00020077APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
LICIiNSEO CONTRACTOR'S DECLARATION
1 herchy affirm thm I om licensed under provision. of Chapter 9 (commencing
AHa)o. Uivisinn 3ofthe Bell.,, and Pmfe„ions Code, and my license is
in roll 4aceanJ cRen •-7
Licennc (C'lass Lich J
i - R_t an
Dam Comm. -
CAU C)
TY OF CUPERTINO
[IKITCHI?N R17,M OCE L
nuH,DINC-MECH NICA
rLusHDNc-nlEcnn
rEunH'r N(
BUILDING DIVISION
APPLICATIONIFERMIT
Pllhn.
BUILDING PROJECT IDEN'1'I F'ICAI
��
IMPROVEMENT
C SWIMMING FOOI.S
CHATHI2EMUIR!LIRHPAIR
CDEMOI.UION
SANIITRI'NO.
GkHASE'I'RAP
API%ICAI'ION SUBMI'PI'AL DAG]
[,"If-DiNGADDROSS.
SEW'I!N-SANI'IAHY-S'IORM 1!A. 2(a IZ
�/J• II
F.NERGY\dds I I 0
puse of sole.).
C 1, as owner of the property, am eschoisely contracting with licensed contractors to
constrain the psjoe (Sec. 7044, Business and Profession, Cade:) The Cmiumetar's Li-
ens Law does OR apply nt an owner of Pntpcny who builds or improves thereon, and
who contmets for such projects with a contractor(,) licensed pursuun0o the Contractors
QTY.
TENANT
CFOOD SERVICE
IMPROVEMENT
NEW RP_SIDEN*P AL PI.MB. SQ. FT. U
TOTAL'
Ill
OWot
NER'S NA(.11i: c
wE wooJ c �1�
PHONE:
9 � �zc
QTY. MECHANICAL PERMIT
CONTRACI'OR:S NAM is �L17j-b
DU M Jo
NIC
❑
CONTROL
'IIITECI'0!NGINIiIiR: LIC NO:
ADDRESS: u - /
�S
CONTACT.
PHONE:
PLUMBING FIJI
.1
^y AIR HANDLING UNI'1 ('11) ).(X)0 CEM)
BUILDING PGRMIT INFO
RLIHII!LECf
PLUMB AI[CII
rQ�
❑ Consultant Fees Paid by Applicant (Initial)
drns
37,1 gBsZ
11 HIOUSINO Nil 'IILIA] 'ION FEE
HEATING UN1'I' G 0 1 00,IW R'TU)
CJ/
LJy LJ/
yoowin'Section
Y a'F
U U
LICIiNSEO CONTRACTOR'S DECLARATION
1 herchy affirm thm I om licensed under provision. of Chapter 9 (commencing
AHa)o. Uivisinn 3ofthe Bell.,, and Pmfe„ions Code, and my license is
in roll 4aceanJ cRen •-7
Licennc (C'lass Lich J
i - R_t an
Dam Comm. -
QTY
/
[IKITCHI?N R17,M OCE L
n 4 a
ZN Z
ARCHITECT'S DECLARATION
I undemmnd my plmw shall be med as publicmmnls
CMUI.1'1-UNIT
n F-�
5 Q
Y U
W W y
N�
y
X e c
12_N ISN,
S p
h-
IZiI"m
6 3 -
LiccnsAl'ndce,innul
UW NI!RIIeVILD;i Ii DECLARATION
CoATION
I hechy uflirni 1hm 1 nm exempt Tram alto m,,am, Coo Licensee Low co nt,
full -tin, remnn. (Section ]Ill LS, Rosins, and I'rolcxpioro Codc: Any city nr county
whish mipfile, . learn R,rondrucl,ade, imp,vor,demali,la. or ,,artany .wnnre
Pran ,, ulemaract,ka acquirest PPIi. tr It coma to file : 6 collonenent
bar he is licensed p st t in tire provision' I 'he C t tit's Licinise Law (Chaptcr9
(commercial, with Section ](XX)of"Div)nion3 of the Business and Profession, Coxle)nr
aand the basis for the din Any violation of
he is exempt lhcelim exemption.
'butr
Section 7031.5 by any aPplica, [,I,. permit subjcn, the applicant m a,nil penalty of
not marc than five hundred dollars ($500).
7 tmpenudes,
the p e stracrnnY of intended with wa6ca fertile tilei(See
❑ L thework.
osnotapply toHn. ooziness
will dothcwon, math CratisnotlaLWnseed La c does
hof
and ernfcxhisbuCt,,,, hap Cnnmanors Linens law doe, not apply . an ownergh
is o ny who wads ar impmvn thsuch i and why ares each tine dad o r or through
his own employees, provided )tat such improvements em not intended or nrnminered for
sole.,., however, the wilding a enpmvemcnt is told within one yemaf completion, the
cr-builder will have the huNcn of proving that he did not wild or Improve for pur-
MODIFICATION
C CHIMNEY R17PAIR
IMPROVEMENT
C SWIMMING FOOI.S
CHATHI2EMUIR!LIRHPAIR
CDEMOI.UION
C01HER
GkHASE'I'RAP
1Z
Orr 4Q
SEW'I!N-SANI'IAHY-S'IORM 1!A. 2(a IZ
COMMERCIAL:
F.NERGY\dds I I 0
puse of sole.).
C 1, as owner of the property, am eschoisely contracting with licensed contractors to
constrain the psjoe (Sec. 7044, Business and Profession, Cade:) The Cmiumetar's Li-
ens Law does OR apply nt an owner of Pntpcny who builds or improves thereon, and
who contmets for such projects with a contractor(,) licensed pursuun0o the Contractors
QTY.
TENANT
ELECTRIC PERMIT FEE
PERMI]ISSUANCE
APPLIANCES - RESIDENTIAL
PANICS
UP10200AMPS
201-I0a AMPS
OVI!R 10110AMPS
SIGNSELECHWCAL
SPT:CIAI. CIItCUE
'1'1!Mlt MI!1'FR OPOWER DEVICESWIMMING POOOUTLIH:S-S WI
NEW RISIDENI'[A], ELECI'R SQ t1'.
PLUMBING PERMIT
PERMIT ISSUANCE
❑ 1 am cumin under Sec. B & P C for this reason
0 ALTER -DRAIN&VENT-WATER(EAI
netDate
WOR Kin S COMPENSAI';ON DECLARATION
�\ 1 hereby affirm under Penalty of Perjum one of the following declarations:
I hove unA will nminain r Ccnificmc of Cunanun,ell-inmm for Wnrkcr', Campen-
,ation, a, nRwidcd for by Swami ala of the lahnr Cole, for the performance al he
work lin which this peanit Is eltwd.
El I UR and will nm(nfen Worker', Cbnpmnsnlion Instuance, if, required by Saban
17"d If
at ,abnrCnit frail Pcrfiinnunce ul the work lin which this permit is issued.
id WeI r' nip•tsnti In race easier and Yalicy number ore:
Currier Policy No,:
G'1'1 ]CAT :UEIrXI!MI'1'[ON FROM WORKP/g O-^
COM I'I!N SAT; N INSlj101NCQ / V
(ILis,cnian acednnlbccontplmc i h pc s it,ooh a,- doll ($11X1)
or les.)
1 employ
any that u the any rm mer of the work for which this permit is issued. ( shall
not employ any persnn in any manner so as m teams subject the N'orlen' Compcn-
Z union laws of Culihimia. Date
ZO Applicant t
.N. NOTICE TO APPLICANT: If, afar making this Ccnifcmc of Exemption, you should
become subject to the Workers Comlenva ion provisions of the Labor Cale, you must
fonhwlth comply with such movisma, or this peal( shall k deemed related.
LIJ
as CONSTRUCTION I.ENDI NG AGENCY
U (hereby off rm that hem is a crmmmelion lending agency for the performance of
U. - the work for which this permi Jfger. 3(9]. Civ. CJ
U Lender's Name 11 GG
}U Isnder', Addms,
P. I certify that 1 have read this upplicmion and stem than the above information is
FA correct. l agree it) comply with all city and county ordinances and state law, reamingm
U IZ, building constmction, and brachy anthoom mpresenmlow oflh;s city us crier upon she
ukve-numion W proiperty for iu flection purposes.
(WO agrcc hsave, Internal y trod keep ham icas the City of CuPerom aguinst
I iabidticx, judgments, costsand expenses which mry in any way accrue against Said City
In
tt
ncgnenof the granting of shin Pon"In
APPLICANI UN D IiR."' NDS II.I, CDM PLY WITH AL1. NON -1101 NT
SOURCE RT:GU
Z- od
Si• tumor Pai aC...... .teat. Dade
HAZARDOUS MAI 'UR ALS DISOLOSURE
Will taw applicant or berms huilding ncaupant store or handle barallous nmmdal
os defined by the Cupertino Manilmod Cada ChnPter 9.12, and the Health and Safety
Cala Semina 2553200
❑ YO,
Will the applicant or future wilding occupant use equipment or devices which
hamrdous air co maminatns as definal by the Hay Area Air Quality Management
C] Yes 9Nn
1 have sad the ha/ardnus material squimments uMe, Cwptcr 6 95 of the Coli -
a Hulth Or Sam, Cale, Santa, 25505. 25533 and 25534. I utdersmnd Nen if ate
linedces .,It emgalWave a mnay.Jpw it i, my Responsibility to notify the occupant
FEE
JOE DFSCKII'I ION
RESIDENTIAL
O p j,O 0
V (l'
C SFDWI,
[IKITCHI?N R17,M OCE L
C ADDITION
CPLUMBINGR&PIPE
CMUI.1'1-UNIT
❑S'IRUCTURAI.
NTERIOR
MODIFICATION
C CHIMNEY R17PAIR
IMPROVEMENT
C SWIMMING FOOI.S
CHATHI2EMUIR!LIRHPAIR
CDEMOI.UION
C01HER
GkHASE'I'RAP
Orr 4Q
SEW'I!N-SANI'IAHY-S'IORM 1!A. 2(a IZ
COMMERCIAL:
F.NERGY\dds I I 0
❑NEW HLDG/ADDI'TION
CDEMOLIION
TENANT
CFOOD SERVICE
IMPROVEMENT
NEW RP_SIDEN*P AL PI.MB. SQ. FT. U
AREA
HACK FLOW PR(UI!CT. DEVICE
O p j,O 0
V (l'
OOR,NOORARIiA.CGND.
DgUA
nSTORHIS
IYPI1!CCONSTRUC
d PIPER
GS'1'I!M-1 INC.4UUIIFTS
OCC.GROUI'
AIN
GSTEM OV 1!R' (1!AI
GREAS III SPUNIRL WAS IM'L'RCEPTOR
HUII.DING DIVISION FERS
GkHASE'I'RAP
PIANCHECK 171A! J
SEW'I!N-SANI'IAHY-S'IORM 1!A. 2(a IZ
I---`
F.NERGY\dds I I 0
WAIT IIEAItiR W/VENTAILECIR
Its`
GRADING Plili II II
,;E QQ
PAID
Uma Receipt
WATER$YSTEMTRi:xrING UI
WAILR SERVICE III
NEW RP_SIDEN*P AL PI.MB. SQ. FT. U
TOTAL'
Ill
-_'.-T(T,'AL:
BUILDING I71!li
QTY. MECHANICAL PERMIT
FEF
SEISMIC FEE,
PERMIT' ISSUANCE
ELEM RIC FEE
AIITER OR ADD' 10 MEC(;.
PLUMBING FIJI
.1
^y AIR HANDLING UNI'1 ('11) ).(X)0 CEM)
MECHANICAL PILE
AIR HANDLING IINI'I(OVER 100s) CPM)
CONST HIC'I ION'IAX
EXIIAUS'1' IIOOD (W/DIIC'rl
11 HIOUSINO Nil 'IILIA] 'ION FEE
HEATING UN1'I' G 0 1 00,IW R'TU)
WALING Got I (OVER 1W.000 B'I'U)
PAID
Use Raccipt X
VENI'II.AfION PAN (SINGLE RCSID)
BOILER - COMP (31111 OR 10B,M) BTU)
TO'OM,
,OILER -COMP (OV ER I W.000 BTU)
r
AIR CONDD'IONT:R
ISSUANCE DATE
Z -- -7— 2.,0 O Q
NEW RESIDENTIAL MECH. SQ. IT.
ISSUED RW
OFFICE