31177 APPLICANTTO FILLJJ. INF RMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO' .i BUILDING.ELECTRICAL. PERMITNO. �.a1/
BUILDING DIVISION. {. APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENT'IFICAT'ION
\' BUILD' RESS: 1D1' tn ll ' C '1Y y�1 SANITARY NO. AP PLICATION SUBMI'TT'AL DATE
lbw W I� C/, •/I/w(LNS NAAIJ`�,O th 6'{.IOA- q 4v^ N/C CONTROL
ARCfII'I'I:CT/ENGINEER: LIC NO: p'FlSo VA+'. �QI1 �tt�a /slik ❑
CONTACT: PHONE: a f vl BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) - BLDG ELECTP U B MECH
LICENSEDCONTRACnORS DECLARATION QTY ELECI'RIC PERMIT FEE
❑ F-11X El
I henry air,.Nat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
��Z with genion]0007.!Division3 nfthe llmincns and Professions Calc nnJ mylice.wx PERMIT ISSUANCE RESIDENTIAL,
0O E.
i full force and e t.4/ qa J
I-UU Liccnm lass �Vb Lica `� • ❑SFDWI. ❑PLUMBKITCH1ING
NREMODFE
z Unm��''Iti Conun� ION ia; PPLIANCIiS-kLSIDLNTIAL ❑ADDITION ❑PLUMHIURAL' IPE
Qom' ALTS DECLARATION ❑M111.T1UNIT ❑STRUCTURAL.
ZOyzj lundcrstnnd my pions shall beueMaspmblic records PA �LS MODIFICATION
OZ—F. UPTO AMT'S ❑INTERIOR C1 CHIMNEY REPAIR
F M 2 q Licensed Professional 201-1000 PS IMPROVEMENT
Q OWNER-BUILDER DECLARATION
a Y y'� OVER IOa1A. S ATH REMODEUREPAIR ❑DEMOLITION
C T hereby affirm that 1 am exempt from the ConrmstCoe License city
o for the
�L�(oat U followingmaw..a (Section 7031.3:construct.aims and Professions Cale:Any city or county SIGNS ELECI'RI OTHER
41 C ya which requires a permit to I.,thaltar.improve demolish,or repair any umcwm
J
Prior to isauanf puratore9virhe rbeapplicant for suchmon's Licensfilefte aw(nhapter t SPETEMPA1. THR ORP _7-_tee
} that mencittnseJ pursmnno the provisions of the Common's License Lriw(Chapmr9
OC (rot he
engwiNSection V(M(1)th basis for
the Business and Professions Calc)or TEMP.MHI'IiR OR POLE IN COMMERCIAL:
F y m eC the he is exempt therefrom and the hurls fns the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4X1 4• Scalion]0315by any uppllcnmTout permit subjects pro applicant wn civil penalty of POWIiR DEVICES
Y ❑TENANT' El FOOD$IiRYICE
�>> toms.Nun tivemproldt,or s,e X0. IMPROVEMENT
f-
#Q ❑ Coeowner ofNepe samenrmycmpinyeu wofferefor wages Nei(See. 044,Bsiness SWIMMING POOL ELECTRIC
p� G will dntrewons and the ew Contractor Liver nraw dos of apply to an owner
of - [I OTHER
LLI and Professions Code:]fie Gammen. License Law does not apply m an owner If OUTLITS-SWITCHES-FIXTURES
pigmy,who builds or improves Hereon,end who Jima mch work intended
or f through /
his own employees,provided trim such improvements are not immndeJ mplinimi,for NEW RPSIDP.NTIAI.FlECTR SQ FT.
owerLhowever Nhave thing or o burenpfprovinisat hewithinion wild or improve
pre SQ.PC FLOOR AREA f/gQ.Ff.
"seenbullderwill have the burden of proving that he did not build or improve far par-
rytsc of soled. w'
❑1,as owner of the property,um exclusively contracting with licensed.....contractors to TOTAL.
cense La the project(Sts.]nab,Business rind Profusions Codai The es then on, nit A
cense Lawdwenotapplyman owner ospcloos whoredom in aNcreoq and QTY. PLUMBING PERMIT FEE ry
U'rowaaas for sash projects wlNncnn.acmr(n)IlceaaeJ purumntmlhc Cnnlrridnfa 1,)j • ' 8 ,
Liccnsc Law. PERMITISSUANCE �YV y�
❑ I um exempt under Sec. ,B&P C for this reason �-L,
ALTER-DRAIN&VENT-WATER(EA) Tl
-Owner Dale C•V/j'U/1 ION
WORKER'S COMPENSATION DECLARATION PACK FLOW PROT[LT.DEVICE ql/V
1 handwaffirm under penalty teperjuryoneofine followingWorkers Con
❑chave and will mar by Section 37me refine mal toLicor Coda,sumfor Workers Conniver- DRAINS-ROOR,ROORAREA,COND. STORIES TYPE,CONSTRUCTION
otlnm,as provided for by Section 3]00 of the hbor Cade,for the performance of the
�w rIk fee which this permit is issued, FIX'1URES-PER TRAP
J 01 have and will maintain Worker's Compensation work
in, hi h required by Section -
] 1of t4h�er•Lob�o�r{,C,odc f.nhe perfnrmuntt of the work for whichthisper�mit�islissued. GAS-IiA,SYSTFM.I INC.000TLF.TS OCC GROUP AI'N.
CwrW�rPLf[4'ens^tie tsar ncc catrlclp"cl'nliay Na.yMUIM4,6 •! GAS-PA.SYSI'JIM OVER d(EA)
CEkTIPICAT' 17I IIMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
This vection need not be completed if the permit is for one hundred dollars(SI W) GREASETRAP.'less.) PLANCHECK EEE
I cenify that in the performance oftrcwork forwhich this permit is issued.INall SEWER-SANITARY-STORM EA,.2W FT.
not employ any person in any manner ut as to buome subjec....he Workers Cumpen- ENERGY FEE
OZ abrin Laws of California.Date WATER HEATER W/VENIDELECTR
Z Applicant GRADING FEE
y NOTICE.TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTUMITREATING
a ; hecnme object to the Worker's C.ntpensati.n provisions of the Labor Cole,you most _ SOILS IPE
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
OCONST RUCI ON LENDING AGENCY NEW RES1DINHAL PLMB. SQ,FT, PAID 1 hereby affirm that them is a connotation lending agirry for the performance of Date Receipt#
Fthe work for which Its permit is ioned(Sec.3097,Civ.C.)
Q U lenders Name TOTAL:
DJ Lenders Address TOTAL:
1 cent that 1 have mad this application and state that the above information is BUILDING PER
N cotrcn.l agreemcomply with all city rind county.rdinan<es and atam laws rclming to QTY. MECHANICAL PERMIT FEE
U Z building convection.and hereby authorise representatives of this city to enter upon Na SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC ITE(We)agree to save,indemnify unit keep harmless the City of Cupertino against
liabilities.judgments.costs and expenses which may in any way accom against said City LTER OR ADD TO MECH.
xe9nenee of the g counitnt this Inrmit. PLUMBING Flili Li
APDL�UNDEATN�DSANID WILL COMPLY WITH AL1.NONPOINT' ql gNO1.ING UNIT(TO 10,!1(10 CFM) MECHANICAL PEE
SOU V
AIR HA .LNG UNIT(OVER 10,00(1 CIM) CONS'IRUCTIONTAX
Sig a um of AppheanVnoweeen Ume EXHAUST If OW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATF.RIAI-9 DISCLOSURE
Will the applicant or future building occupant store orhandle hazardous material HEATING UNIT(TO ,(X10 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Cole.Section 25532bm) HEATING UNIT(OVF.RI WO BTU)
El Yea E3 No VENT][.AT'PON FAN(SINGLE ASUm. Receipt#
ID) PAID
us
WIII 0a pppllcant or!marc huilJing swatpam e equipmem nr devices which -
emithawNnuxaircnneminrinbmAclineJbytheBuyAreuAirQunlityMmwguntrun BOILER-GGMP AHP OR IW,OW 117
District] TOTAL:
❑Yea 7N � BOILER-COM P(OVER I00,000 BTU)
1 have read the bazsrd.us materials reuirements under Chapter fi.95 of Ne Cali- AIR CONDITIONER
4 p ISSUANCE DATE
bunds Health&Solely,Cale,ea Sciences 25505.is my read25534.1 to notify
the
that ifthe NEW RPSIDf:NTIAL MECH. X" ,'
of
stlding dues not eswhitcurrently have th mnet p that o is my ce of
to notify Ne sceupem '
of the tcquiremcros which must be met prior m issuance of a Certificate of(kcupancy.
Ownerorumhomtedagent Date TOTAL: ISSUED BY: L
OFFICE