S 2256 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUD DING PE IT NO.
BUILDING DIVISION APPLICATIONIMERMIT PIN(;P ING-M1IKDENTIFIC 2256
BUILDINI:PRI)JECT'IDENTIFICATION
BUILDING ADDRESS'. SANITARY NO. APPLICATION SUBMITTAL UATE
OWNI! 'S NAME: PHONE: CONTRACIOR'S NAME: V, IAC NO'.
NIC CON'IROLp
RCHITECTIENGIN ' . LIC NO: ADDRESS: i+-. 10 �L. ^ E3
CONTAC: PHONE: BUILDING PERMIT INJ)
❑ Consultant Fess Paid by Applicant(Initial) BLDG ELECT PLUM MECH
❑ ❑ ❑
LICENSED CONTRACTOLDF �ARAI'ION EA
ELECTRIC PERMIT FEE
I hereby an on that I me licensed undeof Chapter 9 Roundeneing JOB DESCRIPTION
OCz with Sation]Oq))ofDivisiontofthe Businessions Codc,and mylicensc is RESIDENTIAL
WOO SUANCE
FWO full fore.deffc ,/ SFDWL ❑KITCHEN REMODEL
aUU Licen.uLiaN '-• ES-RFSIDIiNTIAI. ❑ADDITION E]PLUMBING RE-PIPE
F Z W Dam Canuud
mQy ❑MUCTLUNIT []STRUCTURAL
FOy ARCHITECT'S DECLARATION `'7A}VI MODIFICATION
Z O a,2i. 1 mularso n l my [.,,,hall be tea d aN public records 1 AMPS
CZ'—O El INTERIOR [-J CHIMNEY REPAIR
4�.�,,u.11 I.isxnssJ Pro6wsional MPS IMPROVEMENT E]SWIMMING POOLSWI hereby effinntam I am OWNER-exempt fea.LDER I)E be C n rn�ors License Luw for then AMT'S ❑OT HERxtAHDyBATH 1 f-;.VRGI'AIROyV following muson.lsection]63L5.HuinesN and Anfessinns GNe:Any city nr countyIiCfRICAL >DGr ��d CSN- �'i'"' �—_
Ia13 W yF' which requires v permit Io comtmet.arer,improve,demolish,-repair any structure /�.1y'
Fp�'Oa pnnnoits issuance,aEn regmims the upplicum fo...ch rennin..filea.igneJstamment SPECIAL CIRCUIT/MISC.
Ley her he is lice^seJpursmnl ml he pruvisinmel the Contractors l.iaeno,Law lCode.,9
W^Q� (commencing with Seetlon7")of Division J of the Business and Pndcssimr,Code)or TEME METER OR POLE INST.
a a o�' that he is eannrl Iherdiom and the basis for IM alleged exennption.Any Violin In of NEW BLDG/ADDITION [I DEMOLITION
_ Sectiun7031.5 by unyupplicanlfee.pemtilsubjms the.,piicunuo a civil penally of POWER DEVICES' T ❑FOODSERVICE
19 rn not more then five hundred dollars Wool. 'ROVEMENT
phos owner elle property.nr my employees with wages as theirsole compensation, SWIMMINGPOOLELECTRIC [I OTHER
will do the wink•and the Structure is not intended or offered for sale(Sec.7604.Besides,
i1and Pmfcx,sm,Code:The Connector's License Law Joe,and apply to vn owner of OU'T'LETS-SWITCHES-FIXTURES
d 3— propcny who builds or improves thereon,and who does such work himself or through
his own employees,provided haunch improve.news are not intended m offered for NEW RESIDENTIAL ELECTR SQ IT.
sale.If,howevee the building or improvement avoid wi,hinunc yearofecmpletion,the SQ I'I'.FLOOR AREA S/SQ,FT.
owwnh ddi,,will have the burden of proving that he that not hni1J or improve far on-
pose ofsule.). 'TOTAL:
❑Las owner of the property,am exclusi,sly contracting with licensed contractors to
onsvun the project(Sec.7604,Business and Petitioner,Calc:)The Comment's Li-
cease Law does not apply tovnowner(if pr^peny who builds or improves thereon, ad QTY PLUMBING PERMIT FEE
why can ands for.such projects with a contrueons,Iicamod pursuant(,,the Contracme,
License Law. PERMIT ISSUANCE
❑I um exempt under Su. ,B&P C for this reason
Owner' DataALTER-DRAIN&VENT-WAT.R(EA) VALUATION
WORKER:SCO MPENSATIONDECLARATION BACK PLOW PROTECL DEVICE 4Wt C)0
I m chy aTirm under penally of pe jury enc of 111,bellowing declarations: a./�.!
_ Ihme and will maintain aCenifiesre of Conuntm selGinsurt for Washers Camper- DRAINS-FLOOR.IiIIOF,AREA,CONU. ST(lRi1LS 'I'VPE CONSTRUCIIDt
smion,as provided for by Searle.3]1X)of the Labor Cuda,for the pedommnee of the
oh for which this permit is issued. FIX'I'UR17S-PER TItAP
JE�/1 have and will maintain Worker's Compensation Insurance,as required by Section
IOof the"Me Cale,for the perfmmunce of the work l or which nhi.N/Finland i�s/issue,
GAS-EA SYSTEM.I INC.4 OUTLET!S OCC.GROUP APN
My Work<rs Cs pin lion In urnncc capttmdy Na,nyktt+c"Axr�' ___ __ _ie, GAS-EA.SYSTEM-OVER4(EA)
Cartier: 1� F�I Ah�1 Policy Na:GG�FFiiIL.{([L�Q[]��(�L�
CERTIFICATE OF IIXEMPI'ION FROM WORKERS' GREASFIINDUSTRI.WASTE INTERCEPTOR COMPENSATION INSURANCE NG DIVISION FEES
('Osis section need not hcasmplwWifthcparmhis foronehunJrd dollars($111)) GREASETRAP
or las) PLANC K FE
cenify that in the performance ofthe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.20017.
not employ any person in any manner so as to become subject the Workers'Compen- ENERGY FEE
Z cation Laws of California.Date WATERIIEAI'IiRW/VRNT'/liLFCPR
'0/ Q Applicant ' G D
q NQI'ICE'TD APFLICAN'r:II;after making this CeriGcam of Exemption,you should WATER SYSTEM,TREATING
(~ become object the Workers Compensation previsions of the labor Cale,you must SOILS PEE
fnthwithcomply withsuchprnvNinesor this permitshall the deeneal revoked WATER SERVICE
Q
aN CONSTRUCTION LENDING AGENCY NEW RIiS1UF.NTIAL PLM,. SQ.FT. PAID
1:.) Thereby union manhere isamm�mction lenJi^g agency Tonle performance nl, cnptN
W F-' the work for which this permit is i...ad(Sec.3097,Civ.CJ
TOTAL'
Lenders Name
U
W Lander',Address
1 cenify that 1 have,cad mix application:rad state thin the abeve iateramice is BUILDING FEE
h correct.l agree to comply Isiah all city and county ordinances and mate laws reining to QTY. MECHANICAL PERMIT FEFL
fJ building conduction.and hereby unthnrim representatives of this city to enter nrym the SEISMIC A
aMrve-mentioned property for inspardam purposes. PERMIT ISSUANCE
(WO agree m save,indemnify and keep hemaess the CRY of Cupertino again%, ELECTRI
hiddliuct,judgerenm,costs and expenses whirls may in any wiry accrue again,said City AIT ER OR ADD TO MECH. PLUMBIN
in consequence of egrnntingo this permit.
APPLICANT( ]EB.k�LN ACLYW L OMI' V WITH ALL NON-POINT AIR HANDLING UNIT(TO Il1,INXICPM) MF.CI{gNICAL EBF.
SOURCE RF LA Ci S.
.. (' AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
mooenamro of AFp WCon r as EXHAUST HOOD OVIDUCT) HOUSINGMITIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the nppliedide,fumed building wcupa^txmrem handle hazardous mmedal HEATING UNIT(To us Lougo BTU)
as defined by he Carmine Municipal Code.Chapter 9.12,and the tontim and Safety
Cela,Sodium 25532molHEATING UNIT(OVER[01.0011 BTU)
ED Yes ,r; / VENTILATION FAN(SINGLE RESID) PAID Dae Recto
Will the applanner more building occupam use equipment ur device,which BOILER-COMP(31{P Ok Ia1,INN)B'1'Il)
mil hazardous air smmaminenrs as defined by the Bay Area Air Quality Management '1
District? BOILER-COMP(f IVER LIR ,000TITU)
❑Yes DIN.
Ihave Residue mJnu. no AIR CONDITIONER ISSUANCE DATE
ng25533 sunder Chad, Cali
hs bb Health&S oxlc m O5,25533 and 2.5531 I i nlersmnJ thin if the NEW RESIDENTIAL MECH. SQ.FT.
building Jr •nn} Thant iNmy responsibility to artily the accupanl l �/�
of me e . hick,raty poorm i.Nsuayr ofa Certifi sof ee y. L
owner m ulirited ager ✓ one TOTAL: ISSUED BY:
OFFICE