B 0428 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RLP.CT'FEE PERMIT NO.
BUILDING DIVISION APPLICATIONIVERMIT PLUMBING-MECHANICAL }('7 Lam`/ :-}VI
EUILDING PROJECT]DUN[HVICATION 1'
BUILDINGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DAT
�flo DD� iGct S �=Z� 9y
OWNER'S NAME: FHUNL. CO ACI' R'S NAME: LIC NO: SIC CONT-ROE.of
❑
�ARCIIITYiCfIEiGIN1iER: LIC NO: ADDRESS:
�6YY C -` j30 /ccs a� o�J',r5 S•.i
COANfACf: PHONE: BUILDING PERMIT INFO
y/O/j ❑ Consultant Fccs Paid by Applicant(Initial) lj D ELLE PLUMB ME❑CH
,000
% D 9 fi" '
LICENSED CONTRACTOR'S DECLARATION QTY FULCTRIC PERMIT FEE ,LOB DHSCRIPI'ION
I hereby union that I am licensed under Provisions of Chapter 9(commencing
n�Z with Section Division 7nDhe eatncs.and Pmfe,ions Code,aninty license 1. RESIDENTIAL
WOO _ 1117RMIT ISSUANCE
F•UO- in full Irmcnnd coin /� ❑Sl'DWL ❑KITCHEN REMOUIiI.
�U F• Licensc Class u Lic,# AI'PLIANCILS-RFSIDIiNI'IAL ❑ADDITION C3 PLUMBING RE-PIPE
Fab Date— Comnnti{ '- - - �5 ,
N ARCHITECT-S DECLARATION PANELS ❑MULTI-UNIT' ❑STRUCTURAL
F•n.Zed. I understood my plans shall he used as public record. MODIFICATION
ZOZ O UP ID 200 AMPS ❑IN'I'PRIOR ❑CHIMNEY REPAIR
F 41 Licensed Prtifeslonal !SPECIAL
IOWA IMYROVEM111iNT SWIMMING POOLS
C Q 1 hereby affirm ha NPautlendmPtCGmo the Contractor's License taw for the R 1 S ❑BATT{RE.\fODEI/REPAIR DEMOLITION
�Ed�1U following reaxon(Scmion dol LS,Business and Profcavion.Cndc AnY city or nmmY NSELEC'IR 1. ❑OT"HER
LL7 3 c vFi which rewires a permit to construct,alar,hnpmve,demnfikh,nr repair:my sppnure
F•�-�g prior m its I.....se..Horespires the applicant Fusion permit tri file a si,mol smtemcnt CI RCUIT/MtSC. —V/
mal he is licensed pprarcomthe pros......isfthe Concavities License Low,(Chapter 9 COMMERCIAL:
�y0p (ttnnmm�eing with Section Jggp of Divi.ion)ofdhe Businessland Pondec.inns Code)or R METER OR POLE ,'I'.
c.y e C Iha1 he is exempt mereGom and the hn.is fur the alleged exmnptitin.AnY idols,ols, i ul ❑NIiW BLDG/ADDITION ❑DEMOLI TION
iC 4. Section 703 1.5 by any applicant too.pcnnil.wnjcets me nPPlicannnacivil pewhy of I'(1WER DEVICES ❑TIiNANT ❑FOODSERVICE
'�r�' not mom man Eve hundred donors(s5W).
K
❑1,asownerofthepmNatr ormyempinymswithwagesvstheirsolecnmNnsaion,
SWIMMING IY LELF.CTRIC IMPROVEMENT
Fs
will dti the work,and the structure is not intended or offered for sale(Sec.7194,Business ❑G'l'HER
413 send Pmfew<inn.C'nJ¢'The Cnnm¢tor'n License law doe nm apply m ire nwnerienl ()O'I'L"' SWI'I CHE.S-FIXTURES
L property who build.or improve.Iheretiq and who dies such work hitrwclf lir through
his own employers.provided that such improvements am nor intended or offered for NEW 'IDENTIAL ELECTR SQ IT,
sale.IL however,the building or improvement is sold within line year ofcompletion,the SQ.IT.FLOOR AREA {/SQ.PIM
crbuddor is 11 have the burden of proving that he did nut build or Improve lar par
po,nf.odr.). TOTAL
1.on,owner of the property,am exclusively contracting with licensed contractors to
construct Jte project(Sec.IDaJ,Business and Professions C(de:)The Contractees Li.
r, nrtappfy In an owner of prnPcny who huild-nomprovcs thcaon.and QTY, PLUMBING ERMIT FEE
will)crannies foor.uch projects with a cnmmetur(.)licensed Pioneer to the Conderna's
License law. 1117RMIT ISSUANCE
I um exempt under Sec. .B&P C for this reaa.n
ALTER-DRAIN&VENT-WATER EPA) VALUATIU�
Owner Date
WORKER'S COMPENSATION DELLA RAI'ION BACK FLOW PRUTEC'T,DEVICE /' SGOJ
I hereby affirm under,Penally of perjury one of the Hollowing declarations:
I have and rill maintain a Certificate of Consent to.elf-:mute for Worker's Comel)-pDRAINS-FLUOR.ROOT'.AREA.Co ). STORIES TYPE C(INSTRUCUO
I.as provided for by Section 77M of the Labor Code,for me wof rculdre of the 2
work far awhich Thin pennil i.i..ved. 19%TURES-1'IiR TRAP'
1 have and will maintain Worker'.Compensation Insurance,as required by Section GAS-FA.SYSTEM-I INC OUTLEfg
7700 of the LatiC'
n .de.forthe Performance of the work for which thin femur is issued. (ICCs GH(lUl' AIN
My WorkerCour,atum `umn crearrielmod PolicEir s �y,� ,1
Cnrticr: �-�'M Policy No, r'Tf IClGAS-EA.SYSTEM- ERa(F.A) 2
/ Chfid IIICATH OI'EXEMPTION FROM WORKERS' GREASOINDU.1. L WAST'Ii INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION RIES
Tfhissection neednmbeeompleted ifthepemJl is falarehundml Jullors(SIM) GREASET P
PL.ANCII[CK PIiT;
Less.)
Illy any mat in the anyaneenccof as
ackfor which this thenill.I.s'Comprlll SIiWP -SANITARY-S'fORM EA.2g)F.
not employ any arson in any nwnncr m us m hcconm sunjcet m the Workers'ComRm ENERGY PEE
Z ration Lows of Cull hand.,Date TER H17ATER WNENT/ELECR GRADING FF.F.
Z O Applicant t
Z
lin
NUI[CF.TO APPLICANT:If,after making this Cedificom of Exemption,you should WATER SYSTI:MTREATING SOILS PEI:
!Yi hecp.....object In the Worker'.Cmnpan.ation provisions of the Labor Codi you ain't
forthwith comply with such postvides or this Permit shall be deemed revoked. WATER SERVICE
T1PAID
' a
CONSTRUCTION LENDING AGENCY NEW RESLDIiNAL PLMB, SQ.IT. Dale Receipt x
V Q I hereby amrm that thahem isacon.amction len
dingagency for the performance of
L4 the work for,hill,on,perm,is i.suold(See.7(N7,Civ.C.) "TOTAL:
C) F Lenders Name TOTAL:
Lender's Address .DING FEB /O 7•t0
t1 1 certify that I have wait this application and state that the above information is
to correct.I agree u,comply with all city and county on in:mces and.ue aw.refuttling m QTY. MECI'IANICAL PERMIT FEI3
r-t / SEISMIC IEE . 6C
U z building c..nslrvmion.and heathy umnoriac rcpm.cnmtivcs of this city to cnwr upon the
uiarecoentloned property for inspection Pretionso. PERMIT ISSUANCE E 'R
(We)agmen,ave,indemnify and keep harmless the City of Cupertino against
Iishilities,Judgments,costs and expemi which may in any way accmc against aid City ALTER OR ADD TO MF.CH. ID BE GRtI7.
tier a,encrof the granting el'itis pennil. '
APPLICANT'UNDERSTANDS ANDWITH ALL NON-POIN"1' AIR HANDLING UNIT(1010.000 C 1) MECIIA. '
'1 t CV REGULAHON
� AIH HANDLING UNIT(OVG .(XN)CFM) ONSIR
)( Signut APPlicvnVCommcmr 1 BXHAUS'1'1100D(W/DI I'1 HOUMNGMITIGAHONFEE
/_ HAZARDOUS MATERIALS DISCLOSURE
Will the applicant tie(more Molding wcupnt stow or bundle haeardous material HT:ATINGUNIT(T 00.000BTU)
C In Section
ec by the Cupenin..Municipal Gels,Chapter 9.12,and the Hcahh and Safety HEATING UN' (OVER IIN).000 BTU)
cede.secYes2s57z(m7 S'Zo-9y z?
Yes E]No VF,"L ON PAN(SINGLE RESIDE PAID
Dole RcceiPd p
Will the applicant or future building m'o'unted use equipment or devices which I •tt-COMPOHP OR 100,000 BTUI
mil Indianians air contnmiwnts las defined try Ibe Bay Area Air Quality Management 'IDEA[.:
Dlsnidf BOILER-COMP(OVER WjdadETU)
1 10 C]Yes ❑No
AIR CONDITIONER ISSUANCE DAT
L have mad the bvallous matedds mquiament.under Eloper(.95 of the Cali.
Tornio IleaBh&Safety Code,Seclinn 1550.1,25573 and 25574.L understand that if the NEW RESIDVN'H Al,MliCI1. SQ.FL
tin Ding does not car -.1"have t .no,that h is my m.Pm.ibi 14Y m nail y the oucupanl
ands,
aline req 'm ntvµhicnm mm�$riunniouarae nluCertificac of�upa
( re,at r.c ugcm ,are TOTAL: ISSUIiD EN
OFFICE