S 2283 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTINO HUII,DING.EILELI RICA I, Pr: BT No
BUILDING DIVISION APPLICATION/PERMIT PLu IllfN NIECHANICAL 2 2 8 3
IOU ILOING PROJECT'II)FIXTIFICAfI(EN
BUILDING ADURIiSS: SANITARY NO, APPLICATION SUBMITTAL UA'I'ti
OWNI',It:S NAM I.
I C) AC 1R'S AML LIC N(0: /
I NIC )N'I'ItULM
is
ARCHITECT/' G CCN: LIC NO: )DRESS' '
CONTACT': PHONE'. BUILDING PERMIT INFO
3-] ❑ Consultant Fees Paid by Applicant(Initial) BLDG F,IXCT' PLUNIR MF❑CH
Ili oue
I JCHNSCD CONI RAMOR S DECLARATION QTY. ELECTRIC PP.RMIT FEE
1 terrify:enr�n Bra 1:1111co,sed owner provi,nw„of chapter 9 ammnemillg .OB DF;SCRIPTION
C�d'Z with So,16-7allgol Divisimttoflielholarss.aml l'-m-....Cndn.aIdnly Geemeis RESIDENTIAL
WOO PFRNUI ISSUANCE
F ty,- in full force andcul. ❑SFDWL ❑KI'ICHL,V'RLh100E1.
QUV Lacrw Cl: s ` Lic.# APPLIANCES-RESIDGVI'IAI. ❑ADDH'ION ❑PLUMBING RE-PIPE
G L Dam Con,maor
ARCHI'MC1'.SDECLAR ION ❑MULTI-UNIT ❑SIROCTURAI.
z O y^Z 1 undc.lanJ my plum'¢hull M used us public ra.ord, I'ANI?I MODIFICATION
OZ-O Oil 10200 ANIPS [I INTERIOR [J CHIMNEY REPAIR
[-NF Lw Licensed l'mfessional 201-RIIXIAMP$ 1N1PkOVF :M1T I]SWIMMING POOIS
OWNER-BUILDER DECLARATION
r,=- OVRR REEEIAMPS ❑B HMODI /REPAIR O DEhfOLITION
I terrify:dlinll Ilial 1 rot csanpt front the Cammctnr'n Linnuc Law far the
x 3a.
a.F ftl......rw.nn5
I.(See 19(D ,Ihnsinvss and Prnfc,v.ionv Carole:Any city onm
+ al, SIGNS HI.EC1'RICAL HIiR
y which rcyuimx a pcnon ,,construct,ohne ca"'we,dcon i,b,or mpey arw.
i,anro
E'1=-OC
an In its i..uanrie,also rcquirathe applicant rorweh pcm,iuo file asignedstatanent SPECIAL CIRCUITINIISC.
that he I%licensed p tt the p (if the C I II La (Chapter9
�aCO (a 6 hS ]00(1) ID .' 3 ftl li ' JI f._- _Code)or IRMP.M E'Lit R OR POLE;I NST. COMMF,c L:
=a: x lactl I
sura tis ltc at ,nd Ile o:s'a I, Julhb.d rix tpo f sf ❑
tAnyv'ohSHIN BLDG/ADD I'I'IUN ❑DEMOLITION
X- Section7O3l5byanyapplicmnmr.:pvnnitwhiemslheupplicmrnoaclvllpenulryuf POWER DEVICES ❑TENAM19 ❑FOOU SERVICE
at more than five hundred della.($51p}
F Z TP IN1PkOVIiN1ENT
Q ❑I,a.owncndlbc pmpcny.onny employees with x'ages as their sole compensation. SWIMMING IY)UL ELECTRIC
ASO willdothewo,k.mtd the¢,mcture in malintmded or ottered for sale(Sec.7044,Holiness ❑OTHER
F
�3� and,rant„ion,code:.roe cammwmf,I.ian.a 1.nw odes mm,apply m am�:wwer wt GCTLEfs-swrrcEls-F1x'1vREa
property who fuels.nr wiped that
such n, pr who rasa such wotA d d or f mmugh
his own employees.Pnwided 0a web impmvnnenus am not Intended or offered for NHW RISIDHN'fIA 'C'TR SQ FT.
sale,ll:however,the building or improvement is sold within one year of completion,theh'
crhuildcr will hove the harden of proving Ihn,he did not build or improve In,puo- still .
pn ). F"OCT
❑ 1 ramp pnY' ly , fE ,1 IJ I'¢a.w+ OTAL:s uh p icc,S 7618Il s JI f.. CW )1T C t un,Li
the1 does not apply t f property h builds p thereon,and Q'1 BL IT FEE 1 19381
enmmeet for such projects wiat a aommnvr4s)1 cc—s!pursuant the G.prison's
LwinoeLaw. PIR 'ISS CP
Emm mecmpt nnJcf See .I3 K PC for l ti.rc:e,
Owner IAm 'R- 1 ENT-WATER(EA) 3/ VALUATION
Ile
WORKER'S COMPEB SATEON DECLARATION 13 PLOW PROTECT.[)[:.VICE.u J
Thereby off nn under penalty al perjury one of Chef flow;ngd mu ,
(] Ih::vaaud willinwiitaCcRifc'aloof Cnmcnt lu full-incur' oeVI( is Ln.pet 1 S-FLOOR,R001T.ABLA,CONI).
_ S'I'ORIH$ 'I'YI'Ii CON5TRI1Cl'I(1N
15
Sectionsmion,as pnwided foe by Section 1701 of the Lebo,Code. , 'rf
avid,far whicf,hispermit i......d. IT%TURFS-PER TRAP
❑I base and will maintain Porker's Compenmtins myna, e,ioe
3700Inthe Labor Cate,for the performance Ili& orabic his pe O. CAS-EA.SYS'PEM-IINCAOUTIFrS OCC.GROUT' APN
My Wmkcfs Cun:pv lest am lnsunmcc cnrricr and PORI in
Carrier: Policy Nn.; OAS-CA.SYS TEM-OV17R J(EA)
CIiRPIPICATEOPEATION INSURON\ KI?RS' '
COMI'13NSATION INSURANCE GRfASF%hNDUSTRL WASTE:INTENCIiYfOR
BU TNG DI VISIONITiFS
(Thio section need fan MeninPlet vl iOhe pemtil is Forane u cd dnllaen lEllE11 GREASE'TItAI' -- —
ur kss.l I'LANCI ICC,K TEIi
rico;fythatiolhcperfnrmanccnf,hcwarklits which this lm'nnil ki,wncA,I shall SEVER-SANITARY-STORM EA.2001rl.
not employ any person in any nmnner oacto bvenmemWalje,m,be WuCecil,.- LNERGYI+Eli
O z rodeo laws of California.Date PATER EIEATIIR WNIiM'/IILEC R Hili
Z 0 Apphcan, GRADING
NOTICE 10APPLICANT:II::1mr making this Ccrntic:ncot'17ecmptlon,Yon nhnuld WATER SYS'IFM?REA'I'ING
baxomesubjecno the Workers Cmnpeasuawn pnvisioms of IN lafor CnJo,yin mu., SOILS HER
forthwith comply with such provisions or this permit shall fm deemed mvuked. WATER SERVICE
a �
o z CONST'RUCT'ION LFNDING AGENCY NEW RESIDENTIAL PI.MB. SQ FT. PAID
TI
V O l hereby often that diem sn udnslmetiom lending agency for the penorni,acof Nemipt#
U. rH
the work fnr which,his,mit,,i,esuad(Sri,.31x)7,Civ.C)
. I.ma,',Name TOTAL:
U I.cndcr',AJdre,. TOTAL'
} L 1 certify that I have read this applicminn and slam that Ne abuse information i. BUILDING FEE
rUIn crcer l afire 1.comply with all cirynndcoumy orall....I-mi aam lawsrufting n, QTY. MECHANICAL PERMIT FEE
Z building 111111 rc
l lmby aull cI.....:to se,nrmisuity uunenthe SO?ISN11C 171217
aMrvcmeminncJ p,,,,cy fnr impaction par no,, I'IiRMI'1'ISSUANCE Oice)agmc m rove,indemnity and keep burmless the City of Cupenino against ELECTRIC PEE
liabilities.judgment.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MF,CH.
In Cmt
sct,muce of the 6railing of Ihs,man, PLUMBING 1TH
APPLICANT UNDCRS'LANDS AND WILL COMPLY WE 111 ALL NON-POINT AIR HANDLING UNI'I'(I 11101000 CI'Nf)
SOURCE;REGULNI'IONS. NECHANICAI.PEE
AIR HANDLING UNIT(OVHR 10,000 CFM) CONSTRUCTION TAR
Signature mf ApplinmUConwanr Dam E%HAUS'THOOD(W/DUCT) I LOUSING MEI IGATION 193E
HAZARDOUS MArfiRIATS ASCLOSURP,
Will he uppBcum dr furore lin alin8 nenmunlminerteh:malle Imia,Jaue inumriul HHAIING UNIT'('fir 11E11EE)BTI,
a%defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cade.Section 25532(¢)? HEATING UNIT(OVER End)
E3 YO, [-I No PAID
VP.N'I'11.A'Il(1N PANTS ;LTi RESIDE Umc Itcccipl#
Will the applicant or mum huilding occupant me ,u,aacaI a,devices which
emit 1c mNou.air contaminants as defined by the Bay Arca Air Quality Manegemem HOILF,R-(:OMP/ 1'OR I(B.000 BTU)
Ui.wicYl tOI'AL:
I]Yes El NI) BOILF,R-CO/(OVER (B.”BTU)
AIR CO 'TIONER
I huvc maid the humNon,m:nerial,re,aiscau-1,under Chwpmr 6.95 of He Cali- I. 'E DATE
lortihold; gos ffi Salcey Calc,e u err nx 255a5.25931 and 25538.1 to nc.,end that it the NEW LSIDIiNT1AL Af ECII. SQ.FT
m Health Jaw.nm curreamy tly Cot
a Ianam,,hm i,i,53 responsibility m notify the hat it t m
of Etc myuimmvm.xhicn must f„mat prior to iswanne of a Ccnilicam of Occupancy.
Owner or each fang agent Dam IDEAL ISSUED BY:
OFFICE