S 1948 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPF.RTINO BUILDING.ELECTa1CM, Mitt INO, 1948
OUIL'ING DIVISION APPLICATION/PERMIT DI.IGPROJECEICIEN OFF I.
BUILDING PROJISC'I'IDIEN'I'14'ICA'1'I(IN �_
BBU^UIILDINOADDDRE/SS:+ �+Q` ,^ �r Q 1 SANITARY NO. APPLLII/CATION SUBMI'PI'AL DAI'4
'`� /45 S 1 CYGN7 G12�r0w- �IrVOe /r
OR'S NA E: �� 0 -I•O'�i{(ypi; CONT A :S NAM'{ _ ,tea • I ICNO:
(y IJP I``V/` NIC CONTItfl1.K
AR II 1'IiC9' GI .I 1: S LICNO. Do ': kL�N �T "'
CONTAd: PHONE: BUILDING PERMIT INFO
G �1L ❑ Consultant Fees Paid by Applicant(Initial) BE
ELLp PLUMB MEECCH
LictiNSEDCONTITACIORS DECLARATION QTY. ELECTRIC PERMIT FEE
I heathyfiml sfInn Imo bmmes ander pmol:inn.of Chapm(9 fenmmcening - JOB DESCRIPTION
0.'Z ms«lion vkl0)of oivisianlnnne linc;nees and Pmfe,:ions taut.ane, Bamxc in RESIDENTIAL,
COp wi PERMITISSIJANCG
IF- in full torte°u�n,J-e��e�l-'�4^/� � IM ❑SFDWE [I KITCHEN REMOUEI.
QUU LlccnIe. • I•{ Lic.q APPLIANCES-ItfiSIDIiNI'IN, [-]ADDITION ❑I'LUMI{ING RGPII'li
y ul Date ,f/�� �"(� ��_+�-Cmnn,cmr PC
F D m ARCHITECTS[ZOA ATION PANELS ❑MULH-UNIT ❑STRUCTURAI,
'�'Z lundcrsund my plans shall bevuJ us puhli<remNs MODIFICATION
OZ-0 UPTO 20DAMPS [I INTERIOR C1 CHIMNEY REPAIR
Pccs W Liunned PrmacslOoal 201-10NOAMPS IMPROVEMENT E]SWIMMING POOLS
GWNIiR-BUILDFR DECLARATION
as 1 heathy affirm rens I ren exempt Into the Comrucmr'e Llaense Low liar the OVER OPOAMPS ❑BA'HI ItEMODE1.IRlil'AIR ❑UI?MOLITION
2�a U fallowin Section]1131.5.Business anti Prnfession<Code An t esmnt ❑OTHHR
�!, g remon l Y ci y lar y SIGNS ELECTRICAL
1+13 ct vFi which require,a permit ,,carovum.ohm,improve,demolish,or repair any,vuaure
I..
To to it,'. n •,aso re"dic,thaccipplicamf h permit, file a signedstatement SPECIAL CIRCIJIL/MISC.
}
'Em he is I I purse I I sl p iol: I in Contra..... I Law Ch:pmr9
al 00 (en 6 ll Seel 7000) fO ui t Ilh Entices,s, JI ft :Code),( I EMR M EI'I:It(IR POLI:I N S'I'. COMMERCIAL:
d y o as 'hal he is exempt therefrom and the ball, or she nllegcd a amption.Any nnlullnn of ❑NEW BLDG/AUDITION :MO ATION
LLX1 1t• Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWERDEVICCS
y not more than live hundred dollars(5500), ❑TENANT ❑FOODSERVICE
4.Z>• IMPROVEMENT
QI]Laxowner dthe pmpcnY•or employces mended
wages Bred foxale(Sole compensation, SWIMMING POOL ELECTRIC
3� will dolhewnak,andthe xlm CcurcCut imm�ded,I.,usrcnt,alas c(Sea W9J,Bnsinexs ❑OTIIHR
and PI'nlesxinnr Cnse',The Cunu'vmnr'e IJecnen Lnw Apex nal apply is,nn owner of OUT LETS-SWI'fC11ES-FIX'TURES
.. property who builds m improves tharmm,and who does such work himself or through
his own employees,provided Ihw Such intpmvemeo¢am nos intended m uttered for NEW RESIDENT iAL ELECI'R SQ Ef.
sale.ILhnwrver.the building orimpmvemem ascots withinone year oftnmpletion.the
SQ 1-7.FLOOR AREA SISQ.IT.
owner-ladder will have the burden o'proving That he did not build or impose liar pur-
p,cenrsnle.),
❑ Lae ownernf the pmperl,,am exclusively convoodng wits licensed contmmnr, ,, NMI,
construct the project(Sec.9194.Business land PmfGssions C de;l'H,e Contractor',Li-
cerise Law does not apply to an ow,ner of pra,rty
i-censeLawdtlesnotapplymanownerofpra,rty who,hold.,or improves thereon,and QTY, PLUMBING PERMIT PEE
whncomites for such projects with acommnorg)fcenwiptimmnt mInc Comme O's
Licence law. PERMIT ISSUANCE
I ant exelopt under See. ,B&P C Inr till,reason
Owner Uwe At SBR-DRAIN&VENT-WATER(EA) VALUATION
Wm under p COMI'ENSATy on DECLARATION BACK ROW I'HOTECf DEVICE ZS " 0 ED
1 hereby affirm under penalty of perjury one of the following ded:unnone. V
❑Ihavcand will mainmino CenifiCelcof Concert msdr-in.cnrcfor Workers Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND.
STORIES TVI'Ii CONSTRUCTION
mono,;is providefor by Section 3]1X1 al the L;,hor Code,for the parfnrmtuna of the
workrnrwhich his permit Ixorke. II%'fURF:S-I'lilt'I'RAP
1 have and will maintain Worker's Conlpc l the w rkfor co. h regainr by Section
3700of the labor Cede fnnhe pedo'mancu nl the work for which this Pentair is iw.uep- GAS-FLA.SYS"lISM-I INC,40U1'LETS (>CC.GROIII' ANN
My Wor�(�m4n i,yylm�gc wandYllic � GAS-BA SYSTEM-OVER Jr13A1
Cartier: I/V�w' /LGprt�G�(�. ZZ=f{
D� �T�RTIF Ili OF F; ON FROM Ws t HR GREASOINDUSTRI.WAS 1'1:IN'PEIICEPTOR
PP.NSA'NONINSTURANCli BUILDING DIVISION VIERS
(11 i,wtainnnceJn Jr, the permit is for ane hundred JOlLvs(41110) GREA$E TRAP
or It".)I PLANC1117CK FEE
I teddy Ill.,inthe pe(formanceafshcl became
for whicblhis the WC i...,'Ca shall SIiWF.R-SANITARY-STORM HA. Ia1'.
not employ any petmn in ony manner no s n,M1ecosnc mhjcet sit the Woder,:Camper- ENERGY FEE
OZ salian Lnw,of Cakfomim Date WATER 111FA'HURWNENT/IflUiC'I'R GRADING FEE
Z Applicant
r
NOT[Cis APPLICANT:If,after making thio Certificate of Exemption,you should WATER SYSTEMIPREPTING SOILS IPE
becemc n,bjea to the Worker's Compensation previsions of the Labor Code,you Inuit
LkI foahwith comply with such ooukimm Crick pcnsdt shall hcdecmcd revoked. WATER SERVICE
Q
CONS TRUCTION uction LENDING,AGENCY NEW RESIUEN'I'IAL PLMB. 5Q.PC PAID
Z Ihach (firm lh:u lhert is acun.atmninn lenJin liv'he litnnnnce of Date ReceiplN
U Qyu ,C.) y per
meworkl far which mac I:annit is issued(Sec.3099,Civ.C.1
U Leudds Name TOTAL:
U Lente I Address TOTAL
�•I a BUILDING FEF.
1-+ teniry mm I have lean this lappbo:Aml arta fine 01atshe above w,lelam,n it
res wore,lo I..ommply as heathylonlaamtarnlmyntativestis nod nmm lawsrc Pon the
QTY. MECHANICAL PHRMIT FEF: 2U
U Z building msuvuction.mA hereby amhorizo representatives of this chymmucr npml the SEISMIC PIID \\
above-mentioned progeny for inspection pmprnes. PERMIT ISSUANCE.
(We)agree to save,indemnify and keep hnmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,cast.(. expenses whicactual h may in anyway acte against said City ALTER OR ADD'I'O MECH. }'LIIMRINGI
sarycn og ,r' ,f suis pcnnll,
le
•
In ren 1
APPLICA N I'A s5 AND WILL.COMPLY WITH ALL NON-POINT AIR HANDLING UNI'P CRs 10,000 CFM)
SOURCE ,GI'A )N d MI' IC L �EE
0 7 AIR HANDLING UNIT(OVER 10,NO CFM) S'lal1C 1 N�X
Situate dr p11 VC mo( tem EXHAUST 11001)(W/DUCI) HOUSING�d IGATION FEE❑iRIA1S DISCLOSURE
Will the applicant oI not ehankiagocco,ant store lar outdle tacticians naaoriol HEALING UN fit('n)IIX),,E If1'D)
as defined by the Cupertino Municipal Cute,Chapter 9.12,and the Health and Safety
Code.Section 25532(0)1 I IIiA'rING UNIT(OVER 100,010 BTU)
E]Ye, ❑No PAID
VENTILATION FAN(SINGLE BESIDE Date Receipt It
• Will the phe al is,(name building uccupam use cP acm or Jcvices which
emit hmanlnuc air conlamiscnse,defined by the Bay Ana Air Quality Maneganam BOILER-COMP(3HP OR 100,000 RTU) I .
Dishidt
El YO, ❑No BOILER-COME'ROVER 100.000 BTU)
i
I have read she im,aahms mmenals recarenccnts under Chapter 6.95ofshe Cali- AIR COrtim ITsNER ISSUANCE DATE
Cumin Hu.111,&Safely Cale,Steins 255115,25533 and 25534.1 unders'nnd Pan if she NEW RESIDIIN'I'IAL MSCI I. SQ,Ff
huddngd,uam actual,h:men tenon,mw it army ae,gmsihihly mandy'11e,wel:pam C7/- 7
of me requirements which must he met prior to issuance ora ccoacom of 0cen,aney. ( (�
Ownen,raumoriaed agent Date TOTAL: ISSUEDBY: 0 //ems 14 \
OFFICE