S 2363 APPLICANT-TO-FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIOILDING-HLEiC'I'RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MVCHANICAL
BUILDING PROJRC'F IDENT1111CA'1'ION S 2363
BUILDINGADDRESS SANIi'ARY NO. API'I.ICATIONSUBhi I'I'IAI.DA'I'E
O A -2 u __(IF ?
OWN�ry�r A ? i'HONE: CONTIi CTOR:S NAME: LIC NO:
V/ G' No] cuNrkoLx
ARCHITITMANGINHER: LIC N : ADDRESS. L ,/ ❑
ST/ Ta /vK
CONTACT: NgpO PHONE:z9J,y-)/ BUILDING PERMIT INFO -
✓ / ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
1:1El❑ rr�
LICENSED CONTRACT ORS DECLARATION QTY EI-ECTRIC PERMIT FEE
I hereby affirm that 1 oat licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
'OZ with Section 7000)of Division 3 Of the nosiness and Pn�f/ewlonqsCode.and my license is RESIDENTIAL'
F�W� is full force ante c f T6✓G� PERMIT ISSUANCE ❑SFDWL ❑K ITCH EN REMODEL
U License Class Lu.X T
at—u APPLIANCES-RESIUF.NTIAI. ❑pDDIT10N ❑PLUM B ING RE-PIPE?
F Z W Dam Contractor
FDy ARCHI'I ECTS DECLARATION PANELS ❑MULTI-UNIT E3 STRUCTURAL
ZOmZ I understand rayplats,hull he usedmpublwoNtrds MODIFICATION
UP TO 2W AMPS 024-0 ❑INTERIOR ❑SWIMMING POOL
r4.t:W Licensed Prefes.ional 281-IINNIAMI'S IMPROVEMENT 0SWIMA1ING POOLS
.J
OWNER-BUILDER DIiCLARATION OVER IODOAMPS ❑BATH REMODEL/RERAIR El DEMOLITION
[ YQ 1 hereby affirm Iho I an,d a,r,1 from the Cc ofa is Lifirme Law for the
[iiyy55 O Y V following rcmom(Socdom 7031.5,Businass taIP..essimrs Code Any City or county SIGNS HLECI'RICAL [I OTHER
I++u ONwti nno Tomouct. II pr demolish, p Y structure
0n pro t I 1 .. 1. I d pit' 1I hOrion 1 fI 'g d.f¢m �CI eat SPAl,CIRCUI'UMISC
Ed ihmh Ip " a n ❑ p Ih C b n L 1 IChupfer9 COMMERCIAL
p-1'00 (cit , d S 7OINB I yv 1i 111 li : nIP 1 C�dc)or TEMP.MEr RORPOLHINSI'.
IY q o eG Ihat he is etw nin thew On n n d the hl,,,On the Arica] xc enp(nn.Any violation of _ NP.W BLDG/ADDITION ❑DdMO1.iT10N
W rn Scetion 7031.1 by uny uppliwnt loan permit subjects the upplicaut m a,ivil penalty of POWER DE ICES NT ❑FOOD SERVICE
F'30 n1 more Ihdn frv,hundred dollars S500), PROVEMENT
C] Las owner of the pngery,or my employees with wugesasthcusale compensation, SWIMMING POOL
= will clothe wh
ars,mrd the Nmol Intended proffered for sale(Sec.70,14.Business ❑0'fHER
W � and Enifessions Code:The Couniclors License Law does not apply in an Owner of OUTLID:S-SW1'1'CHES-171MURES
property who h dhN nr improves th,rcan,and who Jae such work himself ur Cough
his own employees,pmvideal that such impmventenu ate dor intended or..Rercd for NEW RESIDENDAI,ELECIR SQ i4.
sale.IL however,the building or improvement is sold within one year of eompletion.the SQ.FT.FLOOR AREA $/SQ.Fr.
owner-builder will have the burden of proving that he did not build or improve for pur-
fawr of .sale.).
.1 u the
PrOj theproperty,vatexclusively confession,wirdThe d arwh " i- TOTAL:
cense lathepit lenpply(See 7(an Bosoms,addny w hinds Cock:)Thevesfrvcwr'sLi-
whocoawdoesnolapplymao owfact conjorhers whored pur andto the Corson,and QTY. PLUMBING PERMIT FEE
who contracts for such pmjans with a cnmrenodx)licensed pursuam m the Commnofs
License Law. MRMH ISSUANCE
[-J I am esempnmdcr Sec. ,e&P C fur this reawn
ALTER-BRAIN&VENT-WATER(EA) VALUATION
Owner Date
WOR KHR:S COMPENSATION DECLARATION BACK FLOW PRO]ECT.DEVICE ^
1 hereby affirm under penalty of perjury one of the following declarations: j O Y6/ 0
l have and will maintain a Certificate of Consent o sel6insure for Worker's Comped- DRAINS-FLOOR,BOOK AREA.CONDSTORIES TYPE CONS1RUCT10N
vision,as provided far by Section 3010 of the[..her Cale,for the performance of Ce
work for which Ibis permit is issued. FIXTURES-E'ER TRAP
rhave and will mo Twain Worker's Compensation
Insurance,as requited by Section
7l.1 of the"her Code,for the performance of the work for which this Permit issued. GAS-PA.SYSTEM-1 INC_40LIfI.Ie OCC.GROUP APN
My W, it Cecil, �smio t lnlarwe corner and Policy monotare
Curicf.l A�%^ /�— •• Policy No.:�/�prI�O. i I GAS-
EA.SYS']EM-OVER 41i
CER I'H7lCArE IIP I;X.MYI')ON FROM WORKERS'
COMPHNSAOON INSURANCE GRBASPIINDUS'1'RL WAS]171 Ii CMIMR BUILDING DIVISION IVO?A _
('I'loo,ofinn dud not be enmpkted il'1he permit in fur nae hundred dollars($10(B
nr]esu.) GREA$E'TRAPFF8 Is ECKPBE
I certify that in lhepeffurnlatcvof the walk for which this Permit is Toned,],hall SHWER-SANITARY-S'I'ORMl .Nat 171.
na,vydny myPer son In unynllmner sit ns 1n beconlcsuhlcena Jw W..UNCon,tar- ENER' FEE
Z
'inion Low,al'Cnl'ifmnia,Dan, WA'I'P.RHHATCRW/VRN'I'IOX 'PIt
y� O A Hcunl G FEE
q h NO]ICE PO N'PLICAN'T.H:after inaking this Ccrllfcate of Exemption,you should WATER SYSTEMflREM ING SOILS FEE
11
H ? huonue oibico 1n the Wnrkff,Cnlmpclvsntion pro,kiods ol'Ihe Labor Cade,you most
Wr fnllotilhionply withsuch.....visions of this wnot"hall he deemed revoked. WATER SERVICE _
Q
7Z Cadthere IILTIOstuction LENDING AGENCY NEW RESIDIiNTIAI.I'LMIl. SQ.PR PAID
L)Q Iherchy aflirnl that there is acnnsina:Iion lendin6 u„ncy far'he performance of ate keceiplp
LL. . the work lid which this permit i,issued(See.3097.Civ.C.)
Lend,r's Name TOTAL:
[UA Lender's Address 'R RAL;
P. I certify that P have mad this application and state that the alnve information is BUILD N E
F (A came,,I agree to comply with all city and county ordinances and swat laws rdalmgm QTY. MBCIIANICAL PERMIT FEE
L) Z building nmmnion,and hesebyumhnd'a,representatives of this city m enter upon the S[ISMI FEE
alone-mentioned property for inspection Putposcs. PIIRMI'1'ISSUANCE
(We)agree to save,indemnify and keep harmless the Cityof Cupertinoagainst ELE IC FEF.
Piabi]ities.judgmems,costs and enperacs which may in any way acerae against said City ALTER OR ADD TO MRCP I.
in cnnwmmae ofthe gmnti.,of this pendil. PLUMBGFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT AIR HANDLING UNIT(11)10,000 CFMIO
SOURCE:REGULATE MECIJAN AL FEE s
` ef C, AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Stgnawre of Applicmt/Cot +car m EXHAUST HOOD(W/OUCf) HOUSING MITIGATION FEE
HA% RDOUS MATE 1 S DISCLOSURE � O
Will the applica or future building occupant nor,or handle haardot,material HEATING UNIT(101 Maps)111111 2 .
as defined by the Cu no Municipal Cale,Chapter 9.12,and the Health ran[Safety
Cade,Section 25532(17 HEATING UNIT(OVER 101,0(X)HTU)
El Yes o VENTILATION FAN SINGLERESI01 PAID
Date Receipt N
Will the apphca or fwure building occupant use equipment or devices which
emir hinds tar wtmmninvms as defined by the]ivy Are.Air Quality Management BOILER-COMP(3HP OR 1(10,0(10 BTT) TOTAL:
Dkt icfl
❑Ye. I 'O BOILER-GDMP(GV1ik 11101X10 It 10)
I havereadthe haev.dovr lnat”ais tegnircmrnts under Chapter 6.95 of the Cali- Alit CONDITIONER ISSUANCE DATE
fomia IIe.I01&Safcty Calc,Sasiuns 25505,25533 and 25534,P understand]hal if the NEW RESIUEN'I'I Al.MECH. SQ.Ff. O
building does not carnally havmt mount,lhat itis Tay asponsibi l Pty to ami fy the uaupvnt
Of the ,orentans which 1ndH he]net priorm Issuance ata Cerificea of Qmupancy.
Owner or vmhnria,ad engem Dam By I^ ISSUI?D BY:
OFFICE