S 1259 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOECIJPERTINO BUILDING-ELF.C'I'RICA]. I'H ITNO.
-BUILDING DIVISION APPIACATION/PERMIT vLuntnlrvc MH,CUANICAL 125 9
BUILDING PROJECT IDENTIFICATION
RUILDINGADDRISS: SANITARY NO. APPLICATION SUBMITTAL DATH
X437
OW 'S NAMC; PHONE: �!'/1 CON CI'OR'H NAMIi: J LIC NO�: u
ZJ T/1/\/_I NIC CONTROLM
�I ARCHITECTANGINEER: LIC NO: AIAORESSqq:—a 4 /� ❑
Id-;)
J J b7e(jn?AL /J�i t
CONTACT: PHONE: BUILDING PGRMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MI?CH
LICENSED CON'MACfOR'S DECLARATION QTY. ELECTRIC PERMTf FEE
1 Tuesday affirm mat 1 nit,licensed trader previamrs or Charlie,9(cammenclag JOB DESCRIPTION
Z0 with Sc1tinn9(NIII)of Division 3 ofthc Business and I' I...iina Codo,andoy license is pF.RMI'I'ISSUANCE RESIDENTIAL:
F+�-. at full Ease and elect. - ❑SFUWL ❑KITCHEN REMODE
�FUl- License Class Lic.M
N< Date T
Contra.., APPLIANCES-RESIDEN [Al. ❑ADLI )� IPE
'FION YLUMBING RE-P
W.
FUy ARCHITECTS DECLARATION PANELS ❑MULTIUNIT ❑STRUCTURAI,
Z U w 7-y 1 undcnunul my plans,hull he uatA us public records MODIFICATION
UP TO 200 AMPS
O�t-0 ❑INTERIOR ❑SWCHIMNEY
MINGPREPAIR
OL
Fa�F'tA Licensed Professional 201-10Y)AMPS IMPROVEMENT SWIMMING POOLS
CY
-1 OVER DECLARATION OVER 1000 AMPS ❑BATH REMODEURF,PIUR []DEMOLITION
yy CW d I hereby nffinn Ihm um exanipt tram the C..ntom...i License Law lit,the
hd 3 6 Ufollowing recent.(Section 71131.5,Braises,and Promioinrx Cod¢Any city fir cou..ly SIGNS ELECTRICAL ElOTHER
sail u.I- which regwres a permit to construct cher, npress,demolish,or repair any,trvaure
.
f-1�0 priorits issuance.also minutes the slid was for such permit to file a signed statement SPECIAL CI RCUI Old LSC.
thin be is licensed pmorm ,,llie prGm
o,moraol lis uao
ctls License Low(Cliapter9
IsrS� d� (crmmencng w hh Section 7(b(fnf pin..inn 3 lathe Besinessand Pr..fession,Code)ti, 'TEMP.mEl ER OR POI ? .'C COMMP.RCIAL:
6iq5 o that he is exempt therefrom at the basis far The alleged exemption.Any violation of ❑NEW BLDGIADDI'TION ❑DEMOLITION
Wim
Section 7031.5 by any applicant for a permit subjects the applicant.a civil penally of POWER DEVICES ❑TENANT FOOD SERVICE
zy not more than fisc hundred dnllars(S500). IMPROVEMENT
d
E)1.as owner of the rarerly,nrn,y, employees with wages ua theirenlcon"orlion, SWIMMING POOL HLECTRIC
IM will do the work,and the caustic is not ntandedo,aftemd lbrsale(See 7144,15aeine- ❑OTH17R
W 3 ao and Professions Cotte:The Cammi License Law dors not apply to an owner of OUTLE IS-SWITCHES-FI%TURES
precool who builds or improves thereon,and who dna such work himself or Ihrovgn
his awn employees,roasted thin such ill ip.ovemmtd are sol interdict nr offered for NEW RES l DI1N'rlAl.HLF.CI'R SQ ITT
sale.IL howevea she building ar anpoeveeenl is sold within one year of completion,the SQ.PE li )AR'AD BISQ.PP.
owner improver- MM
builder will have the burden of proving that he did not build or far pa
pave ofsale.).
1,as owner of the progeny,con exclusively canna ing with licenwa
d usual to TOTAL: [a�
es simnel ate pmicel(Sec 7044,kusine,s amt Pmle%krus Code:)I lie Conlracla's LF- I�
cense Law cities not apply.an owner at prnpeny who builds or improves thereat,and QTY. PLUMBING PERMIT FEE `slTv
who camract,for such projects with a cnrarcemp)licensed pursuant o the Contractor'sU1-
License Law. PERMIT ISSUANCE Lurch J
❑ I nm exempt timlcr Sec. ,B A,P C ser cols ;,,air )lliV
Owner Date ALTER-DRAIN&VI?SIT-WATER(EAI VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby akiren under penalty of perjury fine of the following critical
❑ I huveandwill maintaion Car,ificatc of Coment to cel hinsam ra Worker's Cnmpni- DRAINS-I LOOK,ROOF.AREA.COND. STORIES 'TYPE CONSTRUCTION
sation,as provided for by Section 3700 at the Labor Cache.lar the performance it the
work for which this permil is issued. FIXTURES-PER TRAP
❑1 have and will maintain A' lair's Cnmpenmtion Instance,as required by Section
390(1,,1 the Lobar Cade fur l he perfanamerofaha work lir which Ibis permit is issued. GAS—EA.SYSTEM-1 INC.401711EIS OCC.GROUI' APN
My Wnrk Con m colla d Policy am mbpc4fR..
Currin: cmc Policy No.:-lis*190/ GAS-EA.SYSTEM-OVER 4(EA)
CERTHI iOF E% PITON FROM WORKERS'
COMI'ENS TION INSURANCE GREASPJINDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FRES
1'Ihisscctlot ,lecd nal 1w,nan Bled H ill,N it is fortune hundred ill IS F 1111) _
or least GREASE'1'NAP PLANCHECK FEE
I cerify that in the performance ofthe work for which this permit is issued,IabaO SEWER-SANITARY-STORM P.A.200 FT.
sol employ any person in any manner so as In recent,subject to the Workers'Compen- LIN ERGY PER
z taliplicaon Laws of Cathartic.Date WATER((HATER WIVIeNT/ELEfa'It
O O Apta GRADING ITEE
NO[ICE TO APPLICANT:If,after making this Certificate of Exeraptian,you shosW WATER SYSTEMII'REATING
abecome subject Ice the Workers's Compensation precisions of the LabCode,you llatestgO1LS FEE
(11
Earth,all Simply whh such provisions ardlis permit faill bedeeoed revokod WATER SI?ItVICE
a Q
COtthemRUCTION LENDING
ngAGENCY NEW RF'_SIDENTIALI'Lh1E. SQ 17. ('AID
L)� Iherehy affirm that mere is aconstmcuion lending agency finite peDormonce n! Date np,M
the work for which this permit is issued(Sec.3097.Ci¢C.)
Lcndn's Name OPAL
Q U Leak's Address TOTAL:
I certify that 1 have read this application and sorra that the nMwe infnrmaiiun is BUILDING PEE
ra/1 toren.lagree.comply with unsay and county ordinances sad nate I....chaing r, QTY, MECHANICAL PERMIT PEE
f) 2 buildingmnsvuclass,and hereby craft..ri......e,crecivesafti lty to ennrup..n the SI?ISMIC FEE
s7. obi ve-nenleared pal ry far Inspenlon purposes. PERMIT ISSUANCE
(We)agree.Ives indemnify cervi keep hmmleA the City of Cupertino against I?LECTRIC r-,
liabilities,judgmenis,costs and eapema which may in any way acemeugains said City ALTER OR ADD TG MBCH. PLUMBING PER
n consequence of the granting of This pecan
APPLICANT UNDERSTANOS AND WILL COMPLY WITH AT.].NON POINT AIR HANDLING UNIT('101 B,BIXICFM)
SOURCE REGULATIONS. MECHANICAL IfE
AIR HANDLING UNIT(OVER 111,00 CFM) CONSTRUCT( TAX
Signature of Appllcanp7manuemr Date 17XIIALJS'IHOOD(WIDUCT) HOUSING MITIGATI PEP.
HAZARDOUS MATERIALS DISCLOSURE
Willtheappliemumbrime buildingaccupamstnrearhounle hazardousnemred HEATING UNITp0100.1010 RTU)
as definnl by me Coastline,Municipal Code,Chapter 9.12,end the littler and Slimly
Code,Section 25532(a)P HEATING UNIT(OVER pains)Is IIJ)
❑Yoe ❑Nn PAID it
VENTILATION CAN(SINGLE RES ID) pate ITT M
X511 the applicant or future building occupant use equipment fir devices which
coil hamrdous air Contaminants as defined by the Ray Area Air Quality Managetnenl BOILER-COMP(3R1'OR To()"M IjTU)
Diana TOD\L:
E]Yes, F1 No N(lI1.P.R-COMP(OVRR I(XI,111X1 E'TU7
I have read The navudous numerical,mgairemens under Chapter 695 of the Cali- AIR CON TONER ISSUA 'PF-
fooia Health&Sufcty Cri I Sect s 25505,25533 and 25534.1 undcatie d mal if the NEW RES THEN'FIAT,MHCI I. SQ.ML
builiingdoes fOid,hat Dant tit ism responsibility Io....lily theacapent
fate which aI me umancc o' CeriIT I pwncy.
u�r
O u rocubmired age Ilan TOTAL'' ISSUED BV:
OFFICE