S 2056 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Rm1.DING-E,ECI'RICAI. PESI'I'NO
BUILDING DIVISION APPLICATION/PERMIT PLUMPING.AIECI IANICAL �J 2056
RU11.DING PROJECT IDENTIFICA'1'IOtN
BUILDING ADDRESS: � SANITARY NO. APPLICAI ION SUBMITTAL,,DATE
-2-o --r ( � �' v zq Q'J
OWNER' IE: PHO R: CON TRACTOR'S NAME: LIC NO',
NIC CONTROLp
AItCH1ITiCl'/1: GINIiIiW IJC NO ADDRESS', - ❑
CONTACT: - PHONE: BUILDING PERMIT IV
❑ Cltt Fees Paid by Applicant(Initial) .DO-,.L 'P PLO i MIiCH
-3 onsuanII� eL'C�
I.ICENSEDC1lNTRAC1ORSDECI,ARATION (/1'y IiLECTRIC PERMITFEE -
I hereby affirm that I um licensed under provisions of Chapter 9(camtmanciog JOB DF TION
O LL'Z. with Semion7(Xp)af Division3afthe Rusinexsu Professions Codc.cadm '.rose is RESIDENTIAL:
LL O O PERMIT ISSUANCE
won, in full force unJ effect. 5 ❑gpUWh ❑KjTCHENRI7MO EL
C)'U License Lic.p APPIJANCHS-11-Sl DIF ❑AUUI'fION ❑I' RI 'li
NQ6 Dale + Contrsemr
ARCI11'IECT'S DECLARATION ❑MIJI.TI-UNIT SF,Dvi PANELSZONZI undemmadtyplans shu11 he arceda.,islic recnrde MOX'S'-'O UP'10200 AMPS ❑IN'f1iR yI(�CHE AIRt.�F'W I.iansed Podssia.ul 2n1-1000AMPS IMI' VEM T /[)'SGP OLS
Yf' OWNEGIIUILDER DECLARATION l`�a
-) OVER Had)AMPS ❑ 'H RF: Il' 'Pi DEMOLITION
0.'C d I hereby aDlnn that I len exempt from the Convoetor',License Law for the
iq5 O E U following rnuvm.(Salton 7031.5,all,ine..oed Pmta,,inns Code:An I 01 Ilio r
m LL F' which m 't m cunstmn,aver,intY ci y ur coon Y SIGNS ELEC'I'RICAI.
Om 4 P p d Tillrepair- Y.t rnre
print t .: I: requires,papplicantf hpe ill TI g J. mment SPECIAL CIHNR/MISC.
(hath . dl) n )( p i( Ith C 1 Lia L Law'(CI pmrY
y (eo mem t6wth Seat n70[Nllnl Dvsi 3 flh 1{ ,' „ JI fresio,Lode).' 'rI:MP MI:'I I:R OR POLL (NST. R '
W 6 O C that he is clampt thercfmm uad the havis for the aIle.$escm none An Inion of i
X^LL
San..7031.5 by any applicant fora pem,it objects the applicant civilrpen rof POWER ICES TKN BLDG/ADDITION ❑FOODSERVI
W—y ' ❑TENANT ❑FOODSERVICE
I more tbun 1'rve hundred Bettors(5500).
Z>' IMPROVEMENT
fFOd ❑ Lottie%(nd(ha pnrperty, rmyot intended muffergesor tale:(nets comp... 1 ,..:TRIC
will Bothe work.and the structure is not intended ondlemJ for sale(Sec.7044,Rusin El 0`1
L 3 se oad Prolbuiom Code:The Cmanscon"License Law drcs not apply to un,- 1 h Ecom to on
property who build,or improve,(hereon,all who dee,ouch work himself Lir th
his own employees,provided Htln such improvement+are not intended car olle aftOwner aCCe 'G '
w]a.If,howcven the building Lir improvement i.s_sold within Line year orcontpletio n SQ.FI'.FLOOR AREA SisQ.FT '
owner-builder will have the burden of proving that he did not build or improve famflity •11 WON
pow ofenlc.), f�J g
❑ 1,a,owner Lir roe prepen,tm,..eltrovely[on re,li.g tail..[sones enn(met�1/M1 VI I OS O
.monad the project(Sec 704T Rosiness and Profession CWI:)'lher,,.I.cl ,
whve Law rites not apply ur an owner of property woo M1uilds or impro�stherrot sled BluelPeif,PERMIT FEE -
ownlmdxfnrx.cal project,wilhaumintclnrtx)(lent+ulparm ala eCnnlor
I.iCea,e Law. rr AJU) rw 9W
❑l am Clamp(under Sec. .B&Plaonnisns ''" •1'AL
-1 AIXE IN V WA ( VALl1AT10N
Owner num
WORKERS COMPENSATION DECLARATION is
have
ambyal mai man CCemlD ofperjuryone nft1f-irsnwingdecllretinnv: f
❑ Talose and will muinmin aCertiOcnmofCnnsenuo self-insure fnrWw,ke.Is Cnt D INS-FLOOR, ,ARr OND. STORIES TYPE CONSTRUCTION
,Inion.,Prosided for by Seat 13700 or the Lahor c in,for am perfnmtunca
work for which on,panni(+I....d. -
❑1 have and will maintain W'orker's Cotnpansomm Insurance,as required by Section
3700of the Let,o.Code,for the lnrtbrman.eof the work fnr whill,'his permit is GAS-EA.SYS .M-I INC.401T1'LP. OCC.GROUP APN
MyW.. •I Ilan I�tpyaJp ,,LrJ Puli.y nlynpggtplJl qy�J
Carver:( IIOO`�YY//Policy No.: 1J1/-/T/F�M/ STEM OV`
4(EAI
ICATEOFEXEMPf10N FROMWORKERS'
NL 60007E COMPENSATION INSURANCE GREAS DUSTRL WASTE INI'IiRC[PfOR
BUILDING DIVISION IRRS
(This section pled not nannnplemd it Ite pemtll i,fonme handled do1Ln,($1011)
CIt
or Co.)lE E
. TRAI'
PLANCIIECK FEE
Icemoyflam intheperfmormaofunaamk forwhwhakisermit o:sued,Ishii) S ER-SANITARY-STORM EA.2W 11'.
not employ any p.non in any.torr,so as ht necome,objm(m the Worker,'Carmen ENERGY FIR
Z
stair.Laws of Calilbntia.Data WATER ITHA'IER W/VE N'I'/ELP,C'I'R
Z O Applicant GRADING FELL
In NOTICE TO APPLICANT:If,after making this Cer ifcate of Exemption,you shouldWATER SYSTEMIBEATINC
a ; become yah,j,d In the Worker',Campen,atLm provisiats of the Lmants,
a. r Cndo,youuSOILS FEE
forthwith comply wllh such Toni siln,or This permit shall he Its, Iinvoked. WATER SBRVICE
0
CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMP. SQ.FT, PAID
U O lhcllb,tt Gnnlhanherc lsucon,m¢'Iinn lending ugen.y tar theperlitn,it elf krope Receipt#
O tti the work for which thin permit is Issued(Seo.3097.Co.C.)
Lender's Name TOTAL:
Laurier:,Address TOTAL:
I cenlly thin I lnvc read this appliemiot and snac Oct the ulnae' ..(union Is BUILDING PH.
V) conectl agraclocturnply with all city and cvmniy ord'ten.s and state w+rdming to QTY MECHANICAL PERMIT FEE
VZ building cnnaroctmn and hereby amhomemprcsemeo'softbect oenmr ury,n the SEISMIC
alame-mentioned p,,,,ny for itspcctme purfvwc,. 1117RMIT.ISSUANCE
(Wel agree In save,ittdentnlI,and keep hurnde,+,theca f Cupertino against ELECT RIC F
Into....cs,juegm tv.rnv,a pence,which may in any way [me against mid City AI TER OR AILD TO MISCH. '
Concert he
the dlM1is permit. PLUMBING IgiI:
APPLICAN D t DS AND WILL COMPLY TH ALL NONI'OINT AIR HANDLING UNI'('(TO IQ(XNI CPM)
SOURCIiI I I MIiC11ANICAI.I'EL
.� AIR HANDL(NO UNIT(OVER 10.000 CFM) CONST RUCTION TAX
Signa roof Applies me Duro EXHAUSTHOOD(W/DUCT) HOUSING MITIGATIONI'lili
I,ZA D1 Ujs M 1RIALS SCI.OSURH
Will theapF.icutn arfutorebail Sore tsene or handle hazardousmateria. 11HATING ON LT.(TO 100,X01111'U)
as defined by the Cupertino AiunicipaI Calc, u opts(9.12.and the Health and Safety
Cade,Section 2553200'! HEATING UNIT(OVER 100.00o RTU)
❑Yes C]No
c.
VENTILATION FANISINGLE HL'SID) PAID
Will rhe applicant Lir fpture hail ng by the B ace equipment or devils which Dem Receipt p
emit huaunlous air ummmivnmx as d .cJ by the Roy Area Air Quuli(y Munugemen( ROl1,ER-COMP(3HP OR IIXI,01N1 RTU) I I L Q
District RORER-COME(OVER 100,0X1 IITU)
❑Yes ❑N
11, sen c .. It,,, nntcrials requircmm�tx undo Chtmlm fi.95 nfIhe GIL AIR CONDITIONER ISSUANCE DATE
tbrom H IIF a G .S,tions 25505,25533:rod 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.FT. ' ,-S /14�
Indict d . t nam haveamman1.thin it is yre"anobilay m Lady Iii,occupant G `I
of th e w most la, rot aCe ! /?
O tern authorised gent v Date TOTAL: ISSUIiD BY: `� CA
OFFICE