S 1325 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECIRICL PF fITNO
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANIC\L � 1325
HUILDING PROJFCI]BEST IFICA'1'ION
BUILDING ADDRESS: SAN]FARY NO. APPLICATION SUIIMI'fl'N,DATE
2,101 Lltrt�
11\ 'S NAME' I'IIUNIi CON'I'INCFII 'S NAME': LIC NO: 1-7,—"IF
YC �� NIC co/nr�eol.x
_e ARCHITECT/LNG NIiIiR: LIC it ADDRESS: ❑ U
CON'FACf: PHONE: 0, BUILDING PERMIT INTO
�L/ 11,4_
� �O L�Yd/Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
l/I
Lra,hulII iCONTRAC'FOH1ivoi sol
QTY. ELECTRIC I'fiRMl'I' FEE
I h.r.hY af9mt iM 1:rat hieor.d leder pmaf.dmf.of chaps.,v fit"hoendng JOB DI35CRIPI'ION
0W7. with Scminn]BlaB of Uivislon3olOm llmincsn and l'f nlrxxinm Coda tiny lirvros.ie R DENTIA
Iv O p /� I'lilt Ml'I'ISSUANCY, _
Nu inlidl litmc unA dfect. S� /'L / riY )WL �KITCIIIiN ItIiMODIJ.
°�[)~ Licenx Clxxs hies a /70 61" '
6 U N'I'LIANCES-RESIDENHAL ADDITION ❑PLUMHING RIii'll'li
ya i Dutc_i��—QLJ Contractor
FDw 7 J 6 ARCIII']IiCPS DF,CLARAL'ION PANELS ❑MULTI-UNIT ❑STHUCI'UHAI.
ZOyZ 1unJcmmnJ my plans shall he used as recnrdv MODIFICATION
OZ�,-, UPTO20dAMPS [I INTERIOR []CHIMNEY REPAIR
[-'fin M Licensed Professional 201-1000AMPS IMPROVEMENT E)SWIMMING POOLS
a:42 OWNIii-BUILDER DECLARATION OVER I(MMIAMPS ❑BATH REAIODEI/Hlil'AIR El DEMOLITION
z z z¢ I hereby union mal 1.fit oicanN from me Cummmo;x Liecmw Law fon he
3 F !Ilowing.aeon.(Section]IULS,liuxinma rod Pm(e%xinna Cute:Nry city or county SIGNS ELECTRICAL El OTHER
y which egram,u p nnuil u,,( cl,alcor,lmpruve,demolish,or repair my marl
sc miis....arca al rc<oircsllmu:flicanl tor.irch un file n.i lalatmncni O
pont m ourmi gaw SI'IiCIAI,CIRCUIT"IMISC.
04 r� nom he is ua.ff..d naraaam fn me proxi.�onxnnha cantmetm'.uc.m.l.aw lcnamer9
04 pp c( anioncing with Socia 70(10)if Division 3ofine[to......andl'mtu,'itme Colgar TEMP Nil,I ER OR TOLE INS'1. COMMP,RCIAL:
L a z fhill he In exempt therefrom and the basis for the alleged evenfption.Any violation of ❑NEW BLDG/MIDI"P[ON
❑DEMOLITION
K�LL Section](131.5 by any applicant for a Nil subjects the applicant m a civil penalty of POWER DEVICES
N not mom than five hundred dollars(S50j, ❑TENANT ❑FOOD SERVICIi
F Z T IMPROVEMENT
E¢i [:1 .owner of the pmpcny.nr my nnplgttx wish....mmcirsnlccomperection. SWIMMING POOL ELECTRIC
aft2 will Jo the work.and the.Imemm is not intended oref@red for cde(So,.]RN.Business ❑OTHER
W 3 m and Profexvinn.Code Me Contractor%License I,w docs not apply to an owner of OLIFI.ITS-SWI'fc11i7s-171%'NRtiS
property who haildv mlmpto a m r.on.and who docs ouch wmk Iim.df or through
f
It, w ntployce,pmvldad that such ingaovcnmms arc nut Imauled nr offend for NLW RI3SIDFNTIAL I1EC:'R SQ FI'.
add lJ,hovy,c,mc arldi ng of ...prove cut:cold w allit uneyaur or oa:plclion,the SQATI VLOORARFA S/SQ.Pf.
ow uvbnptlxr wall haw the hooka or auving mat he Jib not build nr Improve fnrpnr- I
pna of sle,. 2q-=>
❑ 1.its owner of the nmpany,am excdxively contracting with r.cracd enmmemm to a�
consumer me protect(Sec.aan.9mame%x and Profession.Coil l'1lte Contractor.Li-
ens Law docs not apply to an owner-of pmlcrty who build%or improves meman.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a cxmmal licensed pursuant to be Cneuxetor% V
License"ov. PERMIT ISSUANCE.
lam cmmpt mall Sas ,IIkPCI rthis mason
ALDER-DRAIN.4 VI?Nf- IiA) VALUA'IRIN
Owner Dam
WORKER'S COMPINSATION I)FCI.ARAI ION RACK FLOW PROfEC'I'.IIEVI('; 01;, ` a
1 henry alums under pmalty of pest jary one orounaas
r dm wing dcarrs:
p [have andwillmainrfinu CvmificumofQtmcnuuxlf-innurc l'nr Wurkcr'x Cnmpcn- DRAINS-FLOOR.ROOF ARto ossfi' $'fURIES TYPECONSfHUCI'(ON
a urn, prnvid'd far by Scctinn 3]W of the Labor Cede,for the terksommic of Ibe
r which thio pennif is iaucd, PIMUHIS-PLN THAM
(vee and will maintain Workers Compensation Insurance,as required by Section
37110 of the Labor Calc.for me Fi rfmmunceof the work for whichmi.p—if i\usucd" CAS-EA.SYSTESI-IINC.40MI.1? 5 OCC.GROUT' APN
My Worker' onIn ca pier and Policy number are:
Carrier:_ Policy No.:r'?..fN 2 GAS-EA SYSTIiM"IlV1iRi(13N
CHRI' CA 1f 017 F:%li PTION FROM WOH'111
COMPENSKIION INSURANCE GREASE/INDUSOn.WAS'll?IN'FIRCEPIOR
BUILDING DIVISION Ialif:S
Ixxv.
)(Ifi.—jinn need not be compamcd it the pcmfil i1 or la.handl dullest(51(a) — --
GREASE'fRAP PhANCIII?CK IRI:
I ccrtifymm in the if nnn:uccol he ,,,it for wIridi hv,...it idsuucd,I%Od S17WITR-SANITARY-STORM EA.2N)FI'.
mpluy any pea .myn, .some ret became .bjecun file Worker,' ENERGY IIF:
zZ 'aama Irwu of Cultj�ymra.Date n WATER HEATER WNEM/ELEC R
Applicum / /� / GRADING FEE
y NOTICE TOA A�.If.: r making t n cnifinm of Exemption,you should WAT IiH SYS'IF.M/1'RF.ATING SOILS FEE
C ; became subject to the Workeh Compensation prevision%of the Lxh r Cole,you must
fimhw'im comply with such provisions or pcmfii shall he deemed ravokN. WATER SERVICE
4
CONSFHUCTION 1.17NDINGAGENCY NEW RESIDENTIAL PI.MB, SQ,Ef. PAID
U Z IhcubY u g fftnn fhi,1hcrcu' n .onom,;inlcndaagency funhc Iw'r fnnounce,I D Ha.iptp
U p
We wm k for which this pct foil is Lnned(Fuc.309].Civ.C.)
F i,cndcr'%Name TOTAL'.
V Lc do Address O D�
r 1 mmif that 1 have mad than a I I d sate into Thu above infonnafion is BUILDIN P.
F., a r pp ice inn an
rq correct.[agree to comply with all city and county mdinances and state laws mining to QTY. MECHANICAL PERMIT FEF,
V ,Z, building construction.and hereby authorize rcpresenutives of this city to enter upon the SEISMIC
above"mentioned property for inspection pvrpsiva . PERMIT ISSUANCE
(We)apce to save.indemnify and keep hat the City of Cupertino against ELLCRIC E
Iiabilities,judgmentx.costs and capcn.es which may in any way.arae against said City AUGER ORADDTOMECH. in Ain PI,UM9ING 'E13
of@l7
APPLICANT UNDERSI'ANOS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1(10 II IN)CFNE
SOnaUItCBnfxcqucREnccGULATI()RSofthegranting ts lwnnic. MECHANICAL
iITaC l/—
at/p�✓�� AIR HANDLING UNI T"IOVEH IIIIpI1 Cl a 'ON STHUC'O(lN'fA% /
Sfgnuturc MApplf'feecunVCnmratlnr Dum EXHAUST FOOD(WIDUCI) HOUSING MI'I'IOKIION FEE
HAZARDOUS MATERIALS DISCLOSURE IIY V v�f'L71i ,
Will the applicant or future building occupant%tom
re or handle hzNou.material HEATINGUNIT(TOL00.0M)ITU)
as JefinN by the Cupertino Municipal Gdc Chapter 942,analthe Health and Safety
Cafe.Section 25532m)^ DEATING UNIT(OVF.R 100.01)BTU)
El Yet No PAID
VENTILATION FAN ISINGL i RESIDI D' c He ipf ar
Will the applicant ar tinum budding occupant aw mptipntma or d......which
emit hvanloua air eonmnfinfffns n.d0wed by ma Bay Area Air Quality Man"cren 111111?R-COMP pHP 011 1001(no 1]I'U)
D'nnlct'! H(IILI?k-COMP(OVIlIt Ig),l%q li'I'U)
❑Ycv ❑Nn
AIR CONDITIONER
1 have mad the bvurdou.m:neriulx rcquirnfcnts under Chapter 195 of the Cali- ISSUANCE DATE
foods Health A Safety Calc Sections 25505.25533 and 25534.1 rudimental that if the NEW RESIDENTIAL MECI1. SQ.Ff.
building does not currently have a tenant.that if is my responadoli y m notify me occupant
of the rvluireual which must he mol form,,smove of a Certificateof Clemency.
U viam o u nthmi J ugant Ilam ISSUED BY:
OFFICE