S 1402 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OI'CUPF7RTIN0 - BUILIIINC.-FiducrRICAL PFgR`�11TNO
BUILDING DIVISION APPLICATION/PERMIT rLUMInNf.-MECIANICAI, U 1402
BUILDING PRIIJEC'I'IDENT'IF'ICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SURMITTAf.DATE
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O ER'SN E: ONit,: CONTRACpR'_1�N✓AM1k LIC NO 33 4/ NIC CON ROLM
A 'HC'I*ENGINEER. IJC NU'. A DIi SS n ❑
% KI ✓t!I/IIGI
CONTACT: PHONE: BUILDING PERMIT INFD
- q ��77 - ❑ Consultant Fees Paid by Applicant(initial) ItLOG aC(" PLUMB ME❑CH
J o �s
1 ICNM 1)CON'RAC I ORS UI(1ARATION (ity. LLECIRIC-PERMIT; I FEET- .r
I n br n r th 11 licensed ud p f Chapur,9(to come s .: JOB DESCRIPTION
'00CWZ what. t 700(d (Diviion3 Ohe Sto c.: d Profession.0.lcandmylre r1 RFSIDENTIAI:
WOO PERMIT ISSUANCE Or
FU 'm fill ftrvmd effy, ❑SFDWL ❑K[TC1IHN REMODEL
aUF' licenseClnsx L--hp Lic.N yH3 i9l
<—U APPLIANCES-RESIDHNT[AL ❑ADD[T[ON ❑I'IANI RI NO RP.11PH
v~iaa Date Contractor—
[:J
ppm ARCHITECTS DECLARATION 1'ANF.IS MULTI-UNIT []STRUCTURAL
F'tn uu
Z I d—fdrai my plans shall he used umr
s public redc
O O MODII§CATION
m UP 0^ 1AM
' 200 PS
p2-.p ❑INTERIOR ❑CIIIMNIiY REPAIR
F-.'?Fly Licensed Pode,sional IDI-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
50J OWNER-BUILDER DECLARATION
�I a, 1 hereby uft)nn that are exempt Gam the Contractor',hiccnrc Law for tireOVER Itoo AMPS E)BATH REMODEUREPAIR DEMOLITION
ia5,p C.U lidlo,am,mason.(Section 7091 S,❑usiams and Pade,o me,Codc:Any city or commy SIGNS ELECTRICAL ❑[YI'HER
ty'31y N which becomes a permit to mnHmct,alter,improve,demolish,or repair any.structure
1"'4•pI poison if.......c,,n6ounpineantcapphcaut for suchpvmnt to file asigand upemem SPECIAL CIRCUITIM ISC.
at mal he is licensed pnrsumn I)the luovisimts of the Coalostar's Licence Law(Chnpmly
1,0 (conn ing with Scali on 7000)of Division 3 of the Businesaond Professions Cale)or 'I I!MP.M L'I FR OR POL- M:1 AI'
M q o Z that he is exempt therefrom and the basis for the afleged exemption.Any violation of ❑N. iC.DGIADDITION E)DEMOLITION
iC I+t Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES I� IANT [I TOO[)S17RVICE
W^N loan fro hundred
in s,l dMha's($5(HB.
IMPROVIiMF.NT
�SQa
E]1,arnwncrof me mopeny,nr mr employees with wages astheiradeasmperstfon, SWIMMING POOL fd[I QOf ERyy�F- will do the work,and the structure is not intended occurred for.nle(Sor.7000,Business
W and Prufceaions Cale:The Contractors Limos.Law does not apply to un Baran of 001'LFTS-SWITCHES-F T ES
n I builds nr im - lhercnn,and who stow such work hiurad ur tbmugh
pompe y who ded th his own owelnyees proviJW that such Impms sold w arc nm intended nr..)bred for NIiW RESIUENTIAI.ELECTIt :Q F.
sola If.however,the building or inmprovemem is sold within one year of campinion.the SQ, 4.FLOOR AREA LSQ PI�
er-hnildcr will hdarthe harden of proving that he did not build or improve for ms-
M,so of side.).
0 1,as owner of the property,am eachaosely eommaing with licensed combatant a, '1 O'I'AL:
obs me,the project(Sce.7W4,Pushed,and Pmfcssinns Caic:)'Me Commcmrs Li -- -
serve Law does assupply to an owner of proceny is hit holds or;operves I hercon.and QTY, PLUMNINC PERMIT' l!, FER
who couthicts for such pmjmtxwth a cont nr(s)Icensed por II,,llc Cnnr tar's
License Law. PERMIT ISSUANCH
❑I am Corrupt under Sec. ,R&P C for On,teasnn
N;I IiR-DRAIN&VIiNT-WAI'f:R(EA) VALUA'I'I ON
Owner i ])are ///ill •
WORKER'S COMPENSAT ION DECLARATION RACK FLOW PRO]ECL DEVICE � 7tDo
I hereby affirm under penalty of pedury one of the following decWration V
Ihavemlwillnuni main a Cenlfcato ofConsenti,self-inion,lar Wader's Compmr DRAINS-FLOOR,ROOF,AREA.COND, STORIES '(YPE CONSIRUCI ION
..tion,tis provided liar by Section 3700of the Labor Code,forma,pednrnnnnce of rhe
work(or wh,,h,his pa.n d,is issued. FIXTURES-PER TRAP
haw and will nountuin Worker's Compensation Insurance,as required by Section
37(Moflh,LnMu Cei for dur,ironrou,softhe wick far which obis p,nnite.ismmd, GAS-EA,SYSTEM-I INC.4011I'LETS OCC GROUT' APN
My WnrAcr' Cy(np yy antl Policy �}c9ju�/ p
Gorier�` �1/C��rPnlicy No.✓�'F J •J/Ossa GAS-FA.SYSTEAI-OVER4(IiA)
CER'1'IPICA'fE OF EXEMPTION FROM WORKERS'
COMI'L+NSAI'ION INSURANCE NtF.AS1%INDUS'I'RI.WASTH IN'I'P.RCEPfOR BUILDING DIVINI NI'19iS
fHus section need not be complOod if the permil is far one hundmd dollars(lil Qd GREASE TRAP
m less.) 1'LANCHECK FEE
I...Iffy that In the Isrunaince sibs,work fnr which this permit is issued,[,hull SEWER-SANITARY-STORM IA.2(X)17.
not employ any person in any rumor so us,,beemne mhject Is the Worker,Cooper- I!N1il1GY FEE
C) Applicant
laws of California,Date WATER METER WIVENTAILECIR
7� O Applicant GRADING FIiG
G h NOTICE IT)APPLICAN'F.It.Nter,making the,Ceni6uvtc of Exemption,you should WATER SYSTEM/TREATING
L✓ become subject to the Wnrkerh Compensation Prov sinner of 0.Lahr Code, on must SOILS FLU
� ? foMwith comply with such provisions or permit said he deemed revoked. WATER SERVICE
a
CONS I RNLENDING AGENCY NEW 1iMDENTIAI.[LMBSQ. IAIU
V7Ihereby uIEmnhm hercisacersmnind lending for the rfrmanea n
ItacplA
Q
F the wad for which,hi,permit is issued(sm.3097,Civ.C)
1j. 1-cndera Name - TOTAL:
O U lender's AJdress TOTAL: 11111LUING lit
I eco fy that 1 h d this d state that th M m
e'nlhrat is _
F'H . neer I agree to comply with all city anti county ordinances and:mt refiring to QTY, MECIANICALITRMIT ! rOD
U � builAngc pururlam a Jhereby tl r. p , I I . ry
fill' ' t ter upon the SEISMIC FIiIi
above-nmmtioned property fnr in,ecdon Pun,artc, PERMIT ISSUANCE
33
(We)ogrm In save,indemnify and keep harmless me City of Cupertino against RLBC'PRIC VEE
liahilitics,)udgmentx.costs and expanses which may in any way accrue against said City ALmk OR ADD TO MECIL PLUMBING FEE
am.eautiu,of the gmming of this permh.
APPLICANTUNDERSTANDS AND WILL COMPLY WI'T'H ALL NON-POINT' AIR HANDLING UND,(TO 10,1100 Cl
MECHANICAL FF.F;
SOURCE RBGULA)IONS,
AIR HANDLING UNIT(OVER 10,00)CFM) CONSTRUCI'IONTAX
Signature of AppHemau boulor Date EXHAUST I IOOD(WIDUCT) 1 i IOUSING MI'pIGA`I'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplcom or future buildingaccupaatmom or handle hI...is material HEATING UNIT(TO 100,000 If'
as deUn,d by the Cuperino MoNdpal Code,Chapter 9.12,end Tho health and Sefoly
Code,Sersion 25532nd? 11EATINCIJNIT(C)VIIR100,011pIlULI v Iltll'ILJ
❑yes No VENTILATION FAN(SINGLE RESID) PAID Date Rereima /
Will the applicant or future building occupant use eynipmnt or devices which
emit hazardous air contaminants as defined by the stay Areo Air Quality Manvgemenl BOILER-COMP(EIIPOR 100,I1WBTU) 'I'UTn
DouncR ❑N, BOILER-COMP(OVER 100,000 BTU)
❑Ven
I have real the hazardous materials tournaments under Chapter 695 of me Cali- AIR CONDI I'IONER ISSUANCE IJA
Lamin Health&Safety Cale,Sections 25505,25533 and 25534.1 understand that if(tie NEW RESIDENIL TIAL MECSQ.FT. 3+�5 q7
hnildinng Anes nn1 cunenlly hove a Ienvnl,Ihm it is my re spoil iMlhy m nrnily 0e necupant
ofthcop,momcml hichnmsi bcmelpdonuissu:mr.fa Cetificurof Occupancy.
I
Ownennauthnrimd agent Dom TOTAL: ISSUED HY,
OFFICE