S 1588 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY(IH'CUP13R9'INO BUILDING-ELECT'RICAI, 1'IiR 1I No,
ISUII,DINC DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL l`�
1588
BUILDING PROJECT IDPIN'FIMCSTION
BUILDING ADDRESS'. SANITARY NO71'1'1.1(�Afl()NSLJIiM][[Al,[)Ait4
to Novf-rA ER �R- _Urgs
TOWN' SNAMe: A� Yob 25B 1: CONTHACIOR'S NAME LIC ti M NIC CON'BOLp
'ARCHITECT'/IiNGINEEiH: I.IC No, ADDRESS: ❑
CONTACT: A ,/ �/ PHONE.q 13U ILDING PERMIT IN170
4� NGU 45IJ( p3$� Consulfanl Pecs Paid by Applicant(Initial) 1 DC ELECT 1'LUmMIf� MIiCI
uC1iNMiU CON'1'RACfORS DEiCLnitnl'ION QTY ELECTRIC PERMIT PEE
1 hereby affimt that I ma Bcen,ed under providers of chapter 9(commencing JOB DESCRII"PION
WCZ wind SvvIfm70Xq.f Division 3ufthcBusincuanA l'rn&sninnn GNe.and myliccnx is RESIDENTIAL:
W O PERMIT ISSUANCE
lm2 in full force and effect. ❑SEDWI, ❑KI'I CHEN REMODEL
¢UU T.i¢nee Clans hic.N API'LIANCIS—RESIDEM1T,AL )DII'ION ❑PLUMNING HE['[for-.
F Z m Dote Commcnn
tete. MULTI-UNIT ❑S'I'RUCfURAI.
ARCIII'I'T:CTS DECLANA'I'ION
Fpm UP TOS MODHCHIMN CATION
Z O N? 1 understand my plana mall be used as public records
UPT02UTAM11Y5 ❑INTERION ❑CfIIMN1iY REPAIR
2rnFa LPeeosed Pnreceinoal 201-HPAAMES IMPROVEMENT SWIMMING IOOIS
C`1E
OWNEK-BUILDER DFCLARAI'[ON OVER 1000AMPS
❑HAI'II REMODHI/REPAIR ❑DEMOLITION
ti C W¢ I hcrchY afhrtn that I am exempt from the Co lmern's Limnec Law for the
3 a F following reason.(Section 7031 5,Business and Prnfmsime Code:Any city m eounty SIGNS ELECTRICAL OTHI.k
m which requires a permit m constrict.alter,improve,demolish.or repair any amctere
F-�'06 prior to its issuance,also requires lheit"Iicam fmsuch pe Iran I,file aslgned statement SPECIAL CIRCUIT/MISC.
o'ifly— That he is licensed pursuant set the provisions of the Commocm's License Law(Chapter Y
(commencing wish SectionTX00)of Invition Sol he limine.and Profession.,Cidc)or TEM R METER OR POLE I T. COMMERCIAL:
a d c C that he isexempt Therefrom and the basis for ithe alleged exemption,Any vialalion of ❑NEW tlLDG/ADUI'I'ION ❑OGh10LITION
Xmu. Section 7031.5 by any applicant for apcmtit subjects the applicant to a civil Penally of POWER DEVICES
tr:^m T17NANT FOOD SERVICE
not marc ohne five hundred JMfun y employees
IMPROVEMENT
ESD
E]1,as owner of the property,or my employees with wages its their sold compensation, SWIMMING POOL F,
L willdome,v k,andthcslmcwreisnalinmudednrnIlcmdforsale(Sec.]I114,Businms / ❑OTf11iR
13 w and Pmlrssiom Code:
roThe Contractor's I.iecme Low does not apply to an owner of OITILETS—SWITCfIE U
property who builds or improve,.thereon,and who Joel such work himself or through
his awn employees,provided that such Improvements am non intended or oftbred for NEW RESIDENTIAL EL[C FI
1.
sale.Iow ,The buildlngortnpmvcomnl is and wiihinnnc year nfcon:pletlaa.The O SQ,Er. "EA
$I$U.PI'.
L bs
Edd '11have'h bN IPnv gthanh (hot at IJ P elrper (/1 p W
pu� t. ). V
I . flbei moY Iasi ly I' i gwth1 . 1 mintsut yp 1I�I[�
I uM1 P rui"S '044 H ' n.v dl wCol )11 C t.narx[-I-
cer", JUL a " /Yl1TD
Law Jou.nm apply monuwnvm al'no,va,y who hail:.m...aovcs mcrnm.and QTY. PLU RING PfiRMIT EEE
wool mo-ued l'orsnch prujr ca wish ncnn;n;ctnrtsl licunmd punuenl lu the Cnnwaots p �/ `'U
Llry se Lnw. PERMIT ISSUn 'P. `%�T` Irtr 1rUl'Ch{II\y;
❑ Inn rntpl amlrr sre ,HArC.Int dd..rra.ott
n1:niK—uenl .n T—wn'neR fen) vn1. UaN
tq
owner amu /'
• O<K.(S 0 ot"pe A'1'If1NoNle,Alinuo,O HACK IIOW PH(YI'fiCT.D C
1 hereby utbrm under pen. Iy of penury tete nl'the fi:llnwing duclnrmionx: $
E] Inuvs swill lnuinby ection 1cumof Cmm�nlr Cule,forcllr Wndnam Comp cm IJHAIN$—IROOH,ROOF,AREA. STORIES '1'Yp1i CONSTRIICfION
winklas ora h hi for by$,Jinn 3IlX10l the Inbar Calc,for Thr Pednnnal¢c of the
wink forwhich Ibispaten Psi11tell
Worker
IIXTURES—PER TRAY
(]1 have and will ntninbtin WnrAor's Contpcnmtinn Inwr;mco,sea required by Section
3700 of the Labor Code,I...helerti;nnunivol the work lir whiclnitin pennll to issued. GAS—I; SYS'IIiM-I INC.40UTLEPS UCC.GROUP AI'N
My Worker'i Contryn.anion In urmec carrier unit Polley number are:
Carrier: Polley No.: GAS—EA.SVS'fEM-OVER 4(EA)
CERTIFICA'T'E OE;EXEMPTION PROM WORKERS' GREASOINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCES BUILDING VIMI)N IgiGS
Gbis section need not he conpinnl if The pemtil in intone hundred dollar,($100) GREASE'IRAI'
1'LANCHECK 19ili ��
Icerifyihal in the performance ofthe work tirwhich Thispermil isiswed.l shall SEWER—SANITARY—STORM EA.200 Fr.
not employ any personan
in y mannso
er as Io hm
cae.uMm object the workers'Gtmpen-
ENERGY FEE
O cation Laws - ifs ties. ): WATER BEATER WNENVELECTR
Applicant GRADING PER
Z NOTICE TO APPLICANT t after nmking his Ce.ificu of Exemption,you should WATER SYSTEM/Ilt[ATING
F heroine[object to me wt,rk Comlenaadmt Prov ani onhe LaMtr Cale,you..'ISons res
a ..� fonhwilh comply with such nNpermiteM1 previsions nn it xM1ull be Jcemd revoked. WATER lERVICIi
kkI
Q
M.
CONSTRUCT iso I'[ON LENDING AGENCY NEW RESIDENI'IAL PLMB. SQ.FT. PAID
I hereby affirm that isaromwcfion lending agency for perfitmunce of Dom Rnciptx
it2 the work for which this portrait is issued(Sec.30997,Civ.C)
TOTAL:
QLenders Nome
U Lenders AIRRI TOTAL:
} G 1 crnify that I have mad this application and some that The ohne nomination is BUILDING PER
to correct.l agme comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE SEISMIC FEET. 14,
V Z building construction,odd hereby matiornc representatives of this city mentor up:m the ^
obese-mentioned property lir ins,action purposes. PEiRMITISSUANCE ELECTRIC ITH e
(Wq agree to save.indemnify and keep harmless The City of Culammt against
.. liabilities,judgmers.costs and expenses which may in any way accred against said City All'ER OR ADD'PO MECIL PLUMBING FEE �_
in consequence of the granting of this permit.
t.
AND WII.I.COM PLY WITT I A LL NON.POINT AIR HANULI NO UNIT(TO I BOOT CFNU MECHANICAL FEE
SOURCEREGULA'1'IONS.
AIR HANDLING UNIT(OVER 10,0110 CFM) CONST RUCf1ONTAX
Signa of Applicun/Comraclnr Duro EXHAUST'HOOD(W/UUCI) HOUSING MITIGATION IT H
HAZARDOUS MA'T'ERIALS DISCLOSURE
Will lhcapplicumorfmnrenuilJingoecupant vorior handle hoaonmis.material HEATING UNIT(TO 100,000 RTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely HEATING UNIT(OVER 100.000 BTU)
Calc,Srnlon 2553201!
[]Yes r7 No V12N'I'ILATION IAN I SINGLE RESID) PAID
Dale NecrPl M
Will the applicant or future building acopen¢m nimpacta or devices which IREIEN—COMP(3HPOR t1O,000 BTU)
mil M1:vardnuv air cortmninnms re Jellied by the Ray Area Air Uualuy Management TOI'AI.:
Loy"'
bUILIiH—GGMP(DV ER IW.IIW B'TU)
Nn have road the lmennlons mmetials m Ia under Chnteri of oho Cali- AIR CONOIIIONIR SSIJAN EDA'I'H
P'1ffi ldn" S 'I e255O5 25$N 125534 J 't l ll efthe NI.W tI SIDI:N1IAI.MLCII. SQ.PI'.- t' r Jyl at"I I I Ya' ennwhJ h 'I pt PUC It 'I ffAc 11,, y.
tr uu onria ugv. DJIc TOTAL: ISSUED Of
OFFICE