S 2905 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ]IT][DING-ELECTRICAL PERMIT NO,
BUILDING DIVISION .. APPIACA•1'ION/PERMIT PLUAiIILNG-MECHANICAL
dIUILDING PROJECT IDBNTIFICAXION'
BUIL.IIINGADDIS ESS: SANDARY.O. APPLICATIONSURMITTALDAI'E
o y� �111VSv,J �� Z, :a g
G ER'S NAh� 1yy{,_ o� CO HACrUIfS.AMR: LIC NO', /
O-CMCJ S NIC CON'I'HOLp
ARCIIIFECTANDINIiER: LIC NO'. AI )I ESS: ❑
CONTACT: PHONE: - BUILDING PGRMIT INFO'
❑ Consultant Fees Paid by Applicant(Initial) BLDG, EL[CILAMB MFCII
LIC(?NSEDCORfRAC'FOR'SUI!CI.AIIATION Q'fY. . ELECTRIC,PERMPP FEE
I hereby mHma mat Ina Eceesed under,aveiainm of Chase,9(a+mme.dng JOB DESCRIPTION
WOO withS,,fio ]BBBIotD.ckia'n/I at he Be,irinvand Pafesxiary GWe'ndmy license is pl!I2MI'I'ISSUANCF: OF T
FSS in full force and effect.6 /'l/ I SIUWI. ❑it]ICIIHN REMODEL
al F License C�I�I)�j�`� Us p .t1 -
6z U / API ADDITION El PLUMBING RE PIPE
y6C Dote d/J Cnnlra
F,7y AHCHITECI'5 DECLARATION PANELS
❑MUL'1'bUNI'I' ❑S)'RUCT'URAI.
z O+al'Zz I undmor.nrt my pinuv shall he uwaI av public records MODIFICATION
Oz`=C - UPP0200AMI'S [Iloll PRIOR El CHIMNEY REPAIR
(qq'nl I-icemeJ Pnafcssional ]III-10(01AMPS IMPROVEMENT E]SWIMMING POOLS
•t 2'� OWNER-BUILDER DFCI.ARA'I'ION
C"9 a OVER 101DAMPS ❑BATH REMO WItEPAIR EIDIiMOLITLON_
Q 1 hereby affirm that I am exempt from the Common v"meow ow for the .�'Fo%oe�
3 0.r IiJlmer,reason.(Section]uJl.S,Bucinuvl uml Pnafexsinns G a Any c y it county SIGNS 111.1?CTIIICAL OTHER�t.,�t
ad 0.y which rcyuircs a permit to cnn.atvm,abet,improve.Eo �'d
pa' try structure ��R//gree
"nn,,it,o'neuce,:dvoreynin,the opplicam for sate good s4nemc'nr til'ECIAI.CIRCUIT/MLSC.
that he is licemcd pia it the prnvisinn.v of rhe Wnme Law(Chapter 9
��{�� (commencing with Section]INp)nf Uivisinn3nDhe Bnl'essions Gnle)ir TCb1P.ML'TIiH OR I011.F.INST, COMMMERCIALchat he II a,nopi m clam.nd rhe hnsis far the u l Any vinialion of ❑NEW BLDG/ADDITION ❑DEMOLITION
Scainn]B3LS bye yapplicwt fora permit suhjcas advil pena0y if POWER DEVICES ❑TENANT ❑FOOD SERVICE
229. tot marc than live undred dnuto llSI�NT, IMPROVEMENT
F. D L."cose"of t to pmpsny,army employ w •esox flach,ole compenon o, SWIMMINGPOOLEI.F UPIC
Saa_� will do the work,a tithe nacmrei.s not intendedoffered for sale(See.]Oi,U lNeoness ❑OTHER
Ei m nod Prol'essi.... mll Tire Cnmmet on se w does nor apply no anw
oner nl' (AUTI.I?'I'S-SWITCI IES-FIXI UR11S
s
CCCC66.... property who but nmproves rh wloo d x such work bimealfor mrougM1 -
ba nwn employe e,pooldrd that men imp, 'nems are not intend.nr offered lir NEW RESIDENTIAL.ELECFR SQ rL
safe.If.howmrr,he building or it powmact is J within one year of completion,the SQ.19.FLOOR AREA $/SQ,FT.
pweer-builder wi I h:rve n of paving that he did not build or improve for pur-
ofsale.)
I,as nwnerof ma nae property. cxrkiweely contmcdng with licensed emonow nn m TOTAL.AL:
mktthe Tera(Sen.](WJ,II ex end 11 reosinnv Code:)The Conoecmr's Li- -
censl.uwdmsnotapplyman in nfpropriywhohuildlmlmpavesheraan.aod QTY. PLUMBING PERMIT FEE '
who contracts for such projects with omnncem%)licensed pursuant no the Communes
Licensc Law. - PERMIT ISSUANCE?
❑Ianiesenynunder Sec. ,B&I'Cfonhisnicumn
Owner Dae - ALTER-DRAIN&VENT-W'ATHIT(EA) VALUATION
WORKER'S COMPIiNSAT ION UECLARNI'ION BACK FLOW PROTECT.DEVICE
I hereby anion under penalty of perjury one of rhe following dcclamtim,:
❑I have and will maintain a Cenificam 9f Consentto self-insure for Warier's Compos DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'TYPF.CONSTRUCFION
wtimo, vprvvichd liar by Section 371X1 of the Labor Code for In,p,,oraanwofrhe
for which this Icrmit is issued.
FIX I'UR S-PER TRAP
!M1_r1W111r`
_GAS-EiA.SYSTEM.I INC.40U'I'hETS i NOUI' AI'N
:�VsG/�/lL��./JIAnIIaY Nn. GAS-I!A.SYSTEM-OVI!H 4(BA)
CEHTIFlCCOMPE COMPENSATION
WORK. S'
C.OMPIINSATI(1N INSURANCE GREASFJINDUSTHh N'ASTIi(NTIiRCF.ITOR B 11 Ql ISI(Nd
(Thixsecocs.neednor Ice ovelned ifthe pe.it isfornnchunfinddoll.S10) GNEASE'FRAI' 1
or less.) I PLANCHECK FER
I.yan,thrumtloe say.mmsenf th to orkIsco e,ardjhthlsphe W.kis c,'C, ,..shalt SEWER-SANITARY-S'I'ORM IiA.2X1 FF.
not employ any perxun in any manner mus ro become sunjecnn the Wnrken.'Compcn. ENI3HGY PEE
OZi Intent Laws an CuliEvnie.lime WATER l ll!Al'1?R WIVIiMI'II?LEC'I'It
Q Applicant
h NOI'ICF,T(1 APPLICANT':It,after making this Certificate of Esem ante.you should WATER SYSTI!M/IAIiAIING
." become stibjeet a the Worker',Cnmpenoman pro'kions of the Lnho,Code,you most SOILS FEE ,
t� forthwith comply with such prnvinom,or his permit shall how Noticed mviked. WATER SERVICE.
CL. I
CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID
UC T I
li
I henhyafrtn te
thutrhere is lcomingagency,forthe performance of Dulc Recipt
the work for which this permit is i...ed(Sec.3097,Civ,CJ
E" Lender's Name e'l (ll'AU
O U Lender's Address TOTAL:
't" 0. 1 certify that L Imre read this application and stem that the aMme inf rmilinn is a BUILDING FEB
t: fn enrrcerl anerem comply with all my; I county ontinnncen note aatc laws relatingtn OTY ,MECHANICAL.PERMIT FEE
U Z building conarunion.and hereby andromize representatives of this city to enter upon the SI!ISMIC FEE
thove-ratr finned prop ny for inxpcetinn purposea PERMIT ISSUANCE
(We)agree no once,indemnify"nod keep harmless the City of Coperlion against ELECTRIC FEE
Iiabilities.judgences.tests and expenses which may in any way accrue against said City AITP.RORADDTOMECII.
nnseapence of rh Feininger this permit PLUMPING FEE
APPLICANT U ' .I {?A�1DDWILL COMPLY WI F14 AL��N-y'O AIR HANDLING UNIT(1Y)10.IXNI CFM) MIiCHANICALILE
SOOHCFANT O / /F14 A /
AIR HANDUNGUNIT(OVER 10,00 CIM) CONS'I'RUCTION'TAX
Si re of ApplicaMCont ctnr Il,ne (!XII AUST I IOOD(W/DUCi) HOUSING MITIGATION FHL!
IIAF.AHDOUS MATERIAL S DISCLOSURE
Will rim U)licamorfuture building eceupmlmou,of handle hueaNnus material HEATING UNIT(TO 100,110)BTU)
as defined by the Cupcnino Municipal Cale,Chaplor 9.12,and the❑ealth note Safety
Code.Section 25532(.)] / BEA1ING UNIT(OVER 110,000 BTU)
❑Ye, L7No VEN'I'NATION FAN(SINGLE RPSID I PAID .-
[late Receipt
W'+B dm opplirnoor An are building aeaapam use egnipmenl or devices which BOILER-COMP(31111 0111fN1,D01 RTU)
•,in htomlinsair cinwminann us defined by the Bay Arca Air Quality Management L�
District' BOILER-COMP(OVER 100,000 RTU)
[3 Yes Z>o
L nice read he hvnNios materials teuptircments under Chapter 695ofhe Cool AIR CONDITIONER ISSUANCE DATE^
fomia Ileahh&Safety Code
tt .Sections 2.5505,25533 and 3534.1 understand that if the NEW RFSIDENFOAL MOCK SQ.14. .r / 9
building dnexnmacmly have a ream.food it in my owpnmm a
ibility notify the tmopam L�.�. - f C�
of ma aquircm litasmyt met prior to issuance ofa Ccnificura of(kcupenty.
Owncror aurboroal agril(i / Date TOTAL.; ISSUED BY:
OFFICE