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earl ICANTTn FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - P)LF:CrRICAi.
BUILDING DIVISION APPLICATIONPERMITPLUMBING.NUtcHANICAI.
BUILDING PROJBCT IDEN'1'LFICNIJON
Pliygfrr No,
2118
BUILDING )uHILSS:
AL OA� I
SANI'I'AHY NO.
APPLICATION SUHMI'1'IAI. DATE
°(rZ-4B
OWNIdRS NANIIE I �1'IIONE:
C'flN'fR�A'191<'S NAME: V� LIC NQ'.
�1F1fky''/5T11 /AMF S llUl
NIC
❑
CON 'I'H(lLk
ARCHITECT/L G I N.Ek: LIC NO:
ADDRES.: R
CONTACT: PIONF.:
IJUILDING PFRMI'f INFO
`� l '
I lr"\ Y C/ice\
consul Fecs Paid by Applicant (Initial)
BLDG, ELIiCI' PLUMIt MF:Ct
LVA/
LICENSED CON 'IRAC POI'S DECLARATION
I hereby affirm that 1 am licensed under pro,mart of chapter 9 (commedcing
QTY. F:LIiCTRIC PIiRMI'f FEF
JOB DESCRIPTION
PERMI'I'ISSUANCE
with Section ]o0(q of Division i of the Business and Professions Gavle, and my license is
in full force and eQecl `ay� '1
RFSIDFNTIAL:
❑SFDWI. ❑Kit CIIEN REMODEL.
APPI.IANCITS-RESIDEN'r1AL
License Clue hic.p V 1 H�
Dur nr t44y
[]ADDITION ElPLUMBING RILPII'H
❑MULTI -UNIT [I STRUCTURAL
MODIFICATION
[I INTERIOR ❑ Cl I IMNEY REPAIR
IM OVHMENT []SWIMMING POOLS
ARCI{I'IHCTSrS DECLARATION
1 mAcra my plans shall N used as public me ch.
M
PANIiI S
UP'f0200AMPS
Licensed puemeded
201-1000AMPS
OWNER -If UII.DHR DECLARATION
I hn ereby aftirn that I reexempt from the Conlrecuor's License Law for the
following reamn.(ticai-7031.5. Business and Prufe,,mrs Gde: Any city or county
ATH RFMODELAU7 IR ❑DLMOIATION
0GHER
pyER lINOAMPS
SIGNS HLECfRICN.
which requires a permit to construct• aluc, improve, demolish, or repair any structure
SPHCIAI, CIRCIJI'r/MISC.
prior to it, i"a... 0, also require"Ire a,dd,z nt french permit to filen signednlatemem
Imo he is IceweA pun.. to, id the provisiens nl'mhc Commcmr's ucanm Lou (Cham,,9
(cminccort, with Section 900(lpf Division Sof the Businc,,nd Professions Code) or
TEMP METER OR I4)LE INSI
COMMERCIAL:
that be is exempt therefrom and the basis liar the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 7031.5 by anyapplicunl forepennil suhjcns lheit,dcmmm acivil,mmlty of
notmo.c t ham Five It ]red doll;... (8510).
[-IL asownerof the property.,,,,,,, employees with wages as theirsole cn.u,sm,mion,
will dome work, and the sauclure knot intended m offered for sale (Sec. ]M4, Haddess
POWHR DEVICHIS
❑TENANT' El FOOD SERVICE
OI3MIiNT
THER
❑ OTHER
SWIMMING PDOI, BLECfRIC
OVIICIS- SWITCI IIS -FIXTURES
and Professions Code: The Commcmrs License Lew does dol apply In ;in maser of
NHW RIISIDENTIAI. ELECHt SQ Irl'.
pmixi wno builds or impmvus then..., and wlm docs inch work himself or though
his own employee', prosided Hua inch improvements are nal Inl,ndml um' ofere1 for
sale. IL however, the building or inmprovemeni is sold within one year oioncipletionlhc
SQ. PI'. FLOOR ARBA
VSQ. PT
nowner,hudder will have the burden of proving that he did not build or improve for pur-
poe of ddc).
❑toh as owner of the property, a .elusively commcdng with licensed enntrnemrs to
'TAC:
mxnud the Fmjeem (Se,. 7044, Bmine.. and IMufcssimis Cndc:)'The Comaatore ILL-
-
mxeLawdoesnotapplytoanownurofpmpertywhobuilds at improves dmrenn, and
QTY. I GPEiRMIT ItF.F
who cuntmmts for such pmjmi%with a contreemrp) licensed pursuCommenceso the Commences
1'CRAtI'1'1. UANC
License law.
❑Ii cxcdrauder Sec. ,B&PCfnrlhtsmmon
AIAIiR-D A ,NT WAI : 1 ) O
Owner Oat,
VALIDATION
BACK FLOW PRT. . .D' E
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the t...owing-------tion,
QFJ Q
DRAINS -FLOOR, ROOF, RI' (OND.
E] Ilue,,md willmminmina Ccrlificmc of Cunacnlln salt-i:uurcfor Wurkcrls Camace
,amino, as provided lir by Stan...0 770(of the laha. Cock, fur the "Eta nnnm ofilm
STORIES
7'YI17CONSTRUCDON
OL
lin which this pcmmit is I ... Od.
FIXTURES - PER 'I'RAP
70
irk
1 have and will maintain Worker'. Compenmtio, Ineumnce, as required by S.m.
3(X1 of the Later Coale, for the performance of the work [or which this permit is issued.
GAS -IiA. SYSTpM-I INC. 4091 LEIS
OCC. GROUP
APN
k
My Caro,rrMlUpe P�)`FUt�oic Policy No. nli 191
GAS -IiA. SYS 'I'FM-OVER 4(HA)
GREASED NDUS'IRL WAST;; INTFRCEPTOR
CBRTIF'KATE OXEMITION FROM WORKERS'
COMPENSATION INSURANCE;
BUILDING DIVISION PGCS
(This action need not he completed Tthe permit is unnne hundred dollars ($R0)
or lea.t
GRI?ASI;'TRAP
PIANCHECK PITH
Icenifylhul in the paitorduneeofthe work havnich(Inxp,rmil is i .... d,[shall
not employ any person in any manner so as m Ncnnne subjecuo the Workers' Comped-
SHWHR- SANITARY - STORM PA. 2W FI'.
ENERGY F1117
W'ATHR I IEATHR WNEM'd!LFC1'R
satin. hws of California. Date
Applicant
GRADING ]TUE.
NODOH'TO APPLICANT: If, aha, making this Certificate ol'li.cra,u n, you ehnuld
bec,,nm subject to the Worker's Cmnpe,,smion provisions of the Labor Code, you must
WA'I'HH SYSTEM/I'ItiiATING
SOILS THE
WAIT;R SERVICE.
funovir eved,dy with such pmviaions mania sedual,lall N dimmed revoked.
CONSTRUCTION LENDING AGHNCY
I hereby a0ion that there ism construction lending ago y fnnholmrlormmme it
NEW RE' SQ, ET.
PND
)a' Receipt#
the work for which this permit Is Issued (Sec. 3007, Civ. C.)
lenders Name
'IOTA
CW TOTAL:
Lenders Address
I certify that I have read this application and state that the above information is
BU II.DIN 4F .
conco. I agree to ammply with all city and county ordinances and state laws elating tonm
building msmian, and hereby authorize represenmdves of this city to enter upon the
'Y. ME A PF PEC
SEISMIC TI
d
ISSUANCE (/
RLE(THU @iii
above mentioned property for inspection putiwses.I',R,j
I We) agree em save, indemnify and keep harmless the City of Cupertino against
11iC11. %._D
I'LUMBI ,PGI; O
linhilitice,judgamrseoma and exp,uses which may in any way accrue agahm said City
nuquencecithearantingofllml•pemmil,
APPLICANT UNDHRSTANDS AND WILL COMPLY W I'TI ALL NON-POIMI'
SOURCE. REGULATIONS.
pik HANDLING IJNI f (TO I(1. M7
MIECIIANIC I, PEE
AIR HANDLING IJNI'r(OVER 111,100 CIM)
CONSTRUCI IV TAX
Standout, of Applicant/Conlmmor Dntc
HAZARDOUS MATIiR1ALS DISCLOSURE
P.XIIAUST HOOD IW/DUCT)
HOUSING MITIGATION THE
HEATING UNIT TI'o 1 Will B'1 lH
Will the applicant or future mmilding occupant store or handle ha�ardnus material
as defneJ by the Cupertino Municipal Code, Chapter 9.12, and It, Hamrh and Safety
Cock, S,,don 2553200'1
H17NI'INC UNG' IOVHIt I(NI,fNN1 It EU)
❑Yes E] No
Will the applicant nr future l ulMimg dec....t use equipment or devices which
mil h ... ol.us air eomwmimants as defined by the Be, Arca Air Quality Morax ,mens
DimrinpOT
❑Yes E] No
PAID
part Receipt It
VENTiLAi'ION PAN (SINGLE RISSID)
11011.17R -COMP (711P OR I W.10f1 BTU)
n
ZA C✓
BOILER- COMP (OVER 100,00111)1' U)
AIR CONDITIONRR
1 lilt', madtheh ode, etions25requirements under Chapterrstaoftae Cali
that ifthe
fordia,lace&Sdety Coda,Sections25505, k no,and 25534.1 tmddda the
M1uilJina does nm cummimly huveu anan6lhnt it ie may re pnnsihllity to nmify @c occupant
l.3�yya ISSUANCH DATA
/ S, " ��
l
NEW Ii I;SIDHN'1'IAi. MF.CIi. SQ.
of the rcyuirenmcnin which must N mel pd,,r nm insurance of a Cenilicate of Wcupuncy.
ISSUED BY:
T AL: V
Ownermaul dozed agent Duro
OFFICE