S 2109 -- APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEtIT N0. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 21
1`1
BUILDING PROd L(]T IDEINFIF'ICATION
iSS: SANITARY NO. APPLICATION SUBMITTAL DME
IT�41 gain"Mw y—
�('WNEOR'S NA E: pllONli: _ Cf 'D3A OR'SNAXIi: LIC NO�
Jiss2:2-72Zi
CONI NOLs
ARCHITECT/ENGINEER: LIC NM ADOj{ISS: -^ ��I� ❑
CONTACT: ,r-) PHONE: 'V1 K DUILDING PERMIT INFO
eahl,j y-�YDFA 1'/n /Idl�p�"lfn4 3t ❑ Consultant Fees Paid by Applicant(Initial) BLDG I?LECIPLUMB MEC
LICENSED CON'TRACTOR'S DECLARATION QTY ELECT RIC PERMIT FEE
1 hereby affim,that 1 an lismocd ander provisions of chapter 9(commencing JOB DESCRIPTION
wowith Section 9IXxryofDivision 3.Oh.B.,inras and professions Codeand my license is RESIDENTIAL:
h1= in fullfeceanJcRcct PERMITISSUANCF.
Atli,-r �F�ffti �' $ ❑SPOWL ❑KIICHHN REMODEL
aVV License Class J L's.is APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLU M II I NG RE-PIPE
ti G 0. Ume 1'�—.-, v—Contractor
.M. ARC 111117CS AiCLARAI'[ON I'ANId.S ❑MULTI-UNIT' ❑STRUCH)RAL
ZOy� neunv
lundcrstnnd my pl�ns,M1nll .Wpublicreconls MODIPICA'fIDN
UP TU 200 AMPS
OZ- ❑IMPROVE ❑CHIMMINGPOOL
REPAIR
F�I_'Yl Licensed Professional 2111-IfMMl AA11'S IMPROVEMENT SWIMMING POOLS
K 6 I hereby affirm that I am OWNER-�xeln pc Gam the Contractor's License Law for the OVER I"AMPS CLARATION
(3 BATH REMODEIJREPAIR ❑DEMOLITION
d d V follom owing, o.ttiection 703 L5,Business atd Pmfe..tons Cole:Any city or county SIGNS ELECTRICAL. ❑OTHER ,^1
3 LL� which realmor,' permit t,,rincomen,alter.improve,dearrolish,or repairany sauctom ^C
p,I to io, orn, e,al the'ppltl : M1( non II :mard statement SPECIAL CIRCIII'I'/MISC.
Ihnlhcs hrrdrd ptnoun it,the pr ,n- ftl C t m I Los,(Chaptm9
0 ominneencing with Section 90010)of Divisiu 13 ofm,Bmina„andl oil...rots Cade)nr 'I'IiME MPTF.RO .i1NST M R I
d o that he is exempt therefrom and the basis tier Ibe alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DI3M0I.I DON
MSection703 L5 by any applicant for o permitsubjects the applicant ten civil penalty of POWER Dr ICFSVia ❑7GNANT El 1-001)SERVICE
bat more Nan five hundred dollar,(S5IXB.
F-Z> IMPROVIiMIiN'I'
=Q OLothe owner k,the pests,.ur myemntended with wagesastheir(Se.coo,Business
SWIMMIN O ,IiLF.Cr1U
will dmhewnrk,and thestmcmre is not intended(it..feted for sale(See.7044,Business ❑OTHER
and Profession,Cado:11m Contractor',I.ioen,a Law doe.,nm apply to un,wart of OVfLEPS-SWI 114E URB.
LL 3^ pmpuly who bmld,or improves mcra I,; I is due,such work I.... rdr yr in It
his own employers,prnvided that such imprnvemmnk are not im,n Sal,r,fared for NEW RESID17N'I Al.IIIACT SQ PI'.
.,ale If,howeventhe building or imp nrvcnu:nti,so]it within one year of completion,the 'SQ.IT FLUOR AREA $/SQ.IT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
1,as ownerof the prapeny.um car,h,ively contracting with licensed c..nlrurma m TOTAL:
curator,the project(Sita 7004,Basions,and 11 fe..io.,CWep'rhe Contranora Li- -
cenveLawJoesnutapplytoanownerofpropertywhobnildsor linpmves mercon,and QTY. PLUMBING PERMIT PEE
who convnca Ibrnucb projects with a cmuructm(s)li,ametl pm,vum n,Ih,0mcmmors
Licrnvc Law. PERMIT ISSUANCE
❑ I am oxmnpt trader Sea ,B&1'C lbrthis reaam
Owner Doc N.THR-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSXI[ON DECLARATION 13ACK FLON'1'ROTIiCI'.DEVICE
1 hereby off nn undrr penalty of perlury nne,f the following Jedamtinns:
❑ Ihuve wJ wilDnuinminnCenificote of C,nsem mself-insure for Wnrkch Compen- DRAINS-FLOOR.ROOF AREA,COND, STORIES TYPE CONSTRUCT ION
same,,as pmv':d,d ter by Section 3700 of the Loh,.Code ter the pertmmance of rhe
work fur wbleh,hi.pa'nN in ismed FIXTURIIS-PHIR I RAP
5 have and will mninrain Worker',Compensation Insurance.as reaaind by Section
-]W,f Imy yh��e((LL�afan C,C le,fy�r¢tyh�e yp(e?tdtorrr,,,reeematnnrcrol the wrd,in,,,whichttyhis permit I,Mand. GAS
-FA.
SYSTfM-I INC.
40UTLIHIS OCC.,GROUP MIN
CurrierLY'X If VAtfa I1f 11- Poky No}C �LL4," GAS-EA.SYSTEM OVF.RJ(En)
CERTIFICATE OP E IPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE/WDUS'I'RL WAS IE INTERCEPTOR
BUILDING DIVISION FEES
Ofiv,ectiunnoal nm heroniplecal it m,pconitlsfonmehun Insld,lluts(SIBb GREASETRAI'
or lao.) PLANCHRCK THE
Icrrtilythal in the performmceol hewmk fmwhieh thk,itonul ix,aad,I shall SIIWER-SANITARY-STORMEA 200111.
not employ any person u any arm yy t, the Worka"C..a n- 12NERGY Hili
z, station Laws f I'na+a CydtVl 99 WATER HEM ER Vi DELECrk
z0 APPiicamv� �7fY GRADING PCC
NOTICE TO object
I,, he X k if. 'r making this Cisime,of of LLaw,cCodyou should WATER SYSTIiWI KEATING
a ^ become subject m tic Worker,Compensation pmv cions of the LnMr Cale,you man SOILS FEE
L1a tti forthwith comply with such provisions or this permit shall be Jeenmd revoked. WATER SERVICE
Q
O
CONS'CRUC'IlON LENDING AGENCY NEW RESIDfN'I'IAI.I'LMI3. SQ,111'. LAID IAIIc
I herrby aillnu mat orate is o enn,lmnlon lending agency ror ter pem......c cut Rt b
the work for which this pmon Is issued(Sce.3097,Ci,C.)
I•" Lender',Nam, TOTAL:
V Isndcrs AJdrcss TO'T'AL:
} W I craity that I have read this application moisture that the above Incarnation is BUILDING FEL'
� N comet.I agree o,comply with all city and early ordinances anti state laws relating to QTY. MECHANICAL PERMIT FEE
UZ hulldiagconstroction.and hereby anchorite representatives of this city to enter upon the SEISMIC FEE
w' ub,vnmenrl I ov,,trry for lnsN,i pI........ PERMIT ISSUANCE O
We)agree to save,InJcmndy ind krep harmless the City m'Cap,nlnn ngvinst ELIiCI'ItIC FEE
Iinhilines,judgome,,rost,and expenses which may in any way acro,against said City ALTER OR ADD'CO MECH,
in nseyaea t,of the granting..fthis permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO)10.000 CFM) O
SOU CE REGULATIONS.
MECHANICAL P:
I•� �.1�aZ AIR HANDLING UNIT(OVER I0,W CFM) CONSTRUCTION'1'A
Signvmm ofA,p1icam t tat C/ I Date EXHAUST GOOD(WIDUCr) HOUSING MITIGMlON FEE
IIA AR1),MAT 1:14 1 AILS DI SCLOS U R Ii 2—Q
Will Ibc apPlknm,r onto,
a,buidingoccupant bore...hardly hnnmbu,mntmlat I]BATING ON I'I'(1'0110A00 RTI])
as deftnal by the Cupertino Municipal Code,Chapter 9.12,and the Ilrullh unJ Sv[ory
Cade,Section 25532(x):' HEATING UNIT,(OVER 100,0)0 B AD
El W, ON. VENTILATION PANS INGLE RESID) PAID
D.I. ReceiorX
Will chit applicant iofuture building weapon use ea Air Qu of devims which
emit hafarJoav ulrcnmuminannv as delbmd by cbe Boy Area Air Quality Mvwgement BOILER—COMP OHP GR 100,IX10 BTU)
Oi,arict^ 1
El Y, E]No I1011.P.R—COMPtDV1ilR I(X1,I100B'T'U)
I have read the hnztnlou,mamriaL mgoirernenrs and,,, pt
Chaer x95 of the Cali- AIR CONDI'f1ONER ISSUANCE IJA'IT
forma Uealth&Safety Code,Seniors 25505.25533 amt 25534.1 understand that if the NEW RLSIDHNTIA.MECH. SQ.IT. ! L / P
building does urn comencly lave a tenant,that it my responsibility as notify the rccupant T L e
of the rryulremema which mast he In prim I ivsuanee of a Cenmcac of Occupancy.
Owact n mnharieed agent Dole ::&TA ISSUED BY'.
OFFICE