S 1832 (2) IRM
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN O ..i
CITY OF CUPERTINO BUILDING-F.I.F.CTRICAI. P' 'T"°: 1832
BUILDING DI VISION APPIACATION/PERMIT PLUMBING-MNCHANICAI.
BUILDING PROJECT IDENI'IFIC-A'I'EON
BUILDING AD DRESS: SANITARY NO. APPLICATION SUBMITTAL DAIS
/v 3 So 5
OWNIHO S NAME: PHONE: CONTRACTOR'.'NAME: LIC NO:1-4 :
y-1(,y�y�� �(' T NIC CONTROL rI
•ARCHITIiCI'/LNCIN[ER: LIC NO: 29V S. /`^ /'q �l V rr ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION Q'TY. ELECTRIC PERMIT FEF.
I hereby of oor mal I am licensed wader pmrisbnn of Chapter 9(comnencWg JOB DESCRIPTION
"Zwith ScOkm70fkH.fDiivwr3d1 the Bu,Ines,und and lay licensees Prnfewion,Code, RESIDENTIAL
WOO PERMIT'ISSUANCE
F-W� in full
Inc. ❑SFIIWL ❑KITCHEN RIiMODLL
�UV Liwluc_ Li,.I APPLIANCES—RBSIDENf1AL ❑ADDITION El PLUMBING RE-PIPP.
F�W Data Comruc h
ARCHITECTS DECLARATION ❑MULTI-UNIT' C STRUCTURAL
F z8O Vi PANELS MODIFICATION
t2I understand my plans shall be used n public record..
oy_Q UPTO 200 AMPS El INTERIOR [I CHIMNEY REPAIR
Ocensed Professional 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
OWNHR-BUII.DER DECLARATION OVER 10011 AMPS El BATH RI;MOUIiIJREPAIR CDEMDLITI
C a Q I hereby affirm that I am exempt from the Commences License Law for the
O a U following reesm.(Section 9(131.5.Business and ProIissions Code:Any city or county SIGNS ELRCTRICAI, C OTHFR
W 3 W N which requires a permit In"nulla",alar.improve,demnli.sh,or repair any structure .tea
[" 0nn� prior to its iswence,al.so requires the applicanlrnr suet pemtiuo rile a signal stmeme^t SPECIAL CIRCUIT/MISC.
� p Thal he is licensed pursuant it,the provisions ofthe Contractor's license Law(Chapter 9 „�v
GCO (communing with Senian]II(Ifllofllivisin^3ofthe Business and Professions Code)or TEMP.METER OR I1O1.11�INFO. COMMERCIAL'
a�q That he is exempt therefrom and the basis for me allegmpt
ed exeion.Any violation of ONEW BLDG/ADDITION C DEMOLITION
x . Section 1031.5 by any applicant for a permit subjects the applicano a civil lwnalty of POWER DRVICES ❑TENANT ❑FOOD SERVICE
Fy
W^n m not more than rive hundred dollars($Stip). ttIMPROVEMENT Zy s C 1,ns owner of the propeny,nnny cnrpinyecs with wages us their sole cnmpematinn, SWIMMING POOL ELECT RIC
(.O will domework,undthestrunon,i,hot im,ndedomRered for mle(See.90,LI.Business ❑OTHER,
3 m and Professions Gale:The Contractor's License Law does not apply In an owner of OUfLITS—SW ITCHES—FIXTURES
property who builds or improves thereon,and who does.soch work himself or through
his own employees,provided mat such improvements are not intended or offered for NBW RESED17N'ItAL ELECIR
sale.IL however,the building or improvement issold within nuc yew Mcnmpletion,the $Q.FI'.FLOORARRA fISQ.FT.
owarter,hailder will have the harden of proving that he did no huilJ or inrpmve fur par- P A
pose of aIle.). TOTAL:
1,as owner of the property,am exclusively contracting with licensed contractors In �1�
onstrct the project(Sec.]DU,Business and Professions Cadc:)The CammamPEE
rs Li- JUL 13 lIIW'D
.scuawdoes not apply loanowearof mm
property who builds or improves era .and QTY. PLUMBING PERMIT
who contracts for such pmjcc(a with a contactors)licensed pursuant In the Contme th's
License law. PERMIT ISSUANCE;
Into cxanpt under pec. ,B&P C to,Of,mama CITY Ur l,urrn Ia
ALTER—DRAIN&VENT—WX1 Eli(IIA) VALUATION
Owner Dale
WOR KERS COM PENsxriON DECLARATION BACK FLOW PROTECT.DEVICE
1 herehy hfflrm under penally of perjury one of me in lowing declamtinne
❑ Ihnvc anJ will nsuimain aCeniricme of Conncnunsel6inmrefor Wnrkees Cnmpen- DRAINS—FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
action,as provided for by Section 3100 afire labor Code,former performance of the
rk for which this permil is inucd. FIXTURES—PER'rRAP
D4 1 have and will maintain Worker's Compensation Insurance,as,ar,mred by San 0
3700ofthe Latin Code,fire lire perlimnunce of the work forwhi,h Ibis permit is issued. GAS—EA.SYSTEM-I INC.4 OU MES OCC.GROUP APN
GAS—BA.SYSTHM-OVIiR4(1
Cy Worker s_CEenyatinNn^I sal yT� ia�ienmd Policynµty rfl
L�DYl[3C77 ,i, Palley Nn_k� ?A)
C 'IfIC COMPENSATION
ATION1ON IRAN WORKERS' GREASFANDUSTRL WASTE INTERCHITUR
11
COMPENSATION INSURANCE BUILDING DIVISION PF.IS
isseconn rico t be completedd Ore permit is barman hundred GREASETRAP
nr IcaaJ(TbPLANCHF:CK FRE
I army mal in theperfornme,cofthe walk for which this permit is issued.I shall SBWER—SANITARY—STORM EA.2001
not employ any person in any manner in as to become subject n the Workers'Cheapen- ENLRGY FEE
Z cation laws of Cali fomia.Date WATER HEAT ER WNENT/UI.I;CTR
Z� Applicata GRADING FEE
s.. y NOTICE TO APPLICANT If,after,making this Certificate,of Esnnpti.a.you should WATER SYSTI;M/TREATING SOILS FIFE
a , become subject nc me Worker's Compensation provisions of the Lahnr Gstc,you most
LIJ fonhviam comply with such far,00ns or this permit shall he decmedreroled. WATER SERVICE
U O CONSTRUCTION riuionm.LENDING AGENCY NEW RESIDIiN1'Ig1.PhM11. SQ.FT. PAID
mr
I hereby afrithauhert isacnnswalending agency for We peT4nrmnncc of Dale ReceiplN-
(,Qme work for which this permit is issued(See.3099.Civ.C.).. tender's Name TOTAL'
U Lender's Adi TOTAL:
W� BUILI3ING FEB
1 certify IhaT 1 have read this application and stale Lha the grove infnnnation is
fn araeat.In"ce to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEF,
U Z building construction,uadhereby aomarimnprexentativex ii City Incineration the SEISMIC PIiIi
abovememinned property for inspection puproms. PKRMIT ISSUANCIi
(We)agree in save.Indcnrnify and keep bamdcss the City of Cupcnnoiagainst ELECFRIC ITE
liabilities,judgments,coon fart astatirc,whichmay in may way accrue agarnt said City ALTER OR ADD TO MF:CH.
PLUMBING F[E
in asequence of the granting of this permit.
APPLICANT UNDIiR S AN W .L ;OMP
ANDLY WITH ALL NO
AT N-POINT AIR HANDLING UNIT(TO IB,(NNI CPM)
APL NULT NS. / MPCHANICAL ITE
/ / AIR HANDLING UNIT(OVI:R 10,000 CFM) CONSTRUCTION TAX
ig�ofA acanl/Contmmor IU EXHAUST HOOD(W/DUCT') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or forum building accupammsre or lmndle huhromms material HEATING UNI I'(10 IWadds)BT HE
as defined by the Cupertino Municipal Cod,,Chapter 9,12,and die health hall Safety
Code.Section 25532(x)'? HEATING UNIT(OVI;R I00.0")BTU)
oyas PAID
VIiN'I II.ATION FAN(SINGLE BESIDE PAID
ReceiptM
Will the applicant or future building occupant use equipment or devices which BOILER—COMPGHPOR I 00.000 BTU)
hrd
\ emit manus air conumb res fined by me Bay Area Air Quis ity Management TOTAL:
Districu? Nn BOILER—COMP(OVER I00000BTU)
^
I have read the humar,attlend,requirements under Chapter 6.95 of the Cali- .5 AIRCONDITIONFIR �a� �SUANCE DATE
fornin Ucabh&Safety Cale Sections 255 5,25533 and 25531.1 umlanturd In.'if the NEW RHSIDBNTIAL MECII. SQ.FF.
M1nilAing not cone havwt hn tit lsnry maforismility at amity the occupant
aft ;¢neem, mu ormisauence ofa Certificate of cup my,
au m7tTi ages TOTAL: /v' SSUED BY'.
OFFICE