S 1633 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PEIf`�1IT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.-MECHANICAL v 1633
IIUILDINC,PROJRCT MEN'1'IF'ICAT'ION
BUILDINGADDRESS: SANI IARY NO. APPLICATION SUBMI'1"IAL DATE
2 7 4 Li}nit S-1-gs
O14I31'1 NAME: PHONIC CONI'RAI.E'S NAME: LIC NO:
C7 'f k -P U11 157 N OXQ 33 N/c cONrkoI.X
ARCHHEC'EMOGINHER: LIC NO: ADDRESS:
P&' oSPimc RD s'A{ie.4 a;
CONTACT: PHONE: All BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDGELECT PLUMB :CII
r'y
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
t S1 hereby zhino to d 1 ata InertInertander arovisioet of Chapter 9(1 rou'reing JOB DESCRIPTION
00.'z
wont Section Division 3,dmc Buriness and Po4u,innx Code, d mene
y Nix RESIDENTIAL•
�+IOp onPLkMI'I'ISSUANCE
n full force and etl'ect. ❑SFDWL THEN RIiMODEL
<VU License Class LicX APPLIANCF_S-RESIDENTIAL ❑ADDITION ❑ LUMBINGRE-PIPE
F-ZZ W a
Cnntrnnr
F ARCHITECTS DECLARATIONppNELS ❑MULTI-UNIT ❑STRUCTURAL
Z 9 y Z` I nnderamm nay plans shall M mW at public records MODIFICATION
CZ-c UP TO 200 AMPS ❑VsHERIOR ❑CHIMNEY REPAIR
FN~LLL Licensed Professional 201-10WAMPS IMPROVEMENT SWIMMING POOLS
zt� P, OWNER-BUILDER DECLARATION OVER Hold AMPS BATF(NEM EIIRF.PAR ❑ LIT(
Cv•,
Q .1 hereby affirm that I am eauiopt from the Counselor',License Low for the
Lai U following meson.(Section 7031.5,Business and Prol'esxions Code:Any city oreounty SIGNS EI.IIC'1'RICAI. OCHER T �y�.R_fAti
fffililil 3 LL,y which requires a permit to construct,after,improve,demolish,nr repair any structure
prior 14)its issuance.also requires the applicant for such permit to file a signedsmando SPECIAL Cl RCUIT/ ISC.
�} that he ixlicemod pursuant to the pmvisionsofthe Contactors License Law(Chapar9
�QD (comnnncingwiW Section 9000)af Division 3 ofihe Buir—ad Protessient Cad0oa TEMP.M RPOLII DISTCOMMERCIAL,
d as tM1m he is exempt therefrom and the basis her the alleged cxcnmatinn,Any vinlwion of ❑NI'W BLDG/ADDITIONEl DEMOLITION
^m Section 7031.5 by any applicant for a pent subjects the applicant a civil pcnuhy of POWfik I Cl TENANT 0 1700 SERVICE.
non mom than five hundred della,,(5500). IMPROVEMENT
3,:
❑I,as owner of the property,or my employees with wages as their sole compensation, SWIMMINCPO01. . RIC El OTHER
will do the work,and thearacmre ix not intended or offered fatale(SCC.904FL,Bu.si't
and I'r lessions Code:The Contractor's License Law does not apply to an self Monti owner o[ OUTLiz rs-SWITCHES
- ES
�' .. polarity who builds or improves thereon,and who does such work him
his own employees,provided that such improvements are not intended or nIere l for NEW RESIDENTIAL ELIitSR 1'.
sale.If,howeveathcboilding or improvement is sold wi'hfnone your Mcomplerion.the SQ.FT.FLOOR AREA y$Q.FT.
ter-builder will have the burden of proving that he did not build or improve for pur-
pose of tale.). pp
1,as owner of the progep
ny,am exclusively contractors with licensed contractors In TDTAI"' P i
conswct the projrct(Sec.]1144.Businessand Professions Codc)The Contractor's LI-
cenal.aw does not apply loan owner ofpmpeny,who builds or improves thereon,and QTY PLUMBING PERMIT FEE
EEforsuch projecswith a commoor(s)licensedpurmant tonne Centmemrs I I1Q(1� ^.,e.�
License Law. PERMIT ISSUANCE WAY e➢TIINYVI
❑ I um exempt under Sea. ,11&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER(EAI TyA1.Uq 1 N'.
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE C(f�iJ`I/�(C�f)lJ�
• I have
hceby alfirnt under penolty of perjuryone ellhe following dwlamd,a s:
and will maintain aCenificnte of Consent to self-insure for Worker's Compel- DRAINS-FLOOR.ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
cation,a provided for by Section 3900 of the Labtsa Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will mountain Worker,Compensation Insumncc,ax required by Section
3900 of the Labor Codc,for the performance of the work for which this Proud iv ivaed. GAS-EA.SYSTEM-I INC.4 Got LEMS OCC GROUP AIN
CamcrrkK�grnygyy'irm Lpsztr,•tBcq ylrie PaIJ Y�Noy�gkhc �0/ GAS-EA.SYSTEM-OVER4(EA)
CCRTIFlC CO MOPEFNSAITION INSURANCE
CWE ORKf:RS' ?(!j— GREASUINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION IgiE' -_
(This section need not be completed ifthe permit is trance hundred dollars($100) GREASE'I'RAP
or less.) PLANCHLCK FEF.
I certify that in the performance ofthe work for which this podook is issued.Ishall SEWER-SANITARY-STORM FA.3110 ff.
not employ any person in ray manner so as m become subject m the Worker:Compel- ENERGY FEE
Z sation Laws of California,Date WATER HRATER W/VENT/F.LECIR
O Applicant m GRADING FEE
NOTICE TO APPLICANT If,after Making'his Certificate of Exemption,you should WATER SYSTE ATREAI'ING
ti SOILS FEE
f~ throb it subject NuchpsCompensationprovisions b'he Lena Codc,you mus'
Lak1� forthwith comply with such provisions rnM1it permit shall be dcemeA revoked. Wq'I'ER SERVICE ar 91
Q
CONSTRUCTION[.ENDING AGENCY NEW RESIOfiNTIN,I'LMH. SQ,FI'. PAID
Z thereby affinn'ha"hero isucnnstrudinn lending agrnay lin the paa(rrmance of Date keceiOpt p
the work for which this Permit is issued(Sec.3097,On.C.)
Q U Leal Nunn TOTAL:
HJ Lender`s Address. 'TOTAL:
1 BUILDING FEE cenify that I hove rend this application onJ Hera thorn the above infornnninn is /X
ai
Ion correct.1 agree to comply with all city and county ordinances mad state lawn rdaing m Q'fY. MECHANICAL PERMIT FEE
Ll Z building comwction,and hereby authorize representatives rf thin city to enter upon the I� FA
aMsvementioned property for inspection purposes PERMIT ISSUANCE E
(We)agree us save,indemnify and keep Imnnless the City of Cupertino against
liobi li t lex,judgment.,,,costs and expor t which may i n any way name against City ALTER OR ADD TO M ITCH. EE
APPLncquence of me granting of this acre L
ICANT UNDERSTANDS AND WILL COMPLY WI fit ALL NON-POINT AIR HANDLING UNIT(TO 10.0(10 CPM) L
SOUR •REGULATIONS.
F� �� �O AIR HANDLING UNIT(OVER 10,000CFM) ON XSigmnurcof'ApplicunUCrn roan' `1 Parc 7 IzHAUST FOOD(WIDUCT) TIGATIONF
HAZARDOUS ATERIAIS DISCLOSURE
Will theapplicont or fuwrt hwldingoecuxurf, me ordidle havallom motorial HEATING UNIT(TO IW.000 BTU)
as defined by the Culs nine Municipal Code,Chapter 9.12,and the Health and Safety
Codc,Section 2553201^ HEATING UNIT(OVER 100,000 BTU)
❑Yes [:I No PAID
VENTILATION FAN(SINGLE RESIDE Uare RccciptX
WEII the applicant OF future building occupant on equipment or devices which BOILER-COMP(3HP OR 100,00(1 BTU))
emit havadous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
D'slrct4 BOILER-COME DOVER 100,000 BTU)
❑Yes C]No
I have readthe haallous emend,requirements under Chapter 6.95of the Cali- AIR CONDITIONER ISSUANCE DATE
Term.Health&Safety Care,Suctions 25505,25533 and 25534.1 understand that if an NEW RESIDENTIAL MECH. SQ.FE.
bailNng docs no'currently have a tenant,Nat it is my responsibility to notify the occupant
of the requirements whleh must be and poor In issuance of a Cenllicree of Occaaoney.
Owner oramhorizoJ ogee Dae
TOTAL: ISSUED BY:
OFFICE