S 0932 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-I,],n:cTRI AI, 1'FTT NCI. ❑ q ^
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL J JL
IHHUDING PROJECT IDENTIFICATION
BUILDING ADDRESS: ^f ) - p1- (.SQ�� SANITARY NO APPLICATION SUBMITTAL.DAl
V / rpsz er� Info, �e
OWNER'S NAME: I I'I10NE; CONTRA 10k:S NE:AMSCZ LIC NO:
c�.� _ NIC irya CONTROL#
• ARCDII C,/ENGINEER LIC NO: ADDRESS:Zap f� El
CONTACT, PHONE: BUILDING PERMIT INTO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT .E
1 hereby affirm mw 1 am licensed under pmviniaas of Chapter 9 orommeneiag ]OB DESCRIPTION
OoZoln mSecean]f0nufDivision 3ofnhe Basinxssand Pmfes.ion.Cnde,andmy license is RESIDENTIAL:
ILL- 'm full""CC
and clTccl PERMIT ISSUANCE
C LL F a d� ❑SFDWL [I KITCHEN REMODEL
't License Claus Lic.X Y APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RHAIPB
rt; Dine cammc •\. !
ARCHITECTS DECLARATION 0MUI.TI-UNIT ❑STRUCTURAL
F.7 N PANELS
ZOmZ I undcrstand my PWnsshall be mcsl to public records MODIFICA'T'ION
OZ=O UP102WAMPS ❑INTERIOR J2 CHIMNEY REPAIR
Ha.~LL Licensed Professional 201-PAl11AMPS IMPROVEMENT E]SWIMMING POOLS
CY�� OWNER-BUILDER DECLARATION OVIik I(Nx1AMi'S ❑BATH RIiMODIi{�I"AIR ODIiM0111ftTN
C 6 I hereby affimt mat 1 am exempt from me Cootrwoo,La,mw Law for be -{ I U #AM M,v/✓4
�6U hollowing Nature.ISeclinn 7031.5,Busimaximd Profession,CWC Any mtyor county SIGNS ELECTRICAL �f7IHI'R "'YYY
W aLL h which tnquimrm
t a peit w comma,ahr,improve,demolish,m«pair any,howare
F. 0J prior In its issuance,also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUITIM ISC. (Ap r
CGSthat he is licenxW Pursuentmthe Pnrviunnsof the Contmcetrs License Lnw lChaPter9
moo (commencing with Section 7000)of Division Sot the Bowness and l'roksxionsCWe)or TEMP.METER OR`O/NST COMMERCIAL,:
E r O y' that he is exempt therefrom and the basis for me alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOL1 NON
Xm Sxaon7031.5 by any.,,]Irani for.perm subjects me applicantto a civil Penalty fel' POWER UIiVIC ❑TENANT CFOOD SERVICE
fS
LL—y
t mare man five hundred dollars 75500).
(^Z Y IMPROVIiMENT
dO 01.us owner of the propenl or my employees with wages to mcinnlc compensation. SWIMMINGP OL ELECTRIC
F will Jo thewon,,Cale
swqum isnotimenense Law
sal apply ,,a.owner
❑OTHER
3 m and eny who
ills or I'he Cnnbhereo License law rocs not work
hi s if owner n[ ()Of 1. -SWITCHES-FIXTURES
propeny who builds or improves thereon,and who does such work himself or through
his own
owever,thepilding thatpatchitionisold within ary nal intended nr uOercJ fur N2 CS[DEN'I IAL ELECT R SQ IT.
xrlco,mr,however.t]hav ilde sail i o at Nosint is sold t n one year oRomplaion,the SQ.[fip FI QOJ A®A R/SQ.I"f.
wnoof vilJ.r wJl have the sailboat proving mut be did nut buil)ar improve mr Fur- 1� H
post of sale.). Ir
❑Lasownerofine Sec.70Y..Business
Professions with.) ,,,Amnnacmr.ut - TOTAL: A
con w L w d project(Sec.]Bw,Balinese and ny Wh ions CWr:)pro Cammoruls Li- IV .90
#�
c se Lawdocs Moi hle,jeennwnrmofprstri linnbmldtnrnnpr,the Ciannn.me, QTY. PLUMBING IT FEE
whoLaw.far such pmjecn win,a contrmtagt)licensed,ursmnt m the ContmnnVs
License0l am etc opt under Sec. ,B k P C fur this¢ane RMI'r ISSUANCE CIIy v� ���en 1,{w
Owns, Date ALTER-DRAIN&29T- ER(EA) VALUATION
7
WORKER'S COMPENSATION DECLARATION SACK Fl,IIW PlttyfECi'.UIiVIC Q�}}
IhandwilE aintai a Penalty
tePerjury one ofinefollosimuse for xNalWorker's
rk r'sCo ap t �� �J
,;❑ Imus and will maintain 37mof Ce sern inLabor sole.fore for Wformace of theer- DRAINS-IEAON,RO( GA.CO U. STORIES 'TYPE CONSTRUCTIC
xmion,us provided for by Section 9]1x1 or the Lahr Code.for the Performance of the
work for which this Fiction is issued FIXTURES-PER TRA 1
1 havof
and will odemaintain Workrx Com,of me n walk
hi h required by Section
3]fxl of the Labor Code for me perfntmancc of me work for which this permit is issued GAS-EA.SYSTIiM-I INC. ❑ S OCC GROUP APN
My Worker tia^o-�ln�eumWj carrier and Policy
Cartier. dGo Lunn, 'Tisa�{ Policy Na:; .9�_ CAS-GA.SYSTEM-OVEk EA)
h1sCEER�TIFICATE OF EXEMFLION FROM WORKERS' ID Y
{
COMPENSATION INSURANCE fah) //y(// GREASMNDUSTRL W/TE INTERCEPTOR
Gbit section.ecd nm he enm,leted if the permit is for one
hundred Jt Ilar�1s III BUILDING DIVISION PERS
or less.] GREASE TRAP
PLANCHECK TEF,
lemony that inthe pcymanner as theas t work for subjech thio are W rkmissued,lsh.11 SEWER-SAN ARY-STORM EA. FT.
macopied,
Law any petwn in any manner m as become subject the Wnrkcrs'Compcn- ENERGY PEIi
Z salon laws of Califnmia.Date WATER H RR WNENFLIELEC1'R
Applicant t GRADING FEIi
ti NOTICE TO APPLICANT:If,after milking this Cenificutc of Exmnpenn,you should WATERVSTP,M?kEA'fINC
a' become subject to the Worker's Compensation provisions of the labor Code,you must SOILS IEIi
{Ta forthwith comply with such provisions or this proton shall be deemed revoked. WI/R SERVICE
a0
CONSIAUCcION LENDING AGENCYagency EW RESIDENTIAL I'LMIi. SQ.it,. PAID
UO work for
wyaffirm that there isacan,trve.30lending agency for the performance of Mat Rece p
Lis theworkfor wnicM1 this pcnnit is issue)(See.31Yd),Civ.C.)
O Lender's Name 'TOTAL:
L) Lcndcr's Address TO'I'Al.:
FG 1 cenily mat I have read this cphenfoo and smtc mat me above i invo hien is BUILDING FEE
rn atrmm.I'.giro to com,ly win,.11 city and count,orditmnc,sand nate lawsrelating e. QTY. MECHANICAL PERMIT FEE
LIZ Wildingconstruction.and hereby aumnrlse rtprescamovesofihis city toenmr upon me SEISMIC FEE
above-mentinned n,,Ay fur inspection purpose'. 1'IiRMI'1'ISSUANCEOwe)agree m.vave,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
kabilitiee,judgments,emts andexpenses which mayinany way aceme against said City ALTER OR ADDTO MIiCIi.
in uquence of the granting of this Iwrntit. PLUMBING Ill
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('rO lgflfx)CFM)
SOURCE REGULATIONS. MECHANICAI.IEE
AIR HANDLING UNIT(OVER 10,000CP CONSTRUCTION TAX
Signature of ApplicanUContracmr Date EXHAUST HOOD(W/DUCT) HOUSING MI'1'ICATI(IN FEE
MATERIALS DISCLOSURE
Will theip,licam or team Wilding occupant stomor handle mallow memrial HEATING UNrrUO I011,(KIII )
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cede.Section 25532(a)] HEATING UNIT(OVEk .IxpBIU)
❑Yes Obla
V. VIiNT11.AT10N FAIJ41NGLE RFSIII) PAID
Will mea Berm or forum brilliin•ocru Date Receipt 9
pp g eBay�ea Air chum dc, BOILER-COM NHP OR 100,000 BTU)
mit is,hazardous air cnmaminant.as Jetined by the Hay Area Air Quality Management
District r 'I(TITL:
❑Yes t2Nn BOILEH;AMP(OVER IIXhIxM]pq'U)
I have read the hazvJaus material. AIRC 'DU IONER
rey25533 an umler Chapmr fi.95 of the Cali- ISSUANCE LATE
fnmia Health S Safety CWP,Sections 25505.25533 and 25534.1 undcrstand that if the N. RESIDENTIAL MIKE. SQ.FI'.
building docs not currently have a mttam,thin it is my msryon,ibility to notify the occupant
oral—,aire y 6
swhi h.. met Frio to i....neeof a Cenificme of(kcu,a cy.
Oer or aur printed gen
wnDate 'FOTAI.:
ISSUED BY:
OFFICE