S 0001 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 11UILBINC-ELI:CI'RICAI.
PEItMI'1'—BUILDING DIVISION APPLICATION/PERMIT
_ NI
BUH-DI A REFS: , t
S0001 _510-0-ul
SANI'D\RY NO. APPLICATION SUBMITTAL DATE
( N' NAA1Ii: PHONE: Cf 'IACTOR'.' �j LIC NO:
I NIC CON01.as
TR
RCM' E YENCANE1!R: LIC NO: A .SS: �/l ❑
dCONTACT': PHONE:
7 r BUILDING PERMIT INFO
❑ Consultant Fces Paid by Applicant(Initial) BLDG ELECT PLUMB nILCH
LICENSED CON I RACTOR S DECLARATION J I '1 'i I 'V' t' i 't . ,1 ❑ ❑ ,� ❑
a Z 1 hereby affirm'hot I Ic d oder pnwisums of Chapmi 9(ennme 1 g QTY 1 F.LGC1 RIC I MIT IT i1
W� tnSalon]ap),rD' Iron3nnnenna news and Pmreacm,acadecadin lieetseia - L" ' .TOR DESCRIPTION
innfull force and eR �� PERMIT ISSUANCE El SFUW NTIAL
U U License Ldp p ❑SI'DWI. []KITCIIEN REMOOIiI.
a,<, APPLIANCES Dare Contractor APPLIANCES-RESIDEN'T'IAL ❑.ADDITION
A IIITI!CT'S UECL lO El PLUMBING RE-PIPE:
zo-Z I umlcrsund my plans shall be used as public ra<I'm, PANELS ❑MULTI-UNIT' 11STRUCTURAL
F
UP T02()0AMT'S MODIFICATION f"W Licensed Prnlessinnal fFR IOR
201-10(p AMPS El CHIMNEY REPAIR
M1n w J OWNER-BUILDER DECLARATION PkOVEMIiNT
L Q I hereby mSect tnol 1 a.S eBusine from the Commcmr's License Law fur IM1e Q SWIMMING POOLS
OVER IIXNIAMPS ❑BATH REMODEIJREPAB QDFAf OLI'I'ION
3 a following reason.(Section]03L5.Business and Improve,
disimli h,a,:Any city nr me my
F LL OE which reyuifns o pcnnil to caudated.alter.Improve,demolish,nr repair any stmcwrt SIGNS ELIiCI'HICAI. QOTHF,H
lin pnnn 1. also q Ihapplicantmance,pc 'ufl g L element SPLCIA CIRCUITIMISC.
�d eE
'fail he lie dl rsuu u 0 p s Ith C I OY:Ii11m111a1ICha,,m1
�CL�Q (comb w lh Sccti mann a , f1h B i JPr An olmdc),1I TEMP.METER ORPOLEINST COMMERCIAL
that h x pt II ref I the h s's fur the IIagW axe npl oa Any v:nlalinn of '
^lin Seen 17031.5by.ny.,jimmorm o permit subjmis the applicant m a civil penalty of POWER DEVICE Ll NEW BLDG/ADUTTION El DEMOLITION
n more[hnn rive hundred dollars(&Sop). 'FNANT ❑FOOD SERVICE
=C,Q Ql,as owncrof the propcny,or my nnploymawith wages astheirsolc compenvtinn, SWIMMING MOL ELECTRIC PR EMENT
tPq- 1111 it,,the L work,and thesmtctum is not intended or offered far sale(Set.7W4,Business t S w and Pmbesaam Code:'Ilse Contractors License Law does not apply to as owner of OU ILETS-SWITCI IES-IIXTURES
Ponscity who builds or improves thereon,and wha does such work himself or Through
own employees,proW d
vidim im
sucM1 pmvunents etc not intended or offered Our NEW RESIDENTIAL.LLEC'I'IT ' SQ FT
sale.If,however.the building or improvement is sold within one yeaofcompliction,me
vo-huilder will Lave One burden of proving(nut be did 11,11 hudd or improm far par- - SQ.FT FLUOR ARBA VSQ.FT,
pose of ted"T -
El �.
1,as owner of the pmpony,ant exclusively contracting with licensed contractorsm 'f0'PA L:
consultant the Project(Sec 9011 Business and Prof..Orbs Cade)The Cm mem s 1 f _
r selowJt"asio nucic"uwnevafanptty h huildsor'mpmveslhmem QTy3 Ij+'4)3'•.tII UMBINCfIERMIT'I�II 1 { ' ' WIRY 16 -RCCIU
who Law. [orsueh pngecOwth a comom OT ensed panuam to lbe Coamnors I '! it .' IEE+'
License Law.
-- .. Q,lame-emplumder Sec. ,B&PCfor this reason PERMITISSUANCE
Owner Dole AL5'FIR-DRAIN&VENT-WATER(IA) - -Lrf I IIIIU
VALUATION -
WORKER'S COMI'ENritary on DECLARATION RACK FLOW PROTECT DEVICE
Ihercby affirm under penalty al perjury one of Wulollowing ticclamtinm:
Q I have ands will nufnmina Cabuiene of Continuo self-insure for Worker's Curran- DRAINS-FLOOR,ROOF,AREA.GOND.
still.,as pomsted for by Seainn 3700 oftba Labor Code,for the performance ul the STOItIES q'YPI!CONS"CRUC'TION
work for which Ws permit is issued. - FIXTURES-PER TRAP -
Q 1 hemeamd will nain.k.Workers Cumpensaion ImOance,us regaimdl by Sanioa
3700af the Whir Cotte,for theperfmmance afthe work for wMy hich this permit isissucd. JCpS-EA.SYS OEM-]INC4OUThEI:S
Carimrketa� tpe� t alnsumncecamerund P,licypy�pr ,I�e ` n OCC.GROUP APN
!_L Policy No.. GAS�/ GAS-EA.SYSTEM-OVER4(EAT
CERTIFICATE OF F.%EMIsHON FROM WORKERS' /
COMPENSATION INSURANCE GREASEANDUS'I RI.WASTE IN'D!RGlel'IQR
or do's.)
(Thissection need not be completed tithe pemtn is for one hundred dmGRI!ASF:]IRAP bm(E IM) BUILDING DIVISION FEES
"
I certify that in 0e performance of the work for which his pemtin is b bed,[,hall PLANCHECK FEE
baI en"k,m y pe dun in any mama as as On wenue suhjeeun O he Workecs'Com,am- SEWER-SANITARY-STORM IIA.200FT.
0 z ..firm Lace-d'Cadifora m.Dole ENERGY FET!
z 0 Applicant I WATFR HEATER WNENTII!LEC TR
lin NOTICE TO APPLICANT'If,afar making this Cenificale of 1!eemptira you should GRADING I'IiC
ks..csubjccl to the Workers ConnK :lien provisions of the Luhm Cidc,you mast W FR SYSTEM?REATING
W �y ronnwith comply with such pmvisiansor this pe.i,shall he deemed invoked. SOILS FEE
WAT HR SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLATE. SQ.Fr. - PAID
U 0 IOil Mian that is a conslmnion landing agency for the performance of Dane Raciplb
LA F the work for which this permit Ovsued f: 3097,Civ.C.)
0 U Lumber N —s 1
F Cwt-
TOTAL:
I nfy that Ih mad application and Ohlth bo information is TOTAL -
H y carecO la, I Ily with sjj,,,and nolim ondantaue,and state[a.,rel.lim,in TYII�,� -- 1I` - BUILDING FEE
U ,z building construction.and h renyamhorize npresemaivesofltiscit ht enaru Q MECFlANICAI IERMIT.. t %'FEE
mwc. m11naned ro t for ins Y pen lM1c I . 1e .a. SEISMIC FEE
P posy indemnity
and keep ha
(We)ngreelo soup indemnity and keep heatless the City of Cupvnino vgoiry PERMIT ISSUANCE
it,consequence
ofthe cos¢undof ewnich oto I!LGCI'RIC FEF,
pe e. yin any way acerae xgain.a said Cily AL'I IiR OIt ADU'ro MECH.
ANTof the graining,1ft ' DWI[. PLUMBINGFEE
L ANT UNDERSTAND AND WIkL,C`OMPLY WI'1'11 ALL NON-POINT' '
P "IO AIR I IANDLINGUNI'1'(TO 10,030CFM)
/ MEGIIANIGAI.FTE
AIR HANDLING UNIT-(OVER 10.001 CFM)
Sign Oreo App1i a Can ractor CONS'I'RUC'I'16N'IAX
ate EXHAUST IIOOD(W/OUCf)
LAZA bounce MATERIALS eorhanl ❑OUTINGMITIGA'110N I1!E
Jly liconlnr fuwreipal ode.( 1 oreorhndti, hvardousmaOrinl HEA'T'ING UNIT(TO 10(I,fXp(ITU)
at
C def nal M1y,t e Cupeninu Municipal Code.( tip r 9.12,and the He:Jlh bud SOtrvty -
Ctsle.Section 25532(a)^
Yee IIEA]]NG UNIT(OVER 100,000 BTU)
❑ t
I` VENTILATION PAN(SINGLES REID) - PAID
Will the applicant or Po building occupant use mryipmmt(or device,which Dole Receipt p
nil hvzadous air eontionamies ns defined by the Itay AT.Air Quality Management 'BOILER-COMP 0HP OR ILBUM)13TU) -
Oistricl9
❑Yes '(�\,/', BOILER-COMP(OVER I01don)TO N) TOTAL:
I have mad the hamore materials requirements under Chapter 695 of the Cali AIR CONDITIONER—
fomis Health&Safety Cale,Sectio 23505,Q5533 and 25534.1 understand that if the ISSUANCIi DATE
doesnot'noma ly It vean omt.Oballt is myn.IptAsibi i, notify Ohernu I NEW RESIDTNTIALMCCH. SQ.F1'.
ui niprior at iuure Ulan
chm •mel ano cae of Uc p
/cc
r au Blamed. t - S Da TOTAL:
ISSUED BY:
OFFICE