S 3009 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPS?MPINO BUILDING-ELECTRICAL PEI ITNO
BUILDING DIVISION APPLICATION/1'ERMIT PIN(;PROJIUMBING-CTII)ENriCAI. 3009
' ;,'I II1111,DING 1'kllJl?CT IDEN'TIFICA'TION ,
BUILDINGNIDRESS: SANI'T'ARY NO. APPLICAI[ON SUBMITTAL.PAT
Jos SToK�S o -2/ �g
OWNHR'SN M� P O�'E:� Co RAC NAME � 70 Z_1+
W NIC CON I BOL#
• ARCHITECT/HNGINIa9R: LIC NO: ADDRESS ❑
CONTACT: PHONE 3 . 'I BUILDING PERMIT INFO
l .r ❑ Consulmnl Fecs Paid by Applicant(Inifinl) PLUG HLO PLUMB M?67 [CF4
l/O J f/ C/ I r - - r.
LICENSED NSI D CON'I'RACTORES DECLARATION ELECTRIC PERMIT' �' FEB:
I h,aff vntI d orderp s of chapter 9(➢o mormin, QTV.,�' r JOB DESCRIPTION
withSection nnJXpofD 1 DI H s -
QatJP f. Cale nndm lie RESIDENTIAL'
won I'LIt MI f ISSUANCE
aW� 't hllf 24-5 ❑SI'IJWI. El KITCHEN REMODI:I.
W I- Lia Clvs Llc.# APPLIANCHS RESIDENTIAL ❑AUDITION ❑PLUMBING RE-PIPE
F Z W Uutc Cni I actor
mQy - ❑MUILTIUNIT ❑STRUCI URAL
AItU II'I l CI4 DCCLARAI'1
Z FOyz I andaaland Toy plan,slmll he a,alar public record. PANELS _ MODIFICA'f10N
❑P PO200AMPS
O z,4Q ❑IN'I'IiltlOk ❑CHIh1N1iY RIiPAIIt
I Ih¢unset Prol cmc,uiunal 201-1000AMPSIMPROVEMENT _ SWIMMING POOLS
OWNHIt-BUILDER DECLARATION OVI7R I000AMPS HAITI RFMODEIIREPAIR ❑DEMOLITION
C d by elllrut that I mil np
xol from the Contractile',License Law fnr the
El
U following reason.(Section 7031.5,loome,uad I'mic,dim,Code:Any oily or coaniy SIGNS Ia,IiGIRICAL ❑0111HR
W 34 i- which nryuirm o permil I,omisdo ct.al' ,imp,oc,demolish,nr legal,any dire m it
�' Print Ili hsuanrc,also myuires the applicantfor such permit to file a signed imminent SIT IALCIRCUIOMISC /—�
fwy ohm he is licensed puaaunuo the pmvisinnsof he Clothetar'e Liewme Law(Clam,,9 _
xyQO (rumn¢ncing with Seclinn 9lMpl ofD visinn3 of the Business and Pro[nsidas Cold)or I RMP.METER OR POLE ICOMM.R
ICIAL
a L e 5
Ili.,lie is exempt therc(mm and the basis for the alleged exemption.Any violmion of [INBW BLDGIADDITION ❑DEh101.1'TION
x^w Section 70315 byaayapplicant fill It permit steed,the applicam an.civil purl',of POWERIIBVICliS C3 MEANT ❑FOOD SERVICE
a more(hall five Imndred dollars(E50u). IMPROVEMENT
f=� Las oxoernflhe pmpenynnayemployees with%rovas their sole compensation. SWI\1MING I'001_ELECI'H ❑O'rHFR
p., will Jo the work,and the strvcmre is not intended or offered for late(See 9014,Hminee,
If
NW and Prnfesdnm Cale:The Concrat License Law dm,nor apply to an owner of Ou"ITI'S—SWITC '' Il RES
6 3— ptnperty,who nmins or intpmvex thereon,and who does such work himself or through
his own Employees,provided that such improvements are not intended or altered Irn NEW RESIDENTIAL ELC R FT.
sale.If,however,the hnildi ng orimprovement issold within one year ofannplelam,the SQ Ff.FLOOR AREA SISQ.17E
owner-buildur will hate the burden of proving that he did not build or improve for put-
pose of sale.).
EJ 1.as owner at the property,am exclusively contracting with licensed contractors to A
on t he pr 1 I(Sev.0111) [Comes, d Inims,oars Cale)Ile Cooled","I I
sce,cLaa,doc,notamlyl t fp prtY b h Id or mproves merean,anal QTY. T (,PLUMBING PERMITt -� Ji'rI -EE
wet artumt,lin,uchp IctlxwllIte nidct r(s)Teemed paananl to the Contractor i
LLccnee Law. PEItMH ISSUANCE
❑ I tan r,s,u,l under Sea. ,B&P C for this reloon
tiACI'1212—DRAIN k VENT—WAI'ER(HA) - VALUATION Owner Dille
WORKER'S COMPENSATION DECLARATION I{ACK FLOW I'll t ' _
IImuch,alfinut titch,pcostly(if pcj ry fine fillowid,d 1 F n,
❑ Ihave ill mannimin it Cl Consentl lf inium I W k 'Conpcn DRAINS II.O OFA D. RfOIi BS '1'YVP.CONSTRUCTION
soli :provided l I y 5 t 9980 of,he Lab Code,f thepct 'e at[he
work f whi,h0li,p T J FIX PH "i P
❑I have and willu,nousid,Wakcfs Compensotiot Insurance as myu,ed by Sccdan
3900 of the Lahn,Cul.,for the perlimnance of the work for which This permil is issued. GAS—PA.SYSr INWITLtagl . 8 OCC,GROUP APN
My Workei s Compensatin I Iso mnee cosier and Policy reactor,are: -
Carrier: Policy Nao OAS_IiA.SYS LOVIiH J[EAT
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASI%INIUP WASTE.INTERCEPTOR
THd,section Hud nor M ntmplmeJ iOM1e pemnil is fomne hundred Jnllaa 13100) BUILDING DIVISION FEESnr less.) GRFASH TRAP PLANCHECK FHE
Icl,rmy That in lhclerfommnaof the work far which this permit is issued,lshall SEWER—SANITARY—STORM IT.2110 Fit
plomm
y any Aon in any nnm as
Enter M�urrom
Ca em to the 5'orkeri Cnmian- - IiNIiRGYIRai
nor em
Q z mein,Laws o1C if, niu.Ilan c WAT17R HEATER WNENTOELEC1'R GRADING FEE
z O Applicant t
NOT ICE TO AI"1 N'R If, s n rRREFof Exemption,yon should WATER SYSTEM/I'kEATING
become subject te Walker',Cnmpe1 s lion pmv,was of the Labor Code,yon nmol SOILS 1'171.2
'W u forthwith cum ifft such provisions nnhi,worailshall N de,.climvokaL WAIER SERVICE
Q
a
CONhere is aconst LENDING AGENCY NEW kIiSIDIiNI'IAh PLMB. SQ.FT. PAID
VQ herebyaffil,tM1ui there isnconMrve.30G.0,agency fonheperfnrinunacof Date RcecipT#
C"' the kf ' ti "kI 1 :.. d(S 1099 0,C.)
I c 1 N 'TOTAL:
LU Le lie Add :. r' F TOTAL: _ BUILDING IIVE
�...i d I Try llet Il' I '
Irl . III and the b honestion is
Fr to mmu lapnaI Eply with�dl,'tyttd county ordinances and slate law,mlillin,"I QTY. 1 1MI?CIIANICALI PERMIT I
�J ,Z building cmetrnctlnn,and hereby authorize repm.enrahves of this city to enter upon the t 1 SI:ISMICI7U
ahovcnianlioncrlpro,seny File in,penin I pmPow, PHRMI'I ISSUANCE 3
(We)"gone nn"I",indemnify and keep Harmless the City of Calxnion against < I11.P,C'rItIC Ala:
Ilohililics,judginents,costs and expenses which may in any way accme against said City ALItiR UR ADD TO MECU
PLUMBING Fiai
in ouseynenceol'the granting lodd,permit.
APPLICANT UNDERSTANDS ANI)WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON I'f(TO to,"CFh1)
MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER((1,000 CFM) CONS'IRUCTION'I'AX
Signature of ApplicanUConrmnor Date EXHAUST HOOD IW/DUCT) HOUSING JOHIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicam nr furore building rccupam score ar Handle hazuNnus nnmerialHEATING UNIT ITO 100.OW BTU)
as defined by the Cupertino Municipal Code,Chapmr 9.12.and the Ileahh and Safety
Code,Section 25532(a)'? I HEM ING UNIT(OVER I00,000 BTU)
C3 Y" F-1 No VFN'I'H.AT]ON PAN(S INGLE RES ID) PAID "—
Wi It the applicam to Enure building occupant use equipment or devices which III ILIiR—COMP JHP OR IOOdI00 BTU) Dam ReceiptX
emir movolnus air conwminonts as defined by the Buy Area Ai,Qmlity Management AL:
Uom"l❑Y: N
ITOILER—COMP(OVER 110,000 BTU)
❑
I havemadII hmaid...ansacdals mquirements under Chapter(JS ol th CII- AIR CONIN IONHS ISSUANCE DATE
I.Ion Health FOSIry( SI '2551152550 all 15534 II Irl il'llc NIIW RLSIUhNI'IAI.MI?CH. SQ.FT.
hnll't Ips unuailyl vu ucu n.d lfanyaspon hllynnui lylhuun
nnh nidi It Ipnnnn'i„ansae araC rtihe r(x y
J L
m'ii l
Owi r ruuthoom,Eliot f1rue TOT ISSEI[D BY:
OFFICE