30497 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO % BUILDING.PURcrRICAL PERMU NO, -
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 30497 o A 7
BUILDING PHOJliCT.imSTIFICATIUN J 4 /
B UILDINGADDRESS. - SANITARY NO. APPLICATION SUBMITTAL DATE
s4 a0
I OWNERS NAME:.' I IPHONE: CONTRACfOR'S NAM LIC NO:
ISI U ^ N/C COMROhp
1RCHITt:. /BNGINEBR: .LIC NO: ADDRESS: ,/ ❑
CONTACT: T dPHONE: BUILDING P17RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLUG EuiCf PLUMB MGC
. .
LICENSED CONTRACTORS DI CI AHATION ❑ ❑ 1:1QTY ELECTRIC PERMIT' FEE
.1 heresy urrmt that I 1 e d a 1 p :i (Chip, 9(commencing JOB DESCRIPTION
WoZ with Smtion]tMXp arDl isi neJoDhe Bus dPrnfesvun..Qvlc and mylitnnse is RESIDENTIAL
Fad- in full lone and of I. G2d PERMITISSUANCE: -
�UkUJ License Class M ✓ Lic.N J TF gi- G771Y ❑SFDWI. El KITCHEN RF,MODEI.
I-Z W Dam Contractor H A0 APPLIANCE,-RESIDENT TAL ❑ADDI'TION ❑PLUMBINGRB^PIPE
Zee -ARC]IITECT'S DECLARATION
'N7y ..�MfH.TI-UNIT. ❑STRUCTURAL
'F PANELS�.' -
O Z-a understand my plans shall be used as public remNs - - MODIFICATION
OZ^Q UP T02W AMPS - C1 INTERIOR ❑CHIMNEY REPAIR
��E'W Licensed l'rofessimtal - ..e 201-10(X AMPS " " - IMPROVEMENT '
,E,'.�] OWNER-exemRDE DECLARATION OVER IMIAMPS - ❑BATH REM P-WREPA1R' ❑DE OLIT
ION
OOCa6 11 ehy rf tl tl pt ptf theC i I 1' lawfa the O
K 3160 folio ng tIS i ]ORIS
Business dP f :Cad Any ly Henry
hch SIGNS ELECTRICAL ❑OTHER
LLl cy ao p' II tt ape np demolish, p y ween
prior to itsI. q cthe applicant fparrat toMe a signed statement SPECIAL CIRCUIT'/MISC.
�y ,hath I¢ Jp u a th p s 0th C Iran .Lc In (Ch pmr9 _ _
x:� team is
exempt
th Serf n t add of D'v eta l he all g ed c.cr 11 Any vii Code)oa I TLMP.METhR OR POLE INET. COMMERCIAL:
a a p
that he is exempt thercfmm and the huffs for the alleged eacmption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031,3 by any applicant fora permit subjects the applicant to a civil penally of _ POWER DEVILS '
not mare than five hundred dollars 0501). '1 - ❑TENAMf ❑FOODSERVICE
-
' ESq ❑I,as owncrof the pmpeny,nr my etnployees with waSes as Ncirxnle mmpcnmtion, SWIMMING Td&C4CTRIC IMPROVEMENT
fir will Olathe worknndlhem,ecturc is ani Intended uroffcrul far sale(Site1044,Busincas ❑OTHER
and Professions G-0e:The Contractor's License Law does not apply to an owner of OUTLETS'-S 1 t -FIXTURBS -
63 property who huilds or improves thereon,and who does such work himself or through
his own employees,provided that web improvements are not intended or offered for NEW RESl14WIA'1-r.9.tJ'R - SQ IT.
sale.IL however.the building or improvement is sold within omeyeao(completion,the SQ.FT.FLOOR AREA $/SQ.FT.
' ser-huilder will have the huNm of proving that he did not hand or imprnve far put- t v
".of sale.). -
❑1,as owner of the prupeny,am exclusively contracting with licensed commas rsm TOTAL:
commit the project(Scu.7044,Business rad Profeai.ns Codc)'Um Coniaacmds Li-
cense Law does nm apply m an owner of pmpcny who builJx or improves thereon,and QTY. PLU IN� MI FEE PA A
.wanta ft r esuch pmjectn with a rnnuucwgs)IlcensaJ punuunun rho ConOnetole 1Y
ho cc
License Law. PERMIT ISSUANCE
lxm exempt under Sec. ,B&P C for thisreown
ALTER-DRAIN&VENT"-WATER
Owner • - Dam- V I 9S
WORnder fa Callyof NSAT10N Dfflicf dowingATTON BACK FLOW PROTECT DEVICE )) y ,7l)
thereby affrn under Conditon ofComeneoftheinsum or declarations:n �ll r UJ• Ld .
Qum,as and will forbinaCen1Oeamd ConwmmCadcnsarefar Womomm rol the DRAINS-PLOOH,ROOK AREA,COAD. JENERCY
STORIES, t' ONSTRUCTION
work for
pmvWhi for by Bodian 3](M1 of the Labor Cola for the por(nrmm�ca of the ,-
work for which this pennil is issued. FIXTURES L PER'FRAP
'❑I have and will maintain Worker's Compcnwtion Insurance•as required by Scotian
3700 ofthe tabu Code,for the performance oftlie work for which this permit is dome. GAS-EA.SYSTI?M-IINCSO13TLETS
. OCC.GROUP APN
' My Wmkc sCo9t7,mion lwmmncccamcrand Policy'y/JbjIr'
s Carrie,: i.i Policy No,:a✓`�r�`A/9 ze�o/ GAS-EA.SYSTpM-OVIiR4UA)r
5
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRI?ASFJINDUSI'RL WASIE INTERCEPTOR
('11d,sectionmeJnol M,matilneJ iDhepe,rmit aforunehundrel dollars(SI00N1 _ Hl1fLUING DIVISION RIES
or lee.) t GRPASETRAP NCHECK FEE
Iremfy that in the pet xeofthe work r,,which this p l ...call l shall, "
tem to an c unman m ral ml be bean theta kenC m SEWER SANITARY STORM EA.20017 employ Y yJ 1 pen ' FEG
Z urianLl of C.bf rnr D ZCz0 'Applicant WATI I2 HI:AI ERWIV[NTIELECTR�tdiag /C—' ADING FEF.zh NOTICbecome: II.the ork 11, Icamkag IhtsCen fcam of Cxate, on you oshould
rural WRIER SV59FM/1'RF.ATING; become mject y it Worker's Coro s or t is provisionsof the rood Coke,youmust LS FEE.
W forthwith comply with such provisions or pemtit shall he JmmN revoked. WATER SERVICE 4
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SO PT. PAID
U O l hereby affirm that there is a construction lending agency for the performance of - Data Receipt®
Us the work for which this permit is iseued(Sec.3W7,Civ.C.) ' ,vr
m -
U LenJeYs Name- _T - , TOTAL:
FH.1 I tnder'n Actions.. - TOTAL:
a 1 certify that I have read Nix application anal state that the mines,information is -- - BUILDING ME
V] correct.ingrec to tonally with all city and courryoninancex and sluts laws relining to QTY. MECHANICAL PHRMIT FEE
UZ butcinllconswmion,and hereby authorize represenhdives ofthis ciiy,to enter uponthe SEISMIC FEE''
above-mentimaod property for inspeaimn purpose¢.. PERMIT ISSUANCE - -
(We)air.m save,lodcmnil'y and keep httnnlew the City of Cupertino against ELECTRIC ME
liabilities,judgments,costs and expeneswhich mayinany wayemmcageinsl said City ALTER OR ADD TO NEED, PLUMBING FEF.
consequence of the gmming of this permit.
APPLICANT UNDERSTANDS AND,WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITfT010.111X)CFM)
SOURCE REGULATIONS. MIiCHAsU'AI.FEE
AIR II ANDI.ING UNIT(OVER I0,000 ChM) CONSTRUCTION'1'AX ,i ,
Signaurcofgpplimm/Contmcmr Date EXHAUST HOOD.(W/DUCT) ,HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicaaor future building owcupamsmr,or handle harallous ntamriil HBATING UNIT(TO 100,000 BTU)
its defined by the Capminn Municipal Code,Chapter 9.12,and the Health and Safety -
Core.Section 25332tm'1 HEATING UNIT(OVER oQ0110 it rut '
❑Yes ❑No, VEN'1'ILA9'ION FAN(SINGLE RESID) PAID
Date Receipt ,
Will the applicant or furore building occupant use equipment or Jnvices which�
emit huaBOILER-COMP(3HP OR IW,IXq BTU)
Dionw?hrdaus air cnnmarromits as delineJ by the Buy Arco Air Quality Manegentent A TOTAL:
❑Yes E]No ., • BOILER-COMP(OVER100,00013N) -
1 have read the hawdow...,cost,requirements under Chapter h 95 of the Cali AIR CONDITIONER
25533a ISSUANCE
buildsain Health&Safety Coda,e.whe e.dist,255]7 end 25534.1 to melons that if the u NEW RESIDENTIAL MECH. SQ.PP. °
building Joelnal sis ich haves mtmn prior oismy rcspanvicdBmnmifythecempam
an gmren •ale., tbn most ' pt;mr td ia.aan afacenmeme artxeapaney. '
D'
Owns a hors. urge Dae 1'O' L' ISSUED BY:
OFFICE