S 1176 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ' ICAL 11151H NO. w
IIUII.DING DIVISION APPLICATION/PERMIT PlAINIHING-MF.CIIANICAL J 1
BUII.DINOPRO1FCr II1RNTIFICAI'ION 'i•
'
BUILDINGADDRESS - SANI'I'NtY NO. AI'I'LICN'ION SUI3MI'I'IAi.HATE
'� 22365 r,c�rl- �a
OW B'S NA F:: PHONIi: N RAC[OR'S NAME O. i
C CV 2 V% 00111
�1 NIC ^C'(1NTROL p4 V
LIC NO: Dili r, OC ❑
g S 4 7J11J L[�
CONTACT: PHONE Al - - 'BUILDING PERMIT'INFO
I ooj�Ccanwdtant Fees Paid by Applicant(Initial) BLDG EI.I!C'1' PLUMB MI!CD
VV LICENSED CONTRACTOR S DECLARATION QTY. BI.ECfR IC PERMIT. FF• r ❑ ❑
I he by ff that l licensed J p : - d hmmr 9(comm g _ JOLT DESCRIPTION
Da'Z with5 T 9(100) fU"sinn3ofllallm'nessonA fe CnJe,t rad my c RESIDENTIAL:
W Q Q PI Ii MI T ISSl1ANCl' ..
FF W.r In fdllincundefl'en 2 ❑. '11001. ❑KITCHEN REM(1DF.1.
st Limnsc Class Lick APPLIANCES-RISIDENTIAL DII'ION [I PLUMBING Ii&1'll'C
F Z W Date Commemr
yQL h1UC1'I-0NI'T ❑S'1'RUCrURA[.
ARCHITIECI'S D N PANELS
I understand my plans shall he used as public reeruds MODIFICATIONQZv� Up 10200AM1'S ❑IN] ERIOR - [_1 CHIMNEY REPAIR
sitLiecnnrd 11 Sessional - 201"11X111 AMPS IMPROVEMENT []SWIMMING PO(R,S
DWNP.RHUILDI3R DECLARATION
RiY�,, OVER III(IOAMI'S ❑xATII ItF' AI@El 7h10LITION
tY W Q 1 hereby,(firm that I am executed from the Contractile,,os e:Any
Law for the rL [[FFJJ �1,J�
' ��('O d U following moron(Section 7031.5.Business and professionals Cale:Any city or county SIGNS LLP.CfRICAI. ❑OFHGR
1+13 0 y which requires a pemt(to con9rnah:mer,improve,demolish,or rektor any someone '
Fpp".R7 -5 primar!,si.......aha acquires lhe npplicam forsaeh mal no f trouper!antemem SPILC IA L Cl RCI(I17 I SC. 1
2yy can fe is licensed purmannnthe provisions ofthe Conamear's License Luw(Chapter 9
W aa�O Cy, femonrma,with Section 7")ofDi,ision3rflhe puniness tied Professions Cale)or TEMP.METER OR POLL INS'1'. COMMERCIAL
thaL p,o 1r- Sectthm l7nlx1.5 by tiny applicant fur.bpermit mhkasis fur =Ise thus, m u inilption mpennity of VOWER DEVICE ❑NEW HhDG/ADDI'I'10' ❑DEMOLITION
IuX.�1 y r� not nurta run Hvc hundrW dollum($511111, ❑'ImpROT UOD SERVICE
2 0 ❑1,us owner of the propeny,or my employees with wages as their sole xuarKasntian, SW I MMING NIDI,ELECTR IC IMI'ItOVEMF 1 ��D
2 will dome w.,k...d thcstrucmre is nm infer ed nrnRcmJ for sale(Sri.]OW.Business �OIIIfsR
Rand Professirns Cost,:the « TL
Contractor's License Law ds not apply to an owner of `� OUETS-SWITCHES-14X1'11RIS -
G,3^ property who builds or impmvea @omen,and who does.such wed It It ser through1�
his own employees,provided that ranch improvements are main nr nlTernl fur NEW RHSIDENfSAL ELECTR SQ 1'C r Ax k
sole.If,I wevec Jm huiWingor imp rovemcut is n,,ld wi thin one ymndrompletinn.the $Q.FT.F, DIt(t#jEAC Pf.
ownerbuilder will have the burden of proving that he did nm build nr improve for par- r�
i prmrfnele.). IVO fll�l it \S
F7 I f the prnpeny,am exclusivelycontracting with I I contractors to wow
fOI EEE 'y
conotruct the project lSce,7044,Business and Prf:: ms Crier:)13he Conamearts Lt • f
rem 1 d nm upnlyman awncndp p ty I huibl. ........lhcrcom tel
QTY, t.PLUM131NO pEl2M FEE -
whn con rects for such pmjcds with a contractur(s)Ilrenscd pursuant(a the Contmctn's Q,,
License Law. PERMIT ISSUANCE -ICY 11-11
I tan exempt under Sec. .R&P C lin this terrain
ALTER-DRAIN&VENT-WNHER(EA) - VALUATION
Owner DflIC /�
WORKERS COMI'IENSATION DIECLARA'I'ION PACK FLOW I'NOfIECT,UEVICI! "'1
have
and yofarm under Certify of ofConrnc of mf-marwing declarations; 1 ✓�
l have end will maintain Certificate of Conserv mzdGinmrefur Workers Cnmpero DRAINS-FLOOR.ROOF AREA,COND. STORI- '1'YI'E CONSIRIICI'ION
smarm,mo purvidal fart by Section 3710 of the Lothar Cale,for the performance of the
work for which this permit is issued. FIXTURES-PER'I'RAP
❑I have and will mnlnmin Workers Compen a ian Inmmneq as required by Sermon '
3700 of the Late,Code.for the erlimmm�ce of the work for which this permit is isoned OCC GROUP APN
MS-HA.SYS'1'IEM-I INC.J OII'I'Lli I$
My Wed tin^1 dPolicy
Cumer ` •`�-�Policy No.:.�. ^r�QS-� GAS-EA.5Y5'rENOVER J(IiA)
CE 'B'CATEOFEXEMPTION FROM WORKERS' GRE SGiND11S'fItLWASTE IN' ERCITTOR
COMPENSAHON INSURANCE 11 IN DIVISIONFHFS
1'Ihis salon need nothcammplclrA iflhcpfnnit lsf ranefundreJ drllnnl$IINq ORHASETRAI'
or Ices:) PLANCHECK
I cmifyfha inthe perfmanimc,ofine work for,,Ich this permit is ismed.(shell SEWER-SANITARY-STORM HA.200 FI'.
not mnplry any pe non in any manner sr as 1rheamme suhjecuo'fit Workers'Canpen. ENERGY FEE �k
,Z xenon Laws of Califunia.Date WAS ;IS HF,A,IdR W/VENTIELGC'1'It
zQ Applimmt 1 - GRAVING FEE
NOTICE TO APPLICANT:If,after making this Cenilicute of Hxcmption,you should WAS fR SYSTEMI-HUTATING
became objectu,the Worker's Compensation pmvm ort,of the Latour Code,you m ,I SOILS FEE
Forthwith comply with such provisions m this permit shall he deemed revoked. WATER SERVICE
Q
UZ CONSTRUCT
en,isa'1(INLENDING di.,.,AGENCY NEW RESIDENI'IAL 1'hMp. SQ.I'I', PAID
I hereby ef6rm lhanhere isnnm trcfirn lending agency for me performance of Uvm eip
UO the wn drwhich thinpermit isis<aul(See.3097.Civ.C)
Q1-' Lendel,Name TO 1 � TOl'AL:
U Leader's Address
Rt I cerady(but 1 have read this upClleation trod state that the abuse inhmmaion is t 1, , r 13UILDINC
ZS correct lofare msonmplywith all etyad ty I tic.an,)store Iws toff gm QTY I , tMECH1 NICALPI:RMIT-. 'I -TEB
U Z build mgcommamnm,and hereby author p : t f : fJ'' 'lyt rater pt not
- I SEISMICh E
idause•menaoned pmpeny fonmpcction pta" . PERMIT ISSUANCE
(We)agree In save,indemnify and keep females,the City of Calmar agmull EI.i CTRIC FF.F.
..r Iiabilone.judgments,ensu and expenses which may in anyway acerae against saidCity ACI'LRORADV'I'OMECH.
PLUMBING PEI
in c asequenceof DERSTAN SIA
Iii ND WIL
APPLICANT UNDI!RSTANDS AND I.
WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'(IYI 10,000CFM)
MECHANICALFEE.
SOU 1(CF REGULATIONS,
AIR HANDLING UNIT IOVIER I0.IM0 CFM1 CONS'I'RUCfION TAX
Signature or Applicaa"Oft"clnr Dam O EX I I A UST HOOD(WIDUCTI HOUS I NG M ITIGAI'It FP.
IIA9.ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oecupmR score or handle armatures material 111!ATING UNIT(SO IW,N,)li'IU)
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety
Cale,Section 25532(a)'1 IH:ATING UNIT(OVER 100,000 It I'US
No'E]yes _�NVIiN'I'IhATIONIAN(SINGLE ItI?SIO) PAID pale _ Receipt -�
Will the applicant or future building occupant use equipment nr device,which
.rnn h eadmis air-cammmnams as dcxned by me Day Arca Air Quality Managem11011.P.R-
ent C(lMl'(311POR IINI,INNI RTU) 'TOIAL:
'District, B0Hd7 -COMP(OVER 100,0011 HTU)
❑Yes ❑Nr
Ihave read me haeardousmatarirls requirements under Castor,6.95of the Culb
At It CON VITI(INlilt ISSUANCE DATE _
flan Heald&Safety Cal,Sections 25505,25533 and 25534.1 understand than if the NEW RESIDENTIAL MECH. SQ.Fr.
building dacN not currently have a tenant.that it is my msrymsibiloy to notify the xeuparn
of the r.qulremenu which must 1e met parr,In issuance of a Cenificom off Occupancy.
Ownerrradarized agent Dale - IGI tuIiD By
OFFICE