31325 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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CITYOFCUPERTINO f, BUILDING-ELECTRICAL P..., - PERMITNO.
' BUILDING DIVISIONr APPLICATION/PPLUMBING-MI!CHANIL'ALBRMI'1" IIHILDINI;PROJECTunsNTIFICACION
3,1325
Y BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
CC
OWNER'S NAME: PHONE: CONTRACTOR'S NAMR: T 00j..(fLIC NO:
HRkA 21'3 _281j_
2 T
16.q e. o;241` see[ L[J>'S NIC CONTROL IE
�ARCHITEC'1'7ENGINFER: LICNO: ADDRESS.
CONTACT: PHONE: BUILDING PERMIT INFO
�. ❑ Consultant Fees Paid by Applicant(Initial) LUG . ECT PLUMII - MECH
�U�} N �oREs ,2s3-2B3r ❑ ❑ ❑
LICENSED CONTRACfORS DECLARATION QTY. ELECTED C PERMIT FEE r
I Lerch firm Ihal I um licensed under rovlslons of Chapter 1)onto
InIywz dh9ecud nnxp.fDivixnn,bnne❑famexa aloe ltar<x,innxc de,nw ''nenentg J BDFSCRIPTION'
1 ,I0.- in full Electoral my icensc's PERMIT ISSUANCE
y'LL]f, B� WL ❑KITCHEN REMODEL
6VU LiaiseClassecto Lic.#
rF�a Date �—
.1 Common 9� - APPLIANCIiS-,RCSIUIiNTIAL
C3 )EDITION ❑PLUMBING R17 PIPE
ARCHITECT'S DECLARATION PANELS ❑MUI.TI-UNIT ❑STRUCTURAL
Z O-Z I understand my plans shall he nscd as puhlie reeoNs .
OZ 4—a � _ UPTO 20o AMFSr MODIFICATION
P in Lima, ad Pride......) 201-1000AMPS IMPR ENT-
❑ L1INTERIOR - CHIMNEY REPAIR-
g -Y OWNER-BUILDER DECLARATION'
pyx, ¢ 1 M1ercby affirm that I am exempt from the Comremnr's License Low for the OVER IIXXIAMPS fH REMODEVREPAIR [I DEMOLITION
O
W 6 U following reason.(Section 9031.5,Business and I'mfessiona Cade:Any city or county SIGNS ELECTRICAL, ❑ fHEk'
F. which m,aimra Exton,t,, mrstruch,der, g d I:M1repair-any structure
6 prior)t)its issuance,alsoe4 the ppl t bit suchp In file asigned structural SPECIAL CIRCUI'1"9MISC.
Ila,le is 1 canuohl formal n th pon,them,ofth Commutators Ice.Law(Ch pier9
p� 111hurnami ng whoSeci 9000)ofO nb 1 ofth Business dProfessions Code) TEMP MIG ER OR POLE.INST. COMMERCIAL,.
0. ma shut h s nae oth
pt en.Ir rat and the h..i,for the a Ilescel exturm on.Any violin on of
Mon Senioo9011.5 byany applicant far-permitxuhjcclsfie applicant too civil paraltyof POWER DEVICES El NEW BLDG/ADDITION ❑DEMOLITION
FZY of more than live hundred dt11a.($50)). - ❑'TENANT ❑FOOD SERVICE
MO ❑ 1,as owner mile propeny,or try employees with wages us their sole compensation, SWIMMING POOL ELECTRIC 3 IMPROVEMENT ,
will da the work,and the anemic is not intended or offered for sale(See,91144,Bronusx P ❑OTHER
�"etre end Professions Code:The Contractor's License Low does not apply m ao'owner of OUTLETS-SWITCHES-FIX1 UIRLIS ""
Property who builds or improves thereon,and who does inch work himself or nourish
his own employees,provided that such improvements are not inrended nr o11'ered far NEW RESIDENTIAL.ELECfR SQ FT. -
sa1e.If,however,the bnllding or improvement is xuld within one yearoRrnnplerror the ,i SQ.FT FLOOR AREA $/SQ.FM
owner-builder will have the banderolproving thin he did not build or improve far party
pose of sale).
❑I,as owner of me ptnpe-ft am exclusively contracting with licensed comment.I. TOTAL:t
construct the proja.t(Sec.70TL Basi next and P..fassion,Code:)The Contractor's IJ-
cease Law docs not apply man owner ofpropeny who huildx or improveslhereon.-nnJ QTY. PLOWING PERMIT FEE '
' who contracts for such projects with u ctnuacter{q licensed pu.tanno the Connor's _
License Law. PERMITISSUANCF 0 s
❑,I um cxImpn under Sec." ,B&P C fnr this reason - '
.. .
ALTER-DRAIN&VIiN'1'-WAl'CR(EA)
Owner � Dene 'VALUATION -
WORKER'SCOMPENSATIO,NDECLARATION'n BACK FLOW PROIECf DEVICE ,
• Ihereby affirm under Penalty ofperjuD one or me following declarations: _
❑ IhavwuW wlllttraintuinxCenillcnlcafCnnsanmselGincare fm Worker's Cnmpctr DRAINS-Iq,0OR.RODE,AREA,COND.
satlon,as provided for by Section 3700 of the Labor Cade,fnr the performance of the p 01111?S TYPE CONSTRUCTION
work for which this permit is issued. FIXTURPS-PEk TRAP e 7
[:11 have and will maintain Workers Compensation Insurance,as required by Section -
,900ofthe Lalan Code,far the perfimnunce or he work for which this gamut is issmd. , GAS-FA.SYSTEM-I INC.401TI'LE'IS
e' (ICC.GROUP ANN +
My Worker's��Co��pen__at n lnsum Policy
No.: p y -
Cartier.�fY//^ioG/ ngXEMP Policy No.: o�o 9L GAS-EA.SYSTIiM-OVER4(CA) P p
CERTIFICATE OMPE EXEMPTION FROM W(IRKERS' W
_ ,iCOMPf:NtiATIONINSUalis for
GREASfYINDUSTRI.WASTF:INTERCEITON
('Chis ce.tionnmJ oat rte completed 11thn pemtit is fnr one M1unJmd JoIln.I$IBB) _ BUILDING UIVISIO +tES
or less) GREASE I RAP
I certify that to the perfnmmme ofthe work for which thispcnni0 issued,I.hall PLANCHEC
0Z Applicant Laws of Caifich ])are 'y
xn as nr huunm subject to Workers^Cnntp WA'IEk I1P.ATF.RnRY-STORM T,A 200 FT. ENRRCY RE
nein Io anSOWER
- W/VFNT/ELGCI'N
INS .
pP
F'Z y NOTICE TO APo the Wi kT,,Cmrmakingdtix Certificate of Labor iomy..ushtaW WATERSYSTCM/TREATING GRADIN F'
x 5 rename afnjecut nit wnHte.aemttpen:attn�rn.ianrnx nr nit l�m,r er.m,rmt ntttxt sols FEE
!21 4mhwith usmply with such pmvisiore or this permit shall be deemed revoked. WATER S17RVICE '
aQ
Z" CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ<T. PAID
UIhesnyuffrmthat lharelYmm�xauctinnlanJing nscnayforlhe perl'nmranwuf / Race' #
LL U-� thewafknewhichmillamanisi...ad(Sec.3099,Civ.C.)
U Isnders Nane
[i7 Lendds AJdhws, TOTAL:
r y 1 certify that I have read this application and xm[e that the above'ofonninion ix - _ BUILDING FEC
Z) correct.1 agree m comply with all it,end edumy laughoces and state law,relating m� QTY, MECHANICAL PI?KNIT FEE,
U Z building commucnion,and hereby authorize representatives of this city to iner.Ipon r1w SEISMIC FE yyI
ohove-mentioned progeny for inspection purposes.
(We)ob
, ared m.sivc, ndemnif g PP,RMITISSUANCE p
yan0 keep harmless the City of Cu ninon ainnt ELECTRIC E.P.P. 40
Iiahilities,judgtnent......said exlan,es which may in any way accure against said City ALTER ON ADD TO MHCH.
in consequence ofthe granting of,hi,pemtin. - PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO I(I,IXIO CFM)
SOURCE REGULATIONS. MECHANICAL HE
AIR HANDLING UNIT(OVER 10,1160 CFM) CONSTRUCT ON TAX
Signature of ApphcaAZARDO I4 - Data F.XHAUS'1'GOOD(W/DUCTj
HAZARDOUS HOUSING ITIGAT10N FEE
' I{ U$MATERIADISCLOSURE
Will the applicant lir future building occupant store or handle huzndous material' HEATING UNIT GO list,"BT U)
tri defined by the Cupertino Municipal Code,Chapter 9.12,and me Health and Safety
Code,Section 255320)? HEATING UNIT(OVER 100,000 HTU)
C]Ya, E]No PAID
V IIN'I ILAI'ION FAN(SINGLE R USED) pole Ncmipt#
Will the.,Ii...I or future building.,.,act use equipment or devices.which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management HOILER-COMP OUT OR IN,"BTU)
District?, r TOTAL:
❑Ycx ❑No ' BOILER-COMP(OV Ii I{I WIXX)BTU) - •,
AIR CONDITIONER s
Ialth Tendthehazardoustion%15 requ5333 an 2553 Chapter 6.95of drethat Cali SLANCE DATE..
fornix Health no Safety Coda Sections 25505,255,7 and 24514.1 understand thin f0se
at NEW RESI DENTIN,MPRH. SQ.Irl'. �L
.firingdcee vot ents;whitlych have heannual.that.he..acsponsihl1 ichanotifDecop ,
' of the natal¢men.which most be inn prionoissuance ofa Certificate nftxcupmcy,
Owner or auhorized usual Dine 'IY)TAL: I ISSUED
OFFICE r