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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING - EUE(:rRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENT'IFICA'TION '
I' IIT NO,1
0162
BUILDING ADDRESS:
�,eks �h D.
SANITARY NO.
APPLICATION
SUR.
it
'ITAL DATE
a
OWNER'S ME PHONE:
L pJR I'
CO 'NAME: /I1� LICpNO:
T-oZA-S
N/C
❑
CON'I'kOl.p
RC ITE (ENGINEER: LIC NO:
ke eZ0 %
ADDRESS
2D3 kat rcleM28z 4au�A k -0-
coisl PHONE:
r 9z D
BUILDING I MI' INF
yI "I D H(,1� ` �'(, ` , ^,2 - 0 2-71
CI
❑ Consultant Fees Paid by Applicant (Initial)
Eli PLUA hlEc
LICENSED CONTRACTOR DECLARATION
I hereby affirm that I am Iicemed under provisions of Chapter 9 (commencing
with Section 700(bii Division3rd'de Bueinessand Prrdcsinm CMp, and myliccmc is
in lull force ondplfee.
License Class Lic.p
Dam 7C
CTSConDE ar
ARCHITES DECLARATIONPA
I understmA my hall be W ux public rccmds
QTY. BLECT'RIC PP.RMIT FEE
�ttZ
-
LW'"
EUU
G i
ern
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI. ❑KITCHEN REMODEI.
DADD] 'TION DPLUMBING RI -PIPE
DAIULTIANI'1' Cl STRUCTURAL
MODIFICATION
PERMIT 'SUANCIi
A IAN AI.
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d Q
L V
LL y
Q
4 eL
Licca dProlbssional
OWNER -Bull. ER DFCLARA'I'[ON
1 herehy affirm thin 1 am captain from the Commdors License Law to, me
fallowing renwm. (Section ]1111 5, Business odd PmfeWons Code: Any city orcnuntY
whitll requires a permit m commayl, In,. improve, demolish, or repair any shature
prior to its issuance, also requires me applicant for such Permit o file u sigdedstmemem
(co}'1 (comm is licensed pursuanuo me pmvixionsN me Cow sines ndProf Loons Codex9
Section
Ihw he is exempt merefrnm ImA the husis far the alleged exclnpJon. Any vialullon of
Oad he is exempt tr end of Diviri for theme,rd Business and Professions lad f
4 U I
201-1000AMP,
❑IN ki011 ❑CIIIMNF:Y RIiPAIR
I N"T GSWIMMING POOLS
❑BATHR I�IEPpIR DDIEMDLITIDN
��//
O M)AMPS
SIGNS HLE RICA[
SPECIAL CIRC '/ S
7
TEM('. MISTER ON I LL (NST.
� -
❑ NI PION ❑ DEMOLITION
POWER DEVICES
Is.
0 y
-Zy
pYE Q
Section 7031.5 by any applicamfor a permit subjects the applicant a civil penally of
not mare than fivehundred dollars
yemp'
wi Las he wornfthe propeny,or myemployeeswimwagnulale(Se. 0W.It smion,
will isnot offend for sale(SmJI xiners
node:
P✓ OV ❑FOOD SERVICE
IMPROVEMENT
❑OTHER
WIMMING POO(. til.l!CfRIC
LO
m
3..
r, Licenses
Profession, The an It
anderty no bit or The Cow thentin License Lawdnen not apply In an owner of
popery who builds or improves memnn, and whittles,... h work himself or (hough
his own employees, provided that such improvements nm not imenAed ur oRemJ for
sale. If,however, the building nr improvement issold wiminadeyesrafcomplc(ion. the
UIT.11S—SWIT'CIIIS—FIX'I'UI(IES251
NEW RESIDENTIAL ELECTR Sp FI'.
SQ. PT. FLOOR AREA
vsQ.F,
will have (lie burden of pmving that he did not build ur improve tut pur-
pocr-builder
of sale.). -
cotnmmin thlicensed coorsoo, m
I, as owner of the n y g with
y,
TOTAL:
Bexne,.,al
See
amwct the project (Sec. ]BM, Business and Professions CMeU TTc Comwc¢tr.x Li-
Sr�
renw, law does not apply to an owner of property who builds or improves thereon and
mer(s) licensed pursuunno the Cnmrnnnr's
who contracts for such prrgeds with a cowm
License law.
D l am exempt under Sec. .H&P C for reason
QTY. PLl PERMIT P.P,
P Q q
` e 0 �
PFRMI'I'ISS E
Owner Date
ALTER — AIN CYNT—WATIiR CA)
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK PLOW P. UTI: , PVIVIPli
t
Ihereby shoat under penalty offerjury one of the following declarations:
D I heardel will maintain tiCerificnte of Consenuoself-insure nix Worker',Comped-
ration, as provided for by naion 3700 of the Labor Cale, for the performance nl the
work for which this permit is issued
/O
DRAINS — FLOON. EA E CO.PjAit
FIXTURIII?"tR'IR P
STORIE
( .
TYPE CONSTRUCTION
D 1 have and will maintain Worket Compemsmion Insurance. as required by Section
37(0(1 of the UnMrt Code. far the performancrilthe work farwhich�this
OCC. GROUT'
AI':y,
GAS—EA. SY 'M INC. UTLETS
My W( : ens yinn n.wmnce nrieroll Policy e, N sppermit sis�issssueedd.
Currier: Palicy tic
CERTIFICATE OF N EMPT10N FROM WORKS T
COMPENSATION INSURANCE
(This.xemion need not MrompleleA tithe permit it (drone hundred dollars ($100)
or Icrs.)
I cenily ohm in me perfnlmancenf mewnrk nix whichthispermit isissucd,Irball
not employ any person in any manner so as to become subject it) the Worker: Comped-
K/.([�n
IV
O GAS—IIA. SYSIT ( ICA)
GREASILINDUST'RI. WASERCEPTOR
BUILDING DIVISION FEES'
GRIASE'INAP
I'IANCfIIiCK FEE
SEWER—SANITARY—STORM HA.200 FT.
ENERGY FEE
WATER HEATER W/VENTELIIR
Z
7O
y
x;
W r
Q
ration lawsnfcitlifnmi. Oath
�R _
i�Rlf
Applicant
NOTICETO n i CeNHcaof of 13xodpdoa, you should
APPLhe Walk If, after n Compensation
becomes comply the Worker's Compensation previsions oethe med rCMe, you mull
forthwith comply with such previsions or this permit shall be deemed revoked.
WgT'IiR SYSTEM/I'ItUATING
WATER SERVICE
NEW RIiSIDENTIAI. PCMB. SU. FT.
D
LL
CONSTRUCTION LHNDIN(i AGENCY
forwhich this .isi issued(Seetian lendin6agency l'nrlhe perbaul:mee of
Le work for which this permit is issued (Sec. 31197. Civ. CJ
PAID
Dale Recciptp
F'
{UTJ
Inde/r Name
TOTAL:
Lender's
T(YI'AL:
BUILDING EEE �
1 artily but 1 orientation, application and ,are that the ,.have ink nrnnllien it
sen d,
.w y
U Z
torten. l agree to comply with all city odd county ordiwnces and state laws reloing to
building construction, and hereby authoe representatives of(hiscity no enter upon the
QTY. MECIIANICALPI?RMIT PEP.
I
SGISMIC FI7IE
PERMIT ISSUANCE
HI.ECTRIC IIB?
`�
alsme-mentioned property for inspection purposes.
(We) dgrce to stove, indemnify and keep handles., the City of Cuperine u'ainm
L'TIik OR AUDI )MECIL
PIeEAPANDS
iabilities,judgmemis,,em, and expenses whichlnay many way acerae againd,aid City
ing ofthis permit.PLUMHING
ND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT(TO 10.00ICFM)'O.
MECHANICAL
AIR HANDLING UND(OVER IIB00CFM)
CONSTIIUC110 TAX
WUN
�
HA7ARcmr -ate
HAY.ARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD IW/DUCT)
HOUSING MITI A] ]ON FEE
IIP.A'1'INO UNIT 1'IY3 W,fq(1 BTU)
o handl M1HenrdausdSafenl
talus buildingc.
WiIIytire
as defined io the Cupertino Municipal C(Je. Chapter 9.12, and the Health and Safety
Cupertino Chaptr9.1ar an tire
Code. Section 25532(a)P
HGATING UNIT (OVER 100,000 BTU)
D Yes DNn
PAN
Dam Receipt N
VENTILATION PAN (SINOLH',ESN)
BOILER — COMP (31111 OR 100.000 BTU)
0,
or furore building by the d use ea Air Qu or devices which
WIII The air contaminants
emit hamNous air rnnmminants es Jefinul by the Buy Area Air Quality Management
BOILGR— COMPIOV[k 100,000 BTTp
District?
D Yes C] No -
AIR CONDITION ER
I have tend me hmerdnus rialmials requirements under Chapter 695 at (let Celi-
ISSUANCE DATE
NEW RESIDENTIAL MECH, SQ. ET.
!amid Health & Safely Codc. Sections 25505,15533 dud 2553,1. 1 understand Ica if the
building does not currently have a tenant. that it is my resporsihilhy in notify the actupem
of the osquirements which must M met prior to issuance of a Cenilicate of Occupancy.
TOTAL:
ISSUED BY.
Owner or oumnnzed e'en( Date
OFFICE