S 2281 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELFCI'Rll'AI, I'liB`�I1'I'NO
BUII,DING DIVISION APPLICATIONMERMIT PLUMBING-MECIIANICAI, t,J 2281
ItU111DING PROJRC'1'IDENTIMCATION
IIUILDINGADDRESS. SANITARY NO, APPLICATION SUBMIMAL DSII
6 II e-LP6jQW00sP CT. jor�
OWNS<. E' PHONE'. CONTRACTOR'S NAME_' LIC NO:
�� - NIC CON'rRO1,N
•ARCH I'IE 1'/IiNGINIiIiH: LIC NO: IT ADDRESS: ❑
F7NXEol
PHONE: BUILDING PERMIT INFO
❑ Consultant Fccs Paid by Applicant(Initial) BLDG ET.I!CI' PLUMB MIiCH
LICENSED CONI'RACI'OR'S DECLARATION Q'FY ELECTRIC PF,RMPr FEE
f ire mall I am Bcenmd under provisions or chapter a(commencing JOB DESCRIPTION
ozz Section Eol+f Division3oOhc Buounwand Prorcwiom Code.and my Been:eh FSIDFNTIAL:
1+102 I'ENMIT ISSUANCIi
Fly._ dlca. ❑SPDWh CHIiN REMODEL
ZULica ' APPLIANCF_S-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPIT
NQ C DatC OnatalYm
FAQ. ARCHHVCTS DECLARA9'ION PANELS ❑MULU-UNIT' ❑S'I'RUC'I'URAL
Z O.a Z I unde...and my plans.hall he u.tvrl as public recant, MODIFICATION
lIPT021M1nMl'S INTERIOR El CHIMNEY REPAIR
F4tw Licensed Prafcoinwl 201-1000AMPS IMPROVEMENT C]SWIMIIENG POOLS
OWNER-If UILDI!R DI!ChAItA'I'ION oVER IIIBOAM'S C1 PATH RE.VIODEIJREPAIR [_1 DEMOLITION
C Q 1 hereby affirm that I am exempt from the Communes License I.uw far the
X OW
U follnwing reason.(Section 91315,Btr,iows and Pmfnstios Cade:Any city or county SIGNS ELECfRICAh ❑OTHER
LL LL y which requires a permit In consnucl,alter,improve,dennlsn,nr repair any urnah e
c{nlQ prior In is isstanec;Jso requires the applicant for such famen to file it signed uatemenl SPECIAL CIRCUITIMISC. t
y` anal he it licensed parsuam In the prnvisinnµnf the Gonunoor',IJccatse Law(Cnapter9
0 (commencing wim5tttinn l(XM))ol Uivision3 of the Nosiness and Pndetsiont Cale)ar TEMP.MEI'I!R OR POLE. NST. COMMERCIAL'
a IL e C mal he Is eacfi,a mulefrmn and run bntis run mu;Jlegud enemption.Any violation of ❑NEW BLDG/ADDITION DEMOLITION
^'LL Semina 70315M1y any applicant far a perm it suhjax¢meapTdcrmu,a civil penallyof I'OWI3R DL.ROR
W_y ❑'i'ENANT ❑1'001)SERVICE
net more than five hundred dollars IS500). IMPROVEMENT
I- QDl.;p uwna ofalis pmpeny,onny mnpinyccs with wngcxaxrosinsolsennpunsnliun, SWIMMINGPOOLELECRIG
oft will do arw 'IO
the work.and the is not intended or uttered formle(Sec. SJ.Businecs ❑OTHIiR
F_
6 3 m and 1'ro(useiunrc Cndc:The Cnnlracmr'-t Lirense Luw Anes not apply to an owner of OfITLI?'TS-SWITCHES-fTXTURLS
property who builds or impmvct thereon,and who drct such work nimsell or through
his own anpinyew,provided that such Improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FP.
sale.ll:however.the landiinlimunprovemem issnld wiminun,yearofeonple,p.me .FT.I OR .A F1'.
01 cr-huilder will have the burden of proving that he did not build or impmvc for pur-
as owner of me property.am exclusively contracting with licenced contracunn n+ 1(W
"f tole' OCT 1 199
L, n L:
construct the Tamect(Sec.704T1,Batmen and Prom,,ism Cam:)The Commences Li
cease law dors not apply to an owner of property who huildsm impmvct me 1,; d QTY. PLUMBING PERMIT PEE
who e(mlme rmen pmjccswim a commetogs)licensed pursuart to the Comracum% p
LI,, ,L' . PERMI'I'ISSUANCE
By
--
LI,,
to Bandar Scc. _,B&PCfor Wis reason
ALTER-DRAIN k VENT-WATER(EAI VALUATION
ser Dvtc
W( KER'S C( PHNSAllO ECLARATION 13ACK FLOW PRUIECT.DEVICE
I I mby off rat under penalty of purryry I Ic d the G,Iluwing Acdar;ainne
El I hastened will minimum.Certific,mafCme .,If-fn.wmfim Wmkcev Compcn- DRAINS-FLOOR.RCOP.AREA.GOND. STORIES 'IYPEC Cl lop
.canon.see Providal nor by Scctinn 390I ol'thc Labor Cade,❑n the PMomumce of me O I
OCC.
work for which this penal is issue). FIX'I UHES-PER'I'RAP
E]1 have and will national.Wnrkch Compensation lmumnce,as required by Sermon
3TIAloflhe Labor C'ndchn derperfnrmm�eeal me work fur whi,h min permit is iteucd, GAS-1!A.SYSTIiM-1 INC.JOtTrLETS GROUP A1 1I'N
My Workers Compes
nsation Ilumnce carrier and Policy romper are:
C romr: Paley No.: GAS-EA.SYSTEM-OVER J(EAT /
CERTIFICATE 01:EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASI%IN'DUSTRL WASTE INERCEITOR
BUILDING DIVISION FRES
(Thinmction ural nal M rumple W it mgsrmt x Throes M1undred dollars(S IIN) -
or Its,.) GRF.ASE'I RAI' PLANCHECK FEE
I cemlyfam mhc perfnrm;m,m,fthework To, hdi this permit is issued.I,mll SEWER-SANITARY-STORM I.A.210 FT.
nal eetploy any Pelson in any manner so as to become subject In Ne Workers Cnmpen- ENERGY FEE
z emior law,of Califnmia.Date WATER HEAT ER WNENT/ELECfR
Z Q A,TpIh,m GRADING FEL!
Z
N NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMGREATING
a bee ale subject ,,Ibc Wnrkctp
Ike,-Coneava i Pnrvinin t,ofmn Labor Code,you Iltasl SOIfS F[E
W fonbwi a comply with such Bmviamoo,06%pemlit shall be deemed revoked. WATER SERVICE
UUZ CONSTRUC PIONLENDING AGENCY NEW HESIDI!NTIALPLMN. SQ,FT PAID
Q Ihrrehy affirm that mere isarnmwcunn lending agency for perlirnnance of RneiplN
IT. F the work fia which Ibiµpcl'Init is ivmcd(Sec.3099.Civ.C)
O U Leaders Nue, 'TOTAL
Lender's Addres, T(YIA1.:
br' y •1 only her 1 have read this application and s,;a,me,the ahnve inl'nrmalnn is BUILDING ITT:
h rr
coect.l agree to comply withal)city and county ordinances and state laws relalingln QTY. MECHANICAL P1iRMIT FEE
UZ buildr,conswcliun.and hrnbynulhnri cmpmwmali,, of lh6 dy,ottow fun,the AQSMICFEE!
abnce-mcntiened property for inspection purlx+mc.
(We);agree save,
In indemnify and keep bamJpe
ess Ibc City of Cupertino against ISSUANCE
l IiLECfRIC FEF. a
Iialdiaw.judgmeals.cnsn and cepenws which may in any way accrue against said CilY ALTER OR ADD'TOME 11
Inc CllmtC a[nG
e of me grunting of this permit. PLUMBING PER,
APPLE N'I'UNUENS'I'ANDS A .I.COMPLY WI'T ALL NON-POINT AIR HANDLING UNIT LTO 101X10 CI'M) %
SOU 1.REGULATIONS. J MECHAYICAI.IEE a7�
AIR HANDLING UNIT(OVER 10.000CFMI CONSTRUCT ION TAX
.igt suns alp lican 'm mor Dat, EXHAUST HOOD(W/DUCT)
IIA%A DOUS MATERIALSI LOSURIi HOUSING MITIGATION FEF,
Will meapplicamorfrmen building eaolval stareor handle horamm,nanctial HEATING UNIT LTO 100,10flp BU)
as Julined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Cole.Section 25532(d! HEAPING UNIT(OVER I00.AXI RTU)
E3 Vie, 7N PDa
VENTILATION BAN(SINGLE NESIUI
en Will thea applicant or future building +ecu t ate e t or devices which Date Recrlpl N
pp gt pvn .,Air Qn BOILER-COMP(3HP OR 100.X10 ETU)
tit IurarAuuc air aml;nninanp as ddinW by me ITuy Arut Air Qlmlhy Mnnugcnmm
District? 'IY)TAI
i
E]yes EjNn ITOILEft-COMP(OVI!R 100.000 ETV)
I have real the harWnus materials requirements under Crater 6.95 oflhe Cali- AIR CONDITIONER
4 p ISSUANCE DATE
loobuild dthk Smientlylue,al etx2550, ismy rwnd2553J.1 Indenend lballfthe NI?W NEBIUI?N'I'IAl,MI!CII. SQ.ter.
built tnnl ,I lb havexm tatois my mtpuni rMy In nnBlj the ar'v
cmcnp whichn 't n t+r u,'c to uCljyncl f'k
)w cr or umh a,d agent Q Ute TO'T'AL: ISSUED BY:
OFFICE