S 1845APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO _ BDILDINc-P:L VC,RiCAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
' BUILDING PROJECIADEN'I'IFICA'1'ION
PE 1l NO.
1845
BUILDING AIJDRESS,.
SANITARY NO.
APPLICATION SUBMI'fi'AL [)ATI;
17 14 na.d C�.
7-16-iir U
t N'fSN MH: IIUIINE'
_ 57 I7 ��
•J
CO ACTOR'S NAME UC NO'
re a///�T
1/a -I
NIC
❑
CON'I'NI11,M,
ARCHINECUENGINFER: LIC NO:
ADDRE:
6W
CONTACT. PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG I71.ECi' PLUMB MECH
FaAl
7
❑ ❑ B- ❑
LICENSED CONT'RACTOR'S DECLARATIONQTY
I'achy amrm dun I nth, licensed node, rm.ioo:t. of amps', 9 (tommOra ng
ELPCTRIC PI°Ry,I PEE
JOE DESCRIPTION
PERMIT ISSUANCE
with Sewion]Q90)nf Division3nf.he ltnsinexsunJ Ymfessiom Cedgandet,licenui,
in full force and clfect.
RESIDENTIAL:
C SEUWL [I KITCHEN RIEAfOUEI.
APPLIANCES -RESIDEN'1'IA),
-
License Or. Lic.It
Dam Cunmumor
CADDHTON LUMBING RF:d'IPF,
[]MULTI -UNIT []STRUCTURAL
MODIFICATION
MODIFICATIONUI'T02f0
❑CHIMNEY REPAIR
IMPROVEMI:NT []SWIMMING pOOLS
ARCHITECESDECLARA'1'ION
I undenumJ my plana shall be used ax public records
PANELS
AMPS
Licensed Pr.fe,oneral
201-1(gg)AMPS
OWNER -BUILDER lam UILDER..d he ConnRAI ION
1 hereby emrm (Section nl ten exempt nom the Conor, Cos e: Any. Law l.r t
nguiresa reason Any ei,Y'' IY
❑ BATH REMODEIIREPAIR ❑DEMOLITION
❑OfIIER .
OVER I000AMPS
SIGNS Ii1.ELTNICAI.
wrindimma-mu..c, imdPmfesion,Cale:
which requires u permit ah imprnve. Je,noli,1 or repair any
which
SPECIAL CIRCUIT/MISE'.
dic,,led applicant r
tohm
ulmnIn ."'Moi iso Yore
dpool
io,ema,Ioi,easigne
Imitsocowm,
that he is licemcl pursumn to the pnwixions nf,hc Conmaanrx Liconw Low hapm
It,
(cut cing with Scninn7lNNp nfDivision3 nLM1.Ousincxs and l'ndc"ido'Cod0o
elT tP. MI3'1'ER OR POLE INS,.
COMMERCIAL '
thin hes exempt thcrefrnm and the basic fim the alleged exemption Any violation of
C NEW BLDG/ADDITION C DEMOLITION
Section 703 5 by any applicant for a permit sunj-1, the u,h, nl ton "OH lrcnalty of
not mmc than too lmndred dollars ($500).
❑I,as owner of the property. or my employees with wagesas.homaaleaaanpc,sabn,
will do the work.;md the souaure is not intended morRred for ole (Sec. 7011, Borons,
POWER DEVICES
❑'1'17NAN'1 C FOOD SERVICE
OTHERMPROIEMIiNT
El OTHER
NIINGF EC'1'RIC
OI LI!'I'. 'l1ES- ' X'I'UItES
and I'mlc,.ne, Cn to'. 'I m Conlmcmra lewnw Law due, no, apply to to owner of
property who builds or inipmves thcrcon, and who does soon work himself or through
his own employees, pmvided that stub impmvcmem, are not intended or offered for
sale. Ir. It .... r, the build s„g nv inauavamemissnid within nneyan ofeonhpLtionAre
nenboildv, ,It nave me harden of pnwVng Out fie did om build or imprnve Lor pars
NEW S LNI'1 FLI:C1 R SQ 14.
- SQ� IT. FLOOR AREA
S/SQ. IR
post, oLm1c)
C I, as owner of .fie property, am esidmively cnntmeting with licensed contractors to
TOTAL:
mmnm, the proiw (Sec. 7144. I3uninrss anA I' olloon., Calm) Thu Cn n ,,, I.i.-
censc Law does not apply In an owner of prnpeny who builds or impro.es tbemon,an
Z\, PLUM ,PIiBMIT„ FEE
V
who contracts for.such projects with a eoneracums) licensed pursuant. no Contact
PERAID ISSU O
e
Llwnsc Law.
-
❑ latned,upttmdcr Scc. ,B&PCfm0v,rcasoo
-
ALTS Y] N & VENT- WATER (IEA)
Owner Uam
VALUATION
_
WORKER'SCOMPCNSAHONDI3CIARATIONB
'p WPROIHC'1'.IIEVICE
1 hereby vdirm under penalty n({xrjury one of the ,..lowing declam.ione
❑ I have and will nmintim a Certificate ofanwatto self -insure for Winker'% Camper.
ac of Ibe
,anon, nx pmvidnl for by Seclioo 97m) of ,he. Labor Cute, fns Thu perrann:¢
,ink for whtlnhis permit is issued.
DRAINS- ILOOR, ROOF, AREA, COND.
STORIES
TYPE CONSTRUCTION
FIXTURES - PER TRAP O
[]- cad will maintain Weri:e/s Compensation Insurance, as requited by Section
3700nithc Loh -Cod, birdie porftn.mo,,ot the work In, lit,[, lixpcnnh its issued.
My Wor- r Cn,np r dao I and Policy n n �'tyay �r�s
Cartier: cam+-� ,icy No.:( ✓gw?
OCC.GROUV
AI'N
GAS-I7A.SYSI13M-1 NC.4011T1.ITS
GAS- RA. SYSTIM.OVIER 4( EA)
GHF.AMUINDUS'FBI, WAS LE INTERCEPTOR
CHRTIFl(. I'E OP I?XIEM ION FROM WORKERS'
CoMI-17NSAPION INSURANCE
BUIhOINO DIVISION THEE
bs .it i,5nont, eddollars($ILO)
Old, bdo need nm lc vo.nplemal if lhlnm
nr )cs,J
GREASE'FRAP
PLANCHIiCK IEE
Iccrtity l bat in rho porfendurceofthe work for which this peord is issued, l skull
bjecn the Worker, Cmnn-
not an, lo' im, person in any manner so as u. become xunpe
SEWN{ -SANITARY- S' I' ORM EA. 200 fT
ENERGY FEII
WRIER I WATER W/VF.N UELECIR
sten, law, of Colifomia. Dare
Applicant
GRADING ItE
NOT ICE 'ID APPLICAN'I's11. sio,,ntking this Ccndwate of Excntp, you ,boWd
one to subject to the Worker, Contra orlon provision, of the Wlwr Code, you must
WATER SYSTRM/IREATINC,
SOILS FEE
,
fonhwih comply with wen pmvi,ion, or his punnet shoo be, dccntd revoked.
NEW RESIDEN'T'IAL PLMB. SQ. IT.
CONSITUCI'ION LENDING AGENCY
I hereby a(rmt that there is a construction lending agency tonne perommance of
PAID
Date Receipt it
,be work for which this pernnt is mond (See 3097, Civ. C.)
Lender', Name
'TOTAL:
Lcrdcr's Address
T r
_ _
BUILDING PER
I ani fy that I have read tai, application and stem d at,hc vMve information is
reet.Intone fieomply with all it, and eoonly noilmu,eesmulmancIr-relxfingto
building construction, and hereby mnlmriec representatives offinis city to enter upon the
Q'I'Y. .. MECI IANICAIL PER MIT, 1 PEE
SEISMIC II?H -
PERMIT ISSUANCE.
ELECTRIC FEF.
abtrvc-mentioned property for inspection purposes.
(We) ogrm said, indemnify and kap hamdes, the City ofCupenino again,,
w
ALT ER OR ADD' 1'0 MIECH
PLUMBING 1138
liabilitics,judg,ucntn, costs and expanses which may in any wayn.crue agaiml said City
in nsequence.f the granting of this permit,
AIR HANDLING UNIT(TO I0,000CFM)
MIiCI IANICAI: FEi3
APPLICANT UNDERSTANDS AND WILT. COMPLY WFIH ALL NON -POINT
SOURCE REG IJ LADONS.
AIRIIANOLINGUMT(OVER 10,(0OCF10)
CONSTROCITON'1'AX
-
Mile ur.ofApplicma/Cmnrnmor Ute
HAZARDOUS MATERIAIS DISCLOSURE
EXHAUSTHOOII(W/DUCG
IOUSINGMI',IGATIONITH
HEATING UNIT (0) IW,000 BTU)
Win me up,llcirm nr future ltlldar,.c.,urd,m,.,handle hvallon, mtedal
.is defined by the Cupertino Municipal Code. Chapter 9.12, and ,he Health and Safety
Code, Section 25532(a)]
1 HEATING UNIT(OVER 100,(100111'U)
❑Yes L] No
PAID -
hate Receipt M
VENTILATION FAN (SINGLE RESID)
8011.1311- COMP (71{p OR IIN0,II0011'fll)
Will ,he. u,iici I or bnnre building ...... 1cw u,'c Cyuiptnc d m dcvices.which
emit hnamino air commninants as defined by he Buy Area Air Quality Management
DiNnal
❑Ye, E] No
f�
T 1 1 ll
BOILER-COML'(OVER 10,0001111D
AIR CONDITIONER
Ih ninelimitationsN nidal i n, ode Chapterh95 time Cali-
broomHealthIts&Safety[] 1 eSectionst.thmi 25533 135514.1 d'. I'that (the.
buil, . u%l dyl y........nCerdide rfydcuecap n
ISSUANCIi DA'I'li �
�q
v7-�
NEW RIiSIDENI'IAL MIiCf{, SQ 17.
r
orb my- nt, whin .Ibe et prion n. roc nt t of Occupancy.
met
T
ISSUED IIY' -� /
TGIAL:
Owen,,,u uathoriad ugcot Dtn
OFFICE