30464 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IBUILDING.ELECTRICAL,,, PHRMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 6
BURA)DR;PROJECT IDENTIFICATION
BUILDING ADDRESS: 'SANITARY NO. - APPLICATION SU15MIl-1-AL DATE
Z i SG EG'�/*RT S-27 16 .
OWNER'S NAME PHONE: COMIRACOR',S NAME: LIC NO:
' F NIC CONH`RRO1.X
CIi1TE /ENGINEER: - LIC NU: r A DRESS: UJ7& fFJ F24OZ
CO ACT; PHONE: - BUILDING PF,RMI'TINNF0`/lG���.JT
'(� ❑ Consultant Fees Paid by Applicant(Initial) - BLDG' - R.Ik?CT iiI PLUMB MECH
LCF NSCDCONTRACfORS UECLARA�)N QTY ELECTRIC PERMIT PEE Ely\• m. ll�q\, E -
1 hereby affirm that I licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�0OZO with Semnn]IKKI)ofU 7 of Buxincss.,,it Pmfcss onCd andmy licenses PERMIT ISSIfANCIi RESIDENTIAL'
eU❑ fell force and enact gj / 7 �•
U License Class ..__ Lic.X f0 ZJ J 3 - ❑SFDWL - t ❑KITCHEN REMODEL.
F m Dare Cnntracvmr APPLIANCES—RESIUF,M'IAL ION m�p, ❑PLUMBING RE PIPE
ARCIIITECTS DECLARATION PANELS - - CM ]T UNIT +CSTRUCIURAI,
IZ O y K 1 undee and my,plans shall be used ns public rxro ds
OZ^O _ ., t1P'102W AMPS MODIFICATION
4L-1 Licensed Professional + - ❑INTfiR10N ❑CHIMNI3Y RIil'q IR
.�.I OWNER.HUILDERDIICLARA'I'ION 201-Ifgp AMPS IMPROVEMENT
6 I hereby uffirm Nil I am exempt from the Commnor's License Law for the OV131t I(M)AMPS El BATH RF;MODEIlREPAIR (]DEMOLITION
V following«.son.(Section 7031.5,Business and Pmfeevionx Cole:Any city or county SIGNS ELECTRICAL GOTHEk
F.�C Fya which myuirea a settop in conetmrt,allot,improve,tlonadi sh,nr repair any etmcmun
rn.] print m its mamance,also reyuikvthe applicant far such varaitto filea,ignedn inno,"l SPECIAL CINCUI'1'/MISC.
�. Nm he is licensed purmamm dee powilions.fda,Contractors Lic<ee Law(Chaptn9
00 00 (emnmeneing with Section 7000)of Division 3 nfthe Hari nos,and Professions Code)or 'I'EMII M]7'1 11 OR IV)LE INET. _ COMMERCIAL
Il d o that he is exempt therefmin and the basis for the alleged exemption.Any violation of _
X"'� Section:]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑NEW BLDG/ADDITION ❑DEMOLITION
=z0^y not more than five hundred dollars($500). - - ❑TENANT ,El FOOD SERVICE
❑I,as owner of the property;or my empleyws wird wages as theirsole conpcnaation, ENEW
Ef�l. CTRIC IMPROVEMENT '
wIIWn Ne work,unA thevlrnewre isnalinlrndcA nrnfferal for cola(SecJ044,(in,nosr / COTHER
rli� and Professions Code:The Contractors Lirense Law dies not apply to on owner of —FIXTURES
properly who builds or improves there..,and who does such work hinadf or through
his own employees.provided that such Impmvunants ore not intended or Micron]for ECTR S
sale,IL howeveg the building be improvement is sold within one yeaofcompletion,the SQ.Fr FLOOR AREALSQ,FT.
owner-buiWcr will have the burden of proving that he did no[huilJ.r improve for par-
pose of soled. -
❑1,as owner of the property,am exclusively contracting with licensed contractors a TOTAL: u
mstmct the Indoor(Sec.7044,1mormrs and Prom,,ons Calot The C..... is Li- '1 _ �/ -
censelawJoesnotapplytoanownerMfpropenywhobuild'or improves thereon,and QTY. PLUMBING PERMIT FEF �V� 2.1 ,1(I(�C
who contmcts for such projects with a contractor(k)licensed Perlman to the Contractor's 1996
License Law. PERMIT ISSUANCE tt
- Q lam exempt under Stt. ,13&P C forthis rcaso. x111 I-'I' V�2('Lt,l BVr1
Owner - Dee AI:113R—DRAIN&VENT—WATER(EA)'•
WORSHIPSVALUATION
Ihercb '
COMPENSATION DECLARATION ("/ �O Rina under BACK FLOW PROTECT DEVICE7Vq
yu penalty of perlury one of the following dwlnnninnr
❑I hzveand will manuentiCenincomnl'Consent inself-insure for Workee,Compere DRAINS—'FLOOR.ROOF,AREA,COND,
sation,as provided for by Section 3700 of the Lmba Cod,for the Performance of the STORIES TYPECONSTRUCIION
work for which this Penh is issued. I FIX I URES—PERT RAP m
I]1 have ono]will maintain Workers Compensation insurance,as required by Section
3700of the Labor Code,for the Performanceof the work for which this permit is issued. GAS—HA.SYSTEM.I INC.4 OUTLETS
My Wohc'v Cn p urn lnsur Ace�carl'r and PMocy number me: - .00CI GROUP APN
/ Caricr.�� polay No.: GAS—EA,SYSTEAfOVER 4(FA) - -
CERTIFICATE )P EXE TION FROM WOR KERS'
COMPENSATION INSURANCE GREASWINUUSTRI,WASTE END 13RCEP'TOR
(Thissection need not be completed ifNepermit is foronchundmld.Ilars IS10H 4101LAING JAVISION FEES
nr Icss.) GRHASE'I'RAP
Icmdy Naun NC Perfommnce nfthe work forwhich this permit is issucrl,Ishall PLANCIIF,
not cmpleyany person in any manner sola to become supjoctl.the Workers'Com _ SEWER—SANITARY—S'FORM HA.200 FT
union Laws of California.Data
pep _ ENERGY,
0 Z - WATER HEATER WNENT/ELECTN GRAD :C -
�! Applicata
C. N NO TICE'CO API'LICAN'f:IL after mmking this Canilirwe of Hxmnptinn,you should WATER SYSTEM/I'1t13A"1'I NG
ai become subject Ri the Workers Cnmpemmion provisions of Nc labor Code,you mull SOUS ,E
W forthwith comply wilExuch provisions or this permit le deemed revoked N'g3TR SERVICE
6s Q ,, r
U
CONSTRUCTION LENDING AGENCY,'L NEW RESIDENTIAL PLMH. $Q.FT. PAID - 1
UC) l for whidfnnt at Permit i isucd(Sce.30teethe.agency nit the lmrfommvnce of _ - Do Receipt
W F @e work for which this pemdr u issued(Sec.'3(19],Civ.CJ '
Ismbes Name
W Lndol''s Address - TOTAL; .TOTAL:
1.. p. I cenify that I have and this application uad sore that the above information is WILDING '.0 �r
f.. IA correct.l agree to comply with all city and county ordinances and state laws rclnting m QTY. MECHANICAL,PERMIT PEE
U Z building construction.and hereby mnhnive rapresnnati ves of this ri ty,,,enter upon Hsu SIi1SMICF
aGnve-mentioned property for inspection purposes.
(We) grow m,ave,indemnify and keep hairless the City of Cupertino against PERMIT LSSUANCH ELECTRIC .H
Imbilities,judgioents;c.nband expenses which may him,wayaccmeugninst said City ALTER OR At)])TO MECH.
in consequence of the granting of this Permit. PLUMBING F
APPLICANT UNDERSTANDS AND ,L COM .Y WITH ALL-NON-POINT ' AIR HANDLING UNIT(TO IQ000 CFM)
SOU :RF ATIONS MECHANICAL FEE
7 AIR HANDLING UNIT(OVER 10,00)CVvH • CONSIRUCTIONTAX
tueofApplkant/Co to Date EXHAUST HOLD(W/DUCT) ,
H .q S MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applic d or future building.ecupant'ertorhandlehaeurdous material HEAP ING UNIT(TO IW.000 BTU)
M defined by the Cupertino Municipal Code,Chapter 9,12,and the Benito and Safety
Ode,Se,ion 25532(a)4'. HEA]ING UNIT(OVER 10.000 H'I'U). ,
Fl yes CNo
VENTILATION FAN(SINGLE RESIDE PAID
Will the applicant or future building cceup.nt Usti equipment or devices which Dam Receipt X
emit hazardous air mmiw
ntants ns defined by the Bay Area Air Quality ManagementDOILER—
COMP CHP OR 100,000 BTU) s
District? ... t, - TOTAL:
❑Vas ❑No,- � BOILER—COMP(OVER I00,(NXI BTU) r ,
F have read the hazadousnuatoals neilrentems under Chace,6.95 of the Culi, - AIR CONDITIONER J - ISSUANCE DATE
home.Health&Safety Code,Sections 25505.25533 and 25534.1 undenmml Nat if Hive NEW RESIDENTIAL MECH. SQ.Em
does not currently have a tenni,that it is my responsibility to notify the occupam
Of the mquiemenrs whichmust he met prior to iseuance ole Ccmficaieof Occupancy, - \''�1•/1/���/
Ownermiodmin•Jagem' Date 'TOTAL: 1551113D BY:
OFFICE