S 1884 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..RLRCI RICA ...i rr rv0 ,r
BUIL884
DING urv[SION APPLICATIONWERMIT PLUMBNG,.hITCHANICAL J 1
tIDH,IIING 1'It0J1!CI'[I)FNI'll'ICNI'IUN
BUILDINGADDItrS5: - SANITARY NO. API'I.ICA'1'IONSUITMITTALDME
()WN"2SN2 vI)I�NV CCONIRACI'OR:S NAME: LICNO:
V
arlrl �- Klm 1� Z/HG-1/6Yy NIC CONTROL It
'•I ARCHITF.C'ULNGINHHR: LIC NO'. ADDRESS: ❑ .
CON'T'ACT':- PHONIi: BUILDING 11I7RNII'f INFO
'T� ❑ Consultant Foes Paid by Applicant(Initial) TiLDG ELIiCT PLUMB MF.CU
a has l�c� � �yG-`fC`l ❑ ❑ 7��
LICHNSHDCONTIACTORS DECLARATION OTY ,' FLEC'II&PERMIT FI:F
1 hereby affirrll that I am licensed under previsions of Chapter 9(aonunencing r JOB DESCRIP'T'ION
o Z with Section 7000)of Division 3 rt the Businnaand Isofeomr,Code.11nd my liemnec is ^ RESIDENTIAL:
WOO PERMIT ISSUANCE C./
�w E- Lufal err Tam and dTea, ❑SFT ❑KITCHEN REMODCI.
QUU license Class Lit. APPLIANCES-RES I DUN'I'IAl. (TION El PLUMPING RE-PIPLi
NQWDate Conned:..
Fly AItCHI'E'EC'1"SDI:CLAI<A'IION PANELS C1 MULTI-UNIT CSTRUCTURAL
Z C i,Z. I understand my plans,hall he used as public records MODIFICATION
OZ„M UP TO 2011 AMPS CWTIRIOR ❑CHIMNEY REPAIR
L,_w Licensed Professional 201.1000AMPS IMPROVI!MIiNT E]SWIMMING POOLS
(IWN[R-IIUILUER DI!CLARATION OVER 000AMPS CBA'I'HRHMODFUREPAIR El DEMOLITION
:Y C Q I hereby affnn that 1 am exempt from the Contractor',License Law for the
O L O whicrIStxi t t 9031 5,I1ua Iter and over.demolish,
Coda:repair
t t ❑077IER
allowing muvon, y city o'etnnt Y SIGNS ELECI'RICAI.
1.
3 LL f- which requires x pennil m mmwq,utter,improve,demnli.ch,nr np:nr any wmcture
v'L^'fie priormit,issuance,aAorap:lms out applicant for such permit o file a signalunerator SPICCIAI.CIRCUIDMISC.
flyhis ha is licensed parnnanl ei the provkiunsnl'rhe ConlNGrr's Lieevre Low,(Chapter 9
WCD (nnnntcnci ng with Section 9IX10)ufDivinion Sof the lmsi,msv and Prum,6mc Code)or TFM P.ME TER OR POLE I NS'I'. - COMMERCIAL:
aa:o C that he is exempt themfrmn and the berms far the.Merged exemptimn.Any einlmin,ill ❑NbW BLDGIADDI'OON C DF.MOL1'1'ION
ySetiou]NIS by any applicam fur a permit subjects the applicant to a civil penalty of POWER DEVICES
rl marc than live M1undred dollars 1851XI1� ❑TENANT C1 FOOD SPRVICIi
F Z_Y IMPROVHo N'f
SQ L as owner of the property,or my anpdmyecs with wages as their rule compeneution, SWIMMING POOL.N.IiC1GC
and Bothe work CWO: so Ccre sour',icenso Lawdolfotatdc(Sva.9f114,lluxincxs COTHEk
6 w ayo send ed,,ion,Cotler The Conmdwoeo License Low d«x Bol apply m 11 owner of OU'rLF,'IS-SWITCIIIS-IlX'I URGS
prnpeny whin builds a aided t v thereon,and who ntsthat,such wnrk himself or uttered for
his own ewoer.the build d that such ideal ,add
are not intended or offered for NI!W R131DI:NTIA1.ELECTR SQ FI'.
sole ll;however.the huilJing nr Lnprrvenscnl lx snlJ within mm Yenl mnlplGiun•the SQ,17.FLOOR ARI:A 5/SQ.FI'.
mer-huilder will have the burden of proving that he did not build or improve for par- '
Past.efsale')' 'I'IT D
C L as owner of the prnpeny am exclusively commning with licensed contractors to
comtrvct me pmjml(Sec.9(94,Ho,inei,mal p...I, in o Co,C:)'nu CoutuwL,,G- _ l
team Lawdmcs nal apply its an owner of propcny who builds or improve thereon.and QTY. I ' PLUMBING PHRMYr FIiE '
who ornmew fa,uch pct9ced with aconnurlon,)I lensed material othe Commetor's
License la W. P. 111'IS CE
I am exctnpinndct Sec. ,11 At PC fill(hit maxrn
ACI'P.R-DRA 1'-WATER IEA) VALUATION
r• Owner Date ,/f
WORKPR'S COMPENSATION DECLARA'T'ION BACK FLOW PROTF D CF, /
I hcmby air J under penally of too,of of Ihm following dcclvonnuar v: it
0 0
❑ I have and will mountain a Certificate of Comeralu self-insure for Wm1xr`v Cmmpem DRAINS-FLUOR.ROOF,AREA,GONDSTORIES 'I'YI It CONSTRUCTION
satin to pmvidel for oby Scotian 3700 of the Luber Code,an the perforoance if the
wnrk for which This permit is isaued. 19XTURLS-PhRI RAI'
❑ I hae,ward will acentain Worker',Compunsatimn Inxunian,Or,required by Section
37fl0ofmc LahurQxle,fortbcpormonamceofthe work fm wllchihisparout is issued GAS-EA.SYS'1'1!M-1 INC.4 OUTLETS OCC❑ItOOP APN
My Workers Compensation Insurance carrier anti Policy number are:
Carmen Policy No.: GAS-VA.SYSTCM-OVER4(ITA)
CERTIFICATE OF HXHMITION FROM WORKHRS' ,
COMPENSAIION INSURANCE GItEASIJINDt1S'fltl.WAST[!INT(!kCP.PfOR
It1111,DING DIVISION FIffiS
flilivsmlinn need not ba nnnplcmtliOhepennit i,fiamna hundreddnllars(sEnB (1RIASE TRAP
or
less.) PLANCIII!CK FEE
[rectify that inic pedarmancerf Newark fWhich ftak,rrail isn,md.Is1Ju11 SIiWER-SAN[TARY-S'I ORM EA.200 IT.
not employ any person irnury mtmnertoa,nibecame sulJea m me Wodmo'Cnmloco ENPRGYITE
Z nasion Lawsof California,Date _ WATIiR HEXI'FR WPVFb T/E.FCI']I GRADING PFai
Z Applicata
NGTICF TO APPLICANT:If,after making this Certificate of Emmption,you should WATER SYSTEMGIFII ING a SOILS Illi became subject Ir the Worker's Conift, alion pnwlsion,of Ibc LubutGvle,yarn mtxl
fnnhwalt comply with such pnrvisionsnnhi.s pemtil shall hedeemed revoked. WATI!R SERVICE:
c. Q
COM1'S'1'RUCTION LHNDING,\GERCY NEW ItISIIjENTIAL I'LMIi. SQ.Irl'. YAIU
UO nmrebyaffirm that there is a cmnxmtcrmm kndiogngmary to Ihmnan
m p,rrccof Rrseipta
F-t the work for which this Permit in ismrd(Sec.30'97,Civ.C.)
ux Lender's Nunn TOTAL:
U Landers Address 10 AL.
Wa ,, RUILANG B 0 Q
cenil'y that hove rcnA Ibis application and stun IM1vt the above infonnution is
rp cored.l agree to etnnply with all city and county ordinancesand nom laws relmingm Q'I'Y. MECHANICA1,PERMIT 'FI?F.'.
V z hIIIIJiltg amametio,l,and Mashy aflhaimmprasmnmivcxoflin"ily nmthT
i> crn"m e SEISMICpr
obovo-memiorud property for inspection poq W'. PHRMI'TISSUANCE
(we) mo,a.,r,indemnifyNitrides,it I keeNitrides,the City of CoNmen ii,eef ELECTRIC FI
r Ii.thtitieu,judgments,casts and expenses which may many way accrm ai,mrst,,id City ALI'17R OR ADD'1'0 MEOH. p'
nxrgncnm ser the granting of this parait. PLUMHINO I E
APPLICANT.UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT. Oat Ill CP
A1ECfIANICAl.1'L i
SOURCE REGULATIONS
AIR HANDL // .1t 11 I ;FM) CONS'I'RUCTION TAX
Signatarc of Applir.m/Cnntmnor Dwc EXIIAUST 110011,(WIDUC r, HOUSING MI'1'IGA'IION THE
HAZARDOUS MAIHRIALS DISCLOSURE
Will the applicant orfulam buildingoecupunl store orhandle hearoo usmaterial HEATING UNIN fIO IIII,00ft lS
as defined by the Cupertino Municipal Code,Chapter 9.12,and the liealih and Safely
Code.Section 25532(a)1 I IEA'1'ING UNIT(OVI:R I(I(I,INI011'[Ul'
❑Yes ❑No V ENIILA'I'ION FAN ISI NGLIi RF.SID) PAID
Dane Receipt x
Will the applicant m rr futuans a building by Ira occupant use co Air Quson or lily M ccs whish
nh M1vnrdnus Or tnnmminums seas AcfineA by the Bey Area Bir Quality Mantlgcmmal BOILI!R-CONI'(iHI'OR IIII,(XNI BTU)
District? HOLLER-COMP(OVER 100,(Klll ITU) Q
❑Yes E:1 No
AIR CONDITIONER
I dlin ,Safety
lCvmdme d...2 505,2 mmmmx under Chnpmr o.95 of the Call-hISSUANCE DA'T'E
building
gdrav n Safety Cal,have
dors 25511.5,25533 and 2557J.I umlenland Ihm it We NEW RISIDFN'I'IAL MEGIE. SQ.PI'.
buildingJarmmCurrently hichhave Titon:n hat itis IumecofaCortimBootyceparal.nt
� of the myuirmrcnu which mart Tivoli...m i>suance of a Crnifcam rf fXcupmcy.
Ownerorauthnrv.ed agent Dam TOT' : I
ISSUED BY: l -)
OFFICE