00010122APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY QLOU K) I ZZ
CITY OF CUPERTINO IIUING-MECUAN AI, PERMI I'N11.
nUILDING ISION APPLICATIONIPERMIT PLUMBINGPROOJI CM IDENI:FIC Q �
nUI1.DtNC. 1'RUJRLT IDFN'TIfIUA'1'IUN
SDR � moRC- D2 T
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❑ Consultant Fecs Paid by Applicant (Initial)
BUILDING PERMI'I'INPO
BLDG _ ELECT_, PLUMB MECH
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QTY ELECTRIC PERMIT FEE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under previsions of Chapter 9 (commencing
with Scniun ]fX011 ofDivisionlol the ltusinecs and Pmfcssinns CnJc. angary license is
nlilll three and cited yvj,
License Class I_ic.X
Dale cmmar,m
C 1'li I'S )[CLARAI'ION
t (-
u
1 en, ad m rall as public recands
JOB DESCRIPTION
SIDENTIAL'
�—
DSFUWI ❑ KITCHEN REMODEL
❑AUDIION [IPLUMBING R1i1111'17
MU I.1 ❑SIRUCI'URAL
MODIFICATION
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT }/,�`fkSWlMMING POOLS
❑BATH RFiMODEURI:I'AIR"LIHILb101.ITION
OOTHER
S'�/l dry4R.I�U
PIiRMIr ISSUANCE
APPLIANCES -RFSIDEN'I']AL
PANELS
UP'10200 AMPS
hicenseJ Professional
OW '!R -BUILDER DECLA TION
1 hereby affirm that am exempt from the mluactor's License Law for the
anJ s. m Code: Any city or county
falling near. (Section 703 L5, Rusinesse
ow
which requires a permit to a,nstmel. alter, impm . demolish, or repair any s melure
pr ort I :u Ica y the p'louralf hpc in ll R demmment
innh I' dp man n p ', cc t t r'.ul I (cnapter9
Iron 6 thScrit 7011ry fD'.i fib B setold I .-.' ,000or
that he is exmnpl therefrom and lha bitsi rnr the ullcgcd cumpunn. Any violation n[
Section 7031.5 by any applicant for a nritxubjetts the applicant) u civil penally of
otmorelhan5vchund.eddoRen6 X11.
❑Las owner of the Pmpeny nn anpluyccswi0%agesaslheirvrtecn:npensminn,
do dework.andtbe I I snot in¢nJeJ orolicrtd for sale l5«ABW. Business
and 11 ficssiome Code: The G mat License Law dries not apply m an owner of
rnpcnywnnbaildsorimp es lhcrcon. and who dcessuch wad himself or through
his own employees, p.,id that such improvements are not intended or opc.ed for
sale. if, however, the buil IT or improvement is sold within one year orcompletion. the
ownr robuilder will hav c burden of proving that he did not build or imrprove for put-
20d-U100AMPS
OVER 10XIAMPS
SIGNS ELECTRICAL
SPLOIALCIRCUIT/MISC.
I HMR MET ER OR POLE INSI
COMM R .IAL:
NEW BLDG/ADDI'HON ❑ DEMOLITION
❑'I-ENAN'T ❑ FOOD SERVICE
IMPROVEMENT
❑OT'HER
POWER DEVICES
SWIMMING IDOL ELECTRIC
OUTLIES -SWITCHES -FIXTURES
NEW RESIDENTIAL EL[CTR Sp I'I'.
SQ. FT. FLOOR AREA
/
45Q. Flt
'1'arnl.:
NEW'0
pnvemX.da.).
I I I,vura the In as owner art prapeny.::m.sel::sivnry armrnming wino IicarmJ contrnrams m
:ns't (Sea 7044. business and Profmsions Code,) Fire Contractor s Li-
ssclawJ«s of apPlymrn owner of propenY who bairn. or improve.. thereon, and
who contracts for such projects with a conuctions) licensed pumuanuo the Contractors
Licen.m Law,
1 a exempt under Sec. ,R&PCforfififi ren
+v
QTY. PI BING PERMIT' FEE
PERM] T ISSUANC
ALTI3R- GRAIN &VLN :R (EA)
BACK FLOW PRUTE ?VTC
VALUATION
O�
Owner - Date
WOR KERS COME-17NS AT ION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
Ihtrvc and will mninmin uCcnlEc:ne ofQmsenuo stir-imurc Tar Wnrkorx Compen-
smian, as provided for by Scali nn 3]1X1 of the Labor Cudc, lin the performance of the
work for which This permit Is islandPIX'1'U
I have and will initiation Worked, Cnmpemmian lawnmce, as red red by Section
3 Xl ofthc labra Code, lot the performance of the work for which this pemon is issued
Co WnrkarsC,o)uocrwai myrpX'amuPoldy No IT l�
Caricc 4R1 [ Ali/
CERfIFICATIi OPIiXEMPTION FROM ORKI:RS'f��f .oT
COMPHNSATI(IN INSURANCE v 11 �'V
DRAINS -FLOOR, ROOP.ARE . U 1).
STORIES
OCC GROUP
'rYPECONSTRUCI'IO
APN
ltl!S -PER TRAP
GAS -EA. SYSTEM -I INC.4 01 LIT IS
GAS -IiA.SYSIIiM- OVER 4(EA)
GREASIVINDUST'RL WASTE INTERCEPT 'In
BUILDING [)[VISION ItiGS
GREASF,TRAP
PLANCIFECK FEE
QTis section need not he completed ifthe permit is for one hundred dollars ($100)
O 0
I-
Q
7z
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FTN
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or lccv.l
I renifY that in thin perinrm:nmenl the work for which his pennil is issued, ishall
not elnpiny any penvn In any manner Xn ns to necome suhjer'I nr the Wrnkcea Co.,.
x:ninn l,nws of California. Date
APpliclmt t
NGTICE TO APPLICAN'1: If, ober making this Cenifcme nl17 cardam,you should
nccnmc subjca to the Workers Congcnsanon provisions of the I.aMr Calc, you must
Goh,'ih comply withmch provisions,n this pe.itshrll he deemed revoked.
CONSTRUCTION LIi WGAGENCy
Thereby nRrm danhert isacnmwc nn lending agency for the perfonrrmrcc of
the work To this permit ie issueJ(Sc .309],Civ. C.)
SIiW IiR- SANITARY -STORM EA. 200 F'f.
IiNIiRGY i'F.F.
WAI'i?R IIEA'I'ER W/VENTjp,EC'IR
WATI?R SYS IP,MRRCATINC.
(iItAUING I'[E
SOILS FEE
WATER SERVICE
PAID
Date RttciptN
NEW RESIDENTIAL PhMB. SQ. P.
'TUTA L:
1<ndcrs Nume
'TOTAh:
BUILDING FCI;
Ism Address
I nTy th'llh 'Jd til J,tt lha The above lot :(s
to tlug cnully t II t I ly J'' 1'r' fl gn
half g t I n, 11 hY Tit 0 t i', il ii 'ty l I- P the
QTY. MECHANICAL PERMIT PET:
SI;ISMIU PT
aha c f ndpopcnyl Y. f tip p
(Wit) agree m save, ender ufy and keep harmless the C t) of Cupertino against
Iinbilitiesjudgmems. cosu and e s which may in any way retain against said City
p,
.1.
GLhCI RIC I'Iil:
ATTER OR ADD TO MECB.
i'LUA1RING FF.F;
AIR IIANDLINGUNITITO 1A11(XICI:M)
MIiCIIANICALF:EE
in nmmyuence of the granting Ihir.pcnnil.
AN LT UNDIiRS'r )ti AND WI I. COMPLY WI'I'll .1, NON POINT
AIH HANDLING UNIT (OVER 10,l)(10CI:M)
CGNSI'RUCTIUY TAX
SOI' WE REGULATI /
G�Sl'1
1/
Ii%IIAUSI'Hf1UflIW/DUCT)
'NPIAT
II11U51NG MITIGA'TIO
Sign: cot Applicant/Gn uchr Da¢
1 I UOUS MATI"RI ) l S OISCL(ISURF
Will lhcnppllalnr iu:en
a Adin�l the a Cuecnino M.......'ullJing t)caupt)m stns mr M1unJleh:rnunimmnuncdal
al Code. Chapter 9.12, and the l Iealth and Safety
Crile, Section 255320d?
Yes r
IIEAfING UNI'P (TO IIN),BIXI 111 "1
11HNFING ON1'1' OVER 11X1,000 It'I IT
PAID
Date Receipt M -
._
VIiNTI1.ATlON PAN (SINGhIi RI!SIDI
Will de applicant or 'more hadding munition use "Itipraum or Jevices which
mit hvardouz air wmmninants a defined hY the Bay Arta Air Quality Management
R01LER-COMP (JHP OR 1 W.fMXI IrrU)
I OTA_
District?
❑Yes
I have real the hvan r nr ring ruyuirc nems order Chapter C95 ofhat Cali-
lirrnia Ilcullh 'dray Calc .t eba 25505, 2.5 3 nn 255)4. nmllad Ill that if the
huilAing dr enol cu cntlyh vc' I an6 ohm hi' yrc nnXibillly unmlil' lhu<' upam
ofthcreircmenu rel prior it)' of a Cenilieamyt ep�
/
HOMER -COMP OVER tons XI it
Al CONDITIONER
ISSUANCE DATE
NEW RESIDENTIAL MECII. SQ. IT.
TOTAL:
ISSUED BY:
Uwncr nr a orizcJ agcm Ila
OFFICE