S 0600 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
r CITY OF CUPERTINO - '. " . BUILDING-ELECTRICAL ,. PF IT NO
BUILDING DIVISION APPLICATION/PERMIT, PLUMBING.-MECBANICAL _ 0600
ll43 t'. -it BUILDINGiPROTJECT IDENTIFICATION C. ' its - -
BUILDING ADDRESS' - -. _ SANITARY NO. APPLICATION SUBMITTAL BATF
0 8 N -A-cr 64glig,
O FRS NAMy. �. Y HONE' CON'TRACTOR S NAME: LIC NO: -
/V•• IL I► N/C ' CONTROLM-
ARCHITECT/ENGINF,P.R:, LIC O: ADDRESS: ' ( ❑
CONTACT: PHTE: - - - j .' 1 `,RUIEDING-PERMITINFO', y
/ D�, � -�•� b QConeultant Pees Paid by Applicant(Initial) BLD PLUMB _MF
-, ',Eli - LICENSED CONTRACTORS DECLARATION - - QITy $f t {3 ELECTRIC?PCRMIT? {t
Ih by ff that 1 d e fCl dpi J( e s ! Sj (-_ ( ;jj,.+,( -,#,i': JOB DHSCRIPTION -
A0'Zwith Scci )000) fD `i 3 flee Hu,. e.a eP f C dc,cdmylicww c RESIDENTIAL '
'00 PLRMI I'ISSUANCE
W� n full f roe and effect. 0''g 7� �, � - ElSFDWI. C1 KITCHEN REMODEL
6VU License LIc.N _ APPLIANCE S-RHSIDENTIAL ❑ADDITION ❑PLUMBING REPIPE
F Z W Gam Commemr
m60. - - - ❑MULTI-UNIT - ❑STRUCTURAL.
ARCHI'CECTS DECLARATION, �, � - -
p ,nz PANELS ` . _ MODIFICATION '
'L O w'� I unJersond my plane seal be used as pnNic records
Oz4Q UP TG 2(IB AMPS ❑IN'I""OR ❑CHIMNEY REPAIR
t,[�.,I"Wa Licensed Professional ' - - `. 2111-I(Ifl(IAMPS 1 OVEMENT ,O SWIMMING POOLS
OWNER-BUILDER DECLARATION'
9R5, 3 OVER Alfie,AMPS ' ATHREMODEURFPAIR CDGMOLHION
y� W d I hereby affirm on 1 ani exempt from me fesnan,Ca .Licence,Law for the -
jsj 3 F which re messmason.(Section 9 construct,
Business and improve,
de Profession,Cndei pny coior n or coumy SIGNS ELECTRICAL - ❑O 'R
F(rQ
which q ' e,permit I t II P demolish, repY.t cure
Prnn I e req m ppl' of I permitt fl signed knimumat SPECIAL CIRCIII I'/h1ISC.
pep y thane I dp tt theP fthC vol L I (CI pmr9
(eat g with5 t 9000) fDivision 7 Of the Brainless s dP f,s' Coal)or TEMP METER OR POLE.INST. CAMMERCIAI:
01st he s exempt demotion and The bass for the alleged esu prion.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLI'PION
YXI W Section Il31.5 by any applicant for permit subjects the applicant to a civil(corny of POWER DEVICES ❑TENANT ❑FOOD SERVICE
1 more than five hundred dollars($500).
O ❑I,as owner of the property,or my employees with wages as their sole conlpenscour, SWIMMING ED +IR RIC OTHER EMI:NTt
will do thek and the stmcture snot intended B •d for sale(S 9044,Boniness []OTHER
3 m and Pmfe..' . Code.The Continuous License La does t ,ply to an ow ler of OUTLETS-SWIT �,E P 'URES _
pmpn)who builds or impresx hervive,and who does inch k Unusedf nr through
his own cialdis provided th t such improvements am non moulded or offered for - NEW RES]DEN'1'IAI.ELECTIf< SQ FT
role If h thebuilding improvement Id within neyevr oreumplmmn the SQ.FT. ORAREA $ISG.PC.
ger builder will have The burden or Forcing that he did not build or improve rot F r
e s f: I ) - I(yfAL .�
L as new net of the propertyly contracting with I revised contractors I AI .
constructlh project(See 90UBusiness and Professions Curie)ThContractur,,L Y}xf + ' } PERMIT fle)Si`� f7)jjfIaKUN INQwreepL d rapply t a fproperty wlob Id hoppers I QTY
who contract,l . h projects with a uonaacmr(s)licensed P slant to the Contractor. , . j ,�4-='E/E'E' ,f'(• -�� ����_ �- '/1
.,
Lutm,p Law. PERMITISSUANCF.
1 n1 exempl under Sec. B k P C foo thipper,or k
ALTER-DRAIN It VENT-WATER(EA) VALUA N
Owner Date - w
WORKERS COMPENSATION DECLARATION RACK FLOW PROTECT DEVICE - I C�
Iherebyuf,code, woultynt Eve ry_ of The Ril ,d lia. - -
❑I haveandwll mainmad.cerlfiwleof Cousent in self-unionefaW rke`,Compcl- DRAINS-FLOOR.ROOF,AREA,CONE. STORIES TYPECONSTRUC'I'RE,
satin,as provided tar by Section 3900,1 the Lab Code,for the jxeif trance of the
work Which this ee 1 .: . d. 'IXTURES PHRTItAP
�(1 have and will common n W I,,,C nprnmt on looter y raj by Section
- -
) cf The Lehor Code,for The frerrrm'nce of the work roe wech Thcperinit i......ed' CAS FA SYSTEM-I INC.40UTLFTS OCC GROUP MIN
My Work ryQ11m sal Inxnm d policy nun bur. : -
Cartcr..]T —./�'j'In —rc Policy Na.o?�b��19 GAS EA;SYSTFM-OVER4(F.A)
CERTITI ATFC .OF EXEMPTION FROM WORKERS' GRLASEIINDIISTRL WAS]17 INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This xectionoeed not be completed lythe permit is fnrone hundred dollars($100) GIIF.ASETRAP . e
or lost,) • PLANCHECKFEE
Iceitfy teal in thpH once,Flee work fnrwli cM1tti.p l:'csued lxhnll $P.WFR-SANITARY-STORM EA:200pf. -
not ply yPenon' y er us to become ahjecn theW kri Compen- ENERGY PEE
Zy _notion Law,of Califoun d.Date s - WATER HEATER W/VF,NT/ELEC R
Z Q Applicant -- - - GRADING F1111
NOTICE TO APPLICANT:If,a[mr ranking This Ceniticm,,f 9xemP0on,you should WRIER SYSTEM/1'REATINO SOILS FEE
abecome subjectto the Worker's Gimpuwation forest Ours of the Labor Code,y,n must
W Cmth ith comply withiuch pmvisionior this permit shall he damned revoked. WATER SERVICE
aq
],.Z CONSTRUCTIONLENDING NLW RESIDF.NTIALPLMB. SQ.FT. PAIU•
I hereby alTrm That rnuuc0 lending agency for the perrnrmane of Da Be ,,I IT
-w . the work for which this permit is issued(Se Me?,C v C.) r
I _ yt#fhT ),a , .
-
T 'TOTAL
OULend Name TOTAL:
Le ler Addr I :
BUILDING 1
nfythat Iha mail this ppl" t 11A.-that 1 .. Xi {it( !
IIst FEET starved. g t comply with all city d county 1 c e star FETE
U sE1gMIC
aheve Hent tined property f..inspection purposes PERMIT ISSUANCE ELECT RIC FF.F
(We)agree to save,indemnify and keep formless lee City of Cupertinoukah'a
i iabllltleajudgmentc,costs and expenses which may in any way accrue against'aid City ALTP.R OR AILD TO METH: PLUMBING FEL
omedErsree of t o,"colln6 of this Permit.-
APPLICANT TU ERSTA'DSA WILL PLY WB'HALT NON- OINT pIRHANDLING UNIT(TOIq(10)CFM) _ MECHANICAL FE
SOUR FG ATI - - _
AIR HANDLING UNIT(OVER10,000 CFM)' CONSTRUCTIONTAX
' .:gnmurenrA �rr.'C 1Gado ole EXHAUST HOOD(W/DUCT) r,
HAZARDOUS MATERIALS DISCLOSURE - HOUSING MI'I'IG F _
Willmeapplleant,rfmure build"ngweup$nlq,a tor hardic bmMo.,material HEATING UNIT(TO 100,000 BTU)its defined by The Creation,Municipal Code;Chapter 9.12,and the Health and Safety.
Cale,Section 25532(0)'! - -- HEATING UNIT(OVER 104000 BTU)
.. ❑Yes ❑No -' - PAIU
. • VENTILATION CAN(SINGLE RESID) t• - Re,cip N
Will II pit I futurebuildingoccupant use eq 'p t dvice -hich BOILER COMP(31LPOR IOO,fN10 BTU)
enno,M1 znnl ms air condominiums>1s del nW In,the Bit,Are A" Q 11y Manageicro TAL:
- of... , - BOILER-COMP(OVER 100,00013TU) - - -
❑Yes El Na
I have mull the hazardous materials T,un der Chapter 6.95o1'the Cali- AIR CON DITIONER ISSUANCE TEComma -
rc,25533n p
- binds He.gdoes n Safety Cycle,Sections 25505,2s or, end 25534.1 understand shot if 0° NEW RESIUENTIAI.METH.
huildin6 docs not currently haven mnom,mut it is my responsibility to notify lh,omnpunt _ •, /'
ofthe vyniremenm which must be mea poor to issuance of u Certificate,f Occupancy.
y..
a
Owner or authorized agent [)aidTOTAL: ISSUED BY: �f
OFFICE ,