S 1355 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-BLEC'I RICA], Pii rr No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-NIRCIL$NICA I1355
BUILDING PROJEC'P H)EN'i'IB'ICA'1'ION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
,iiia
OWN' 'NAME: Pf]ONE: CONI"RACfORSN kl� �I�G ��
�", NIC
CON HOLM
/W wvlor O
ESS
• ARCfIR1[CI'/IiNGINIJ3R: LIC NO: A1RU.�5^ ElCONTACT: PHONE: �/ BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) ELECT' PLUMB MECII
Ii1.Ur
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONQTY ELFC'IRIC PERMIT FEE
I hereby alfimn that I nm h,cnecd Under pmlkn iwIt Chapter v(soul ncneillls ]ON DRSCRI I'TION
AelZ with Section 9BlNp of Dlvi,iou 3 of the Rollie",,Id l'mlax,ion,Unto,andmy lirenm leRESIDENL:
O-TiTIA
W FERMI I'ISSUANCH
1-w= In full force and ctico. ❑SITDWI, ❑KI'I'CHEN REMODEL.
mul—
aZu License Clue Lic.M APPLIANCES-RESIDIH I'IAl. ❑ADDITION ❑PLUMBING RE-PIPE
F Z W Dam Commemr
X61 ARCHITECTS DECLARATION ❑MULT[-UNIT ❑STRUCTURAL
F D w PANELS MODIFICATION
zo.z
I undcolandmy pss
lunhall be used as public rccoNn
OZ. UP'T02W AMPS
❑INTERIOR KCHIMNEY REPAIR
F t?F"I�il Licensed l'nnessional 2111-IUNIAMPS IMPROVEMENT C]SWIMMING POOLS
C Y Q OWN am GUILDER from ECL RON
ATIr's License Law Ing the OVER I"AMPS ❑BATH REMODlillREPAIR C3 DEMOLITION
1 hereby argon
x 0 following maven.(Section]831.5.Husineva and Pmfe stuns Code:Any city or county SIGNS EL[CfRICAL ❑OTHER
W a y which requires a permit uru
m constct,after,imro
pve.demolish,or repair any structure
I"!i: prior i its ismance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/M ISC.
mal he is licemwd porwantin the provisions of the Contractor's license Law(Chapter 9 COMMERCIAL:
ad1'p0 (commencing with Section 7000)of Dnismn 3 of the Bufineo Code)and Professions Ce)or 'I EMPPOL
.M ETH OR E T.
INS
11 C that he i,exempt therefrom and the hack for the alleged exemption.Any violation of ❑NEW BLDG/ADOPTION ❑OEMOLITION
X,TS i Section 7031.5 by unyapplicant lit a permit Subjects the applicannoa civil penalty of POWER DEVICES ❑'TENANT FOODSERVICE
n n marc than fine hunalred dollars($518). IMPROVIiMY.N'I'
Lae owner al the n Ih wu genua
C pompe y.or my mnpaycedo, gc,ol.1c(Scle cum tion. SWIMMING POOLS?LECPRIC
S' will dnlhawork,Im(gch o,Coreat-,Luccodornlf,redl11,11 n1plc.9R4n.l,'at III ❑OTHER
�F�
L3 W 1 1 ( I ' IT C t I L I 1 t poly t mr of OUTLETS-SWITCHES I IX TURES
pop ty 1 alp,ole,t U Isho J k hunw,11 Ihotgh
L" Ely firal p I I ' p t:'rI t IJ liredhr NEW RESIUEN'PIAI.LLI C!'R
1SQ IT.
pule II h i,vq lhu hu ld 6 P I IJ tl' Y I"" pl ion the SQybT. )JRHA
crvbmldcr will have the burden()I pan ng Thal hedid of bu Id or' ,,prove lar par Q/ �q
pww of ole.). EEZEEIL:
❑L as owner of lie pruPcny,am excm.avcly contracting uim liccesed comma,,,In nn 11 ANS°d
msmua the project(Sac.90.14,Business and Professions Come:)'I no Cnntmmor's hi- „n
ecnm Law does Int apply to an owner of progeny woo nails or improves thereon.and QTY. MBI m ERMIT FEE
who canmmm for oah poSeess with a cca ractor(s)licensed pu,uamno the Contractor'. V V F CT\I IIYU
License law. !BACK
RMIT ISSUANCE - ``"Y Ur
1 am exempt under Sec. .B&P C for this reawn
LTER-DRAIN& APER( 1 VALUATION
. Owner Dass
WORKER'S COMPENSATION DECLARATION FhOW PROI'[CT.IJ / 76
1 hereby affirm under pcnelty oe pc Jury Inc of the fallowing d arket'ionshavezindpeoidl marry eCion 37 a or Consent to LaborCade.for thrt Worker's ec Itth- RAINS-FLOOR,ROOF,AHIiA. O S'1'ORBLS TYPE CONSTRUCTION
imlon,nv which
this
for by Section 39fN1 of me Labor Cale,for the perlinn)ance n(IM
work lie x'hkh Int,pcnnn is tamed. FIXTURES-PER TRAP
I hove 1md will maintain Workers ComPeoation Insurance,a,required by Section
37IX1n1'the Lull Cade•ror the perRmmanee of the work for which lite is is J. GAS-EA.SYSTPill-I INC.J OU'I LIT FS (ICC GROUP MIN
MyW,,rr ,tit ,Ito lh,ytqueCean Grany No: GAS Con 1d/'y7)��dl��q�
ome 1't/�-//- s i undNi.: GAS-EA SYS'18M"OVER 4(EA)
CI?k1'11*ICAI'EOI:CXIiMIII ION FROM WORKB114' GRBASUINDUS'PRLWAS'I'I!IN'I'ERCI?I"IDR
COMPENSATION INSURANC17 BUILDING DIVISION bE.E
Oftiexvll,,nac,daul bem.nplcted iOhc pernnit is forma,hundred du11a,(S bill GREASE TRAP - —
PIANCIIIiCKIq?li
or
cvsJ
Loy any thatiothe anytrimerwitolicome Iumechls fthe Wisessuul.Ishn- SI3WER-SAN ITARY-S'IORM IiA.2IXt Pf.
nm employ any M1 un in any manners,,us m become suhjea m dm Wnrker2 Cnmpem ENERGY PEC
,Z union Laws of Calif er ia.Data WATER HEATHER W/VENT/E[.]TmR
ZO Applicant GRADING neat
H NOI ICI?'I O APPLICANT:If,after making this Cenifieme of T:umpunn,you should WATER SYSTEWIREATING
? become object to the Worker's Compensation pmvisions of the Lathan Code.you must SOILS FEE
funhwith comply with Inch ptuvisionsanhis permit shall he deemed mvokes1 WATER SERVICE
CONSTRUC110N LENDING AGENCY NEW RESIDENTIAL I'LMH. \Q.IT. PAID Dae eeeipl
Q Ihc,I,y.,.and there is a lnnsauction lending agency for the performance of
U
UH me and,(br which this permit is issued(Sec.3841 Civ.C.)
lender's Name )TAL:
U TOTAL
Lender',AJJreee :
I cantly drat I have read E.,appfcatino wd sew¢him the ab—i,lot nnmation is
BUILDING FEE
sF. y eorrcal.I agree bi comply will all city and County,,edin:weev and state aws relating to QTY MECHANICAL PERMIT FEE SEISMIC FEH
UZ building niomuctlan,and herenyawhoriae reprccatativee nnhh"city tociner upon the
nh,,vo-.nemioncJ property In,invpcloun purposes. PERMIT'ISSUANCE ELEC71 Bit:FEE.
(W<I agrtt lo.arve.Index 'fY and keep hannlexs thu City nl Cnperlinu again,(
lanJiticn,ladgnrt-uI.,cotyle Inde ccs which may in any way aecmeagain%ta6d City AL'T'ER OR AUD TO MECII. PLUMBING hili
cmnncgncoce In the granting; Ih,Permit.
......I...... 11 'DE R. r, DIVILI.COMPLY WITiI N,I,NON-I'OI N'P AIR HANDLING UNITPIO III,INNICIIM) MECHANICAL ITEE
SOURCE RL'(1 IONS. ......///
AIR HANDLING UNIT(OVER n),IRHI CFM) CONS'PRUCTION'1-AX
St 'Appli aur Co Oo C� Date EXHAUST HOOD(W/DUCT) DOUSING MITIGATION 14T,
H IH SAIATERIAHSDISCLOSURI:
WUIdit qd at fw building,ecupamsmrcnrhandlcharallousmatcHal HEATINGUNI'T(TOL00.000B'N)
as defined by the C unicipal Cwle.Chapter 9.12.and the Health and Safety
Code,Section M5. (a)4 no.
HEATING UNIT(OVER 180.000 B"N)
❑Yes ❑No VENTILATION FAN(SINGLE RESIDE PAID Dara Hcccipta
Will the applicant or future building tecupani use equipment(it devices which BOILER-COMP OR IBB.INNI B'1 UI
e
mit ha,aftil air comer inants as defined by the Bay Area Air Quality Management rOI'AI:
Dlvnic4 BOILER-COMP(OVER IIXLIXNI IITII)
Q Yee F1 No
I have rod Ilm hmnNons materials requirement,under Clause,6.95 on he Call- AIR CONDITIONER ISSGANCE 1)
I'omla Ilcalllm&Sal'my Code,sectiam,25511.5,25533 and 25534.1 nnde,wnd that i1'thc NEW RF.SIDEN'TIAL MECII, SQ.FI'.
nodding dI„ren emmmly htnea tcnam.mat it i.my u,"ar"nihly m mthly 1ha.nctq)am
India regairmmentn wmclm tmt.I ne mel pearly owama Int Ccn111-11 m(Ocenpancy.
Owner or amhnrirad agent Dale 'I OPAL: ISSUED BY:
OFFICE