.amet,alter,immrove,demolish,or repair any structure
E LL•Oq prm,to its issuance,also requireslhc applicant forsnch .,am file a sigvul vale:neat SPECIAL CIRCULDMISC.
fey- mal he is licensed pursuant In the pmviS1eal%afore Gmmacmrs License law(Chapter v
%Ey (commencing with Swtion]fkTO)uf Division Sof the Ravines.and professions CNc)nr TIiMi'.METER OR POLE(NST COMMERCIAL:
d y2
W Ihut he is exempt therefrom and the bol for the alleged exemption.Any violnuo of ❑NEW BLDGIADDI'I'[ON ❑DEMOLITION
,_W Section 7031.5 by any applicant for a permit subjects mu applicant Ina civil lxnalty of POWER DEVICES W y not more mon ive hundred dollars l$SWI. TENANT [I FOOD$IiRVICIi
^Z Y IMPROVEMENT'
fSp [3 1.as owner of the property,or my employees with wages as their sole cnmprreal inn, SWIMMINGPOOLELECI'RIC ❑OTIIER
will dm tm
he work,and dan stmurc is not intended ser offered for sale(Sea 9194,Birsiness
W 3 m and P..ivoiuns CNC:The Comomon's License Law Jae,aur apply ,,an owner of OUTLETS—SWITCHES—VENTURES
p' properly who builds or improves thereon,Iced who docs such work himself or through
his own employees,provided that such imprnvnnents arc not intruded or offered Int NEW RESIDENTIAL ELECTR SQ FII
sale.lf.however.Ihe building nrimpnrvenunt issnlA within one year of complminn,Ila SQ.IT FLOOR AREA $I$Q,FI'.
owner-builder will have the burden of proving Ihm ordid not hulld or improve for pur-
pose of sale.).
&&��r1,as owner of the property,tun exclusively cn.ructing with Roamed nmaaamrs oa TAI"
_n,lb l the pro e,i(Sea 7044.E3uviness and prol'Csslonv CNcO'The Cmnnnemr's J.
cents,Law loco nm apply to an oviner ofpmtuny who lands or l tial fac.aand QTY. PLUMBING PERMIT FEE
who corrects formmh pmjww with a comrucuu(s)lioxnsed Pnrwrol IIIc Conwnor'a
Lleco,Law. PERMIT ISSUANCE Q'
❑I tun csenqu oder Scc. ,It&P C fCl'thls I'wsun
Own - W LN/ D:IIC� _Zy� A1:1'1114—DRAIN&VENT—WAIER(EA) VALOAt1ON
WORKIiH'. MPIiNSA'IION OECLAItA'ION HACK FLOW PROIACI'.DEVICE O O A
1 hereby nlir ander penalty of Ew jury nuc of me following Ise"t k 1
❑I have and will maroon.a CCnifcuro of Consent lnwlfimare for WodCr'y Cnlupcn- DRAINS—FLOOR,ROOF,AREA.CONO S'IORII[ 'I'YPH CONST 14LJC'I ION
cation,as pooled for by Sect! 3700 of de Labor Coda fol dm puffnrnuoeu of fa
work for whall fare purtllh is isaed. PI%'ILRLS—PER l'IiAP
❑ 1 and wi nl main Wader's Com operand I hounua:e av In aired h Seetion (�
have u se P Y
3Il10 of the Labor Count,tombs pertomanm nl'itsworA for which this permLis i.cvucA, OAS—P.A,SYSTEhI-I INC.401TCLE'I'S OCC GROUP
m 0
My Worker's Coensation Insomnia,cr Tier trod Polity another rare: /J
Carrier: poli, No.: GAS—EA.SYSTEM-OVER 4(EA) + -�
CERTIrICAI R OIr IiXEVIPI'ION FROM WORKERS' l If
COMPENSATION INSURANCE GREASE/INDUSTRI.WASTE.INTERCEPTOR
HIIILDING DIVISION FRIES _
(This section need oat he Compldcd it permit is lonnm hundred Jnllun($IfNll CRI:ASE'fNAP
or IussJ PLANCHECK PEE
Icedify(hal in the perfonnanceofthe work fmwhich thispennit is ismed.I shall SEWER—SANITARY—STORM EA.2W FT.
not employ any pcoma in any manner so an nn become subject to the Workers'Contpen. ENERGY fBE
0 z cation Laws of California Date WATER HEATER WNENT/F.LEC R
z 2 Applicant GRADING FEE
,r) NOTICE.TO APPLICANT.If,after mAing this Ccnifcme of Examptian,you should WATER SYSTEM/('REATING /
a > h OFM suhjem to the Workers Compensation provisions of the Latan CNe,you must SOILS FEE
Forthwith comply with such provisions or this petit%hallIs,deemed mvOked. WATER SERVICE
aQ
CONS'er,is. orw LENDING NEW RESIDENTIAL PLMIi. SQ.FT. PAID
� z U e IttteiplM
Us 0 I herebydinn lhenhere iva ed Ner.i30 lemCis.agenc,finmClcrOsmunee Cf
Us .. 'heLe work Na which this permit is issued(Sec,fly)],Civ.C.1
E" Lender's Name TOTAL:
V LemeAAdders TOL l<O
>^ y 1 Certify that I have read this application and state that the above infonaration is - ` 1—1-M..D 1 HE
� tq correct.l agrcem comply with all city and comayoninances and store laws odual-g e' Q'fY. MECHANICAL PERMIT FEF.
U z building constraction.and hereby umhorim tvpresentrives of this City m enter upon the SEES .FRE
above-mentioned progeny for inspection purposes. PERMIT ISSUANCE
(We)ismemsa.indemnify a ad keep hamdess the CiDof Cupcnino.,mind ELIi RIC IT.E.
liabilitiesjudgmams,costs and expenses which may in anyway accme against mid City ALTER OR AGUE'0 MECFE.
in asequence of the granting of this permit. PLU ICING FEE
APPLICAIT UNDERSTANDS AND WILL COMPLY W11[I At.].NON-POINT AIR HANDLING UNIT('010,0000 CFM)
SOURC EGULATIO 5. NIECE A (CAL FEE
.i1 �� ILWDI x NIT(OV. 10.(X10CFT CONSTRUCTION'TAX
Slgnalo'mof ApplicaaVCI r BIW Doc AUS i0[) /DUCIJ
HOUSING MITIGATION PER
HAL a OUS MATERIALS DISCLOSURIi
Will lheapplicar venture buildingaccrmat bore...handle bvnnlnm lnumriul II AT IT NI,db)BTU)
as defined by the Cupcninn MuniCl ul Cnde,Charm,9.12,and our EleW nnJ Suthty Ann
Code.Section 25532fo)'I HIIA'I 'I' V- I TU
❑Yes No VHNTILATION IsAN(SINGLE'RES1 PAID
1 Date RCceipt9
Will the applicant or future building occupant use eqi ipinCnl or devices which �n nu_COMP fiIIP OR IML0010 BTU)
emit hazardous air coal floor,as ddlned by the(tory Arca Air Quality Mllnuymum 2 'TAI
Disuicf.'ElY N BOILER—COMP(OVER 100,000 BTU)
Alit CONDITIONER
I have rcuJ pre Irvnnlnns nlnmdals reyllimulwns undtt Chupmr 6.950 Chu Coll- ISSUANCIi�DAy TE
Inmin fluJlh&Safety Gxlc,Scclions25505,25533 and 25534.Illndcnand lba it l hC NEW RESIDEN'I'IAI.MF.CIL SQ,RT. 3 — Z �F 9
budding Ja snot Cuneady havr a mnar,mw It is
my asp.....olhy 0 nobly the ocatp.'un
the mrseloolluclll c"all p11ash"s\II:iI1CC otacrilllfil Ir11L'C o lulary.
3- - �
O n mnhmocd ngcm Uwe TOI'Als ISSUIN)BY:
OFFICE /