30379 APPLICANT TO FILL IN INFORMATION WITHIN _ r e
_ N RED LINES-.USE BALL POINT PENIONLY •�, ,r'� - '.'•
_ BUILDING. PERM II NO ' 0379 3 7
�. CITY DI CUPERTIN, - - � r I"�+ - PLUMBING-MECHANICAL '^ :`ll JV
BUILDING DIVISION, APPLICATION/PERMIT „g
• - .• Td BUILDING PROJECT IDENTIFICA'pION ' " $ `1 ., ,
BUILDING ADDRESS. 4 .� i - SANITARY NO' : APPLICATION SUBMI TIAL DATE.
Q�ZS ' S cvLnS CC2¢ L. .$ 7—:50 ,• � lr '
No
OWNER'S NAME: .� Oma ^HONL�';:�.2 CONTRACTORS Qr ML �Z��C�.`• NIC CONTROL
1RCIIITFCT/F (NEER: LIC ND'- ADDRESS - ❑ • 4 r'
2 c' 1 co . 35s•�s. �a�'';eiv S::i
CONTACT: - PHOrJE r '-r°' BUILDING PERMIT INFO `
'Vo es
,, ❑ Consultant Pees Paid by ApplicaDt(Initial) � BL G P,LEC PLUMB MECH
T. hn F I I"t K 1 r t�,2 Zy 6 � 0 E]
L10ENSEDCON1RAC1URSDLCLARA1ION QTY- ELECTRIC PERMIT FEE
1 hereby afiren that I F . d a p f Chappell)( ,mme n ng _ SOB DESCRIPTION '
M=Z whh9e l n9 a)o[Dt 'ar3ofine Bus dPmE,,i roC J a'd yFae reE RESIDENTIAL•
W O full force
an
•� PERMIT ISSUANCE •+ -
C 1— in fell force s Lm N `��`' - ❑SFDWL ❑KITCHEN REMODEL
Q U - APPLIANCES-RESIDENTIAL. p . .• ❑ADDITION+, r EIPLUMBINGRE-PIPE,
F Z BT Dem 'Cort t ,.
ARCHIIECTSDCCLARAf10N PANELS L• ❑MULTI-UNIT -O STRUCTURAL, '1
Z O m zj .,L understand try plans'shall be used public ask >. MODIFICATION
OZ..O. ,' ' UPT0200AMPS,. ❑INTERIOR_e I DCHIMNEYREPAIR
r.Hw Lme dProfessional - 1s - e 201-1000AMPS IMPROVEMENT
•� OWNFRBUILDER DECLARATION + OVER IINn1AMPS `f ❑BATH REMODEL/REPAIR.'❑DEMOLITION'.
1 M1 by ff th t 1 pt f Th C t n r Lsen. La f O _
+' - - `BOTHER 5
folio g u: (S c+ 9031 5 B _ d P f Code A y ty n1Y SIGNS ELECTRICAL '•�
which retiree, permit ensu',meet,improve,'d Ilh p; Y structure' ° tf -
C Off, prmrt I issuance alkouppme,he ppl' tf h permitt finit,igned stracei 4 SPECIAL CIRCUIDMISC .rt- " t•`
2 y+ Ihath o Jp ahe C I I License L (CI tm 9
00 0
(commencing with5 I 9000) fD io -'
3 ftheBn.sadProfessions CD) TEMPMETER OR POLE INST o- COMMERCIAL:
0
6 c C that s exempt theref d the basis f the alleged xempl )say I n of - - ❑NEW BLDG/ADDITION ❑DEMOLLOON
" k- Section7031,5h 1applicantf 1 d tTh I ti 'I penalty of - POWLRDEVICES 't -
m Y YP PP _ ❑T ANT ❑FOODSERVICE
F' ¢ atm Lha f h nd dJ Ilat'($SW).
- - PROVEMENT
❑I a. Her flhep perry' myetpl }c. m g m I p t SWIMMING POOL ELECTRIC
p2a9p th m k dd t t t I dd ff df ul (S 911410 . o..
yj 3 w and Professions Code r11C tlractina L se Law does net apply m snootier nlic
OUT SWITCHES-FIXTURES ,Q' f - 'f
�' prop ty 1 bond, p m reon and who don euch-work him.elfor Through!
his own ens,I.,res,powided that such'improvements t intended or offered for'r I NEW RESIDENTIAL ELECTR SQ FE4'
sale.If however me bti king improve Hem's sold wish Harry rofwnplet tin,the• - - _ SQ.FT:FLOOR AREA $/SQ.FT
awrootholder is AT have the b Nen ofproving thath did notband or inibrovefor p x` too'b few f' ). _ lnab t
TTT
_ ❑I fth prp ty IYcontracting
I 't gwith I< edc « t tr. ' T L ',j-'
anomer the Force,(Se 9044 H d P f C de)The C vett Li-'
T
se LawdonnmapFlyt - fl p ny h Ii: P .ih re n d QTY, PLUMBING PERMIT FEE' y %.;
h ,turvien4ratuchp 3erhawid.cmar t q)heensed pursuantotheC ntmrurs
r Lice el aw u W�, - _ ". . d' PERMIT ISSUANCE. c f l
+ DI i mptuniS B&PCfm this reason
. - ALFER-DRAIN&VENT,WATER(EA) --- 1 VALUATIO_
SER
Own - - D t �ey -
WORKERSCOMPENSATIONDECLARATION - PACK PLOW PROTLCI DCVICE - bl�
ih by ff aderpenalty ofperjury of the following d 1 it - ( �:�Erf I0I) a
❑`Ih d will
maintain rtf ata ofC n If' f Worker.0 p DRAINS-FLOOR,ROOF AREA.COND., STORIES
TYPE CONSTRUCT ION
lion as divided for by Sept..3900 of.d Labor Code,forthepe f rm'mce f theT,
r' work for whiehdra permt i5 issued, ( FIXTURES-PER TRAP ey,
` ❑ 1 have and will maintain Workers Compensation Insurancrequired_by Section
e ! _
3900arhe Labor Code for the Penniman,of me work for wh hth Tis is.ied.. GAS-'EA.SYSTENEI INC.4 OUTLETS '
pm'n OCG GRWP rr APN
My Wrarleak Compensation 1 ie �l cy number are: . i
T PolioY No � GAS-EA.SYSTP.Me
JYIu,yOVER4(EA)
CERTIFICATROF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - GREASE/INDUSTRLWASTE INTERCEPT)Rf •, BUICDING DIVISION FEES`
- fD t load the pl t d fth p t' f h d'd I II :($IIXO • >.1
nr lc ) _ - GREASE TRAP •/ PLANCHL CKI FH
Ice ifY lh fnO per' of th kr' 1-hth' P t C I'hll �1.
' t - - SEWER'SANO'ARV STORM EA.200 FT ,
notemploy mY person.hany manner sn est be oma sublcetmthe Workers'Cann- ENERGY FRP.
sminn Laws of California.Date r WATER HEATER W/VENTIELECTR ',;',
z Applicant-- - `• ' ' T ' GRADING FEE '"I
y NOTICE TO APPLICAN P If,Litter k' g this Certificate(if F en pl n you should ld WATER SYSTEM/IREATING -
t~ became sr b)ocua the W k C p t p if th I b Cale you muse. SOILS PEE
�i �y forthwith eonlPly wuhe 1 p Istons or th' q.rm ishall hedwmei revoked WATER SERVICE. - n
� ^ p. .. A
� 1.1 CONSTRUCTIONLENDINGAGENCY- ' ", NEW RESIDENTIAL PI-MB SQ.FT: - PAID
�" IherebysfI lbut hens a emmureelon leading simmyf th perfomm ce of Date.., R eiptI
W.P the work for Ah ch Na peml I is issued(Sec.3094,,Civ.'c.)'I, _ 'I- ..
F'' Lend N me - TOTAL:
Oy W..Lender's Adobes • - '^ '.„ TOTAL: _!' ., " rZ .
�r
]tariff Ih emd lh:appy r d.tt th uM1 b f at n' BUIL❑INO PHP,
Vi rouser lag t uply with II city do q Sac. a state - I t gle, ,QTT. MECHANICAL PERMIT FEE
.0 Z buMagc .v i t a dh rely authorize p e mti c.ofd'. 'ry)o Cmm�pot the SEISMIC FEE, rte,
I slow named npert,fimirspwtienp 'posts. PERMIT ISSUANCE- �p
( c) gr m save,Indcmn fy and keep harmless the City f Cupertino di
nsTi - ELECTRIC PEE'
liahlfe jig m rand pnseswh'ch may in any wayac gas saiJCity ALTER OR ADD TOMECH - '
o tsegnerC of the g' I g rlhir perms PLUMBINGFEE
APPLICAN UNDRRSTANDS'-AND WILL COMPLY WTTHA .NON-POINT AIR HANDLING UNIT(TO 10,000 CPM) '� i+ n key
-
SOURCE GULATIONS `• •, - NICALFEE
MECHA
HANDLING UNIT(OVER Lpg)0CFM) '
b � CONSTRUCTION TAX
atunFuLA,lmmaCommcmr, '-4 Date •. I EXHAUST HOOD(W/DULL)
"HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE'
Will the applicant or future building occupant store or handle hazardous material HEATING,UNIT(TO 100,000 BTU)
'm defined by the Cupertino Munidpul Grde"Chapter 9.12•and no Heahh trod Safely - - '•'^ -
Code,Spelem25532(a)'! IIL'Ai1N0 UNIT(OVER 100,IX0 BTU)
SYS' or+/ , a T' f VENTILATION PAN(SINGLE RESID)t • PAID { -
Date- R rpt# .,..
WJI m ppl t r t building g P m use"eqa p t a c'es wh ch BOILER„COMP(3HP OR 100,000 BTU)
mit h do
re,tt nl ants as defined by the Bay Area Air Qualify Management _- • y, C
f09A_L
h
❑Yes
-,BOILP,R ,COMP(OVER 10(1,1X10 BTU) � t
� �
AIR CONDITIONER
I have rind The Infamous materials reyYements under Chapter 695 of the Cal nd ' .r. ^. ISSUANCE DATE
- 0
foram Health Ar Safety Code Stalin.255115 25533 and 25534.1 anderatohd mat If the NEW RESIDENTIAL MECH.. SSQ.ET. '
mildia,do,,not uveady ha Neem brain a t.tny re,fir Abilily to sulayhoeserapart
r.: oFlherego remems which Host be met poor to lssuaneeofa Cemtieeteof Occupancy. � � 1 '
r Owner or authorized agent • s, Date q ISSUED BY: "1 -
'OFFICE