S 2003 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY I(�
CITY OF CUPERTINO BUILDING-ELECTRICAL PESIT NO 200 �J
BUPLUMBING
u.DING UIFItiR)N APPI,ICATION/PERMIT -.MECHANICAL. PES
ItUILDING PROJECTIUENI'IFICATION
SANITARY NO. APPLICATION SUI1All'1'rAL DATE
BUILDING ADDRESS:
PHOT P III i07-Sx/17 IAD
R CTO 'S NANH LIC NOI� NICARCIIETECP - GINItiIF LIC NO: _S ort ❑
s ✓ -G Sb
CONTACT'. ,fes J qqq 1.14ONE: BUILDING PERMIT'INFO
�/ / // J /� �� ❑ Consultant Files Paid by Applicant(initial) RI. GIiU❑°.CT PLUMB SUCH
LICHNSE?/SI?D CON]RACT R'S U.'LAARAAIIOION QTy ELECT'RIC PERMIT PGI2
1 hereby.Irmo don I:Ire Roamed order provisiam ar chapter v P,oaabenung JOB DESCRIPTION
QmZ 4,fSmuon700(dof Divixinnsnfme aciRESIDENTIAL
woo PERMIT ISSUANCE
❑SFDWL ❑KITCHEN REMODEL
C F- in full(Alice and eRecL
QUU Ltccm" 1-ick 14 - APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE_PII'E
Dao _ CommieDOC
inQa AHCBUECTS OECIARA'HON ❑MULTI-UNIT ❑STRUCURAL
F-HZ 1unJersmnJ my plane.hall he used us public recnNl PANFIti MODIFICATION
ZOZ�G UP TO BY)AMPS [_1 INTERIOR ❑CHIMNEY R1711AIR
5 Lienwd 11 resloaal 201-I000AMPS IMPROVETM17NT E]SWIMMING POOLS
; OWN17R"BUILDER DIdCIARSHON OVER INXIAMES ❑BATH REMOUELJFdIpAIR ❑DIiMOIJ IION
IY C Q 1 hereby amnn mal I tint exempt from lie Conaaeair's 1 item"Law her rbc
X�6U followingreason.IScaion 903IS,Bminex,inl Professions Code:Any city ar eomnY SIGNS FI.ECI'RICAL El OTHER
W 3 LL vFi which a aalter,
mire,a Permit ,cnnamtm, improve.demolish, ro
ar repair any mcm e
F u'0¢ piinno it,ismance.also wagon,In.pplicturat for such permit to Gleasi6m'"l atmnnent SPECIAL CIRCUITIMISC
ALL} thmheislirenscJ,m1...I tie the pnwisinnsid he Cmdracmd License Law(Chapter Y
C y.Q� (commencing w'itn Senin.7(XX)pd Donion Jnf the lluniness and Pr fix iam Code) TTM It MI-11:R OR POLE COM ERCIAL:
d Kay thin he is exempt thercGnnt:ted the basis for the alleged exemption.Any violmiun of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 91315 by any applicnm for apannit-ld.ctn tM1uaNdritnl ton civil punchy of POWER DEVICES ❑TENANT' ❑FOOD SICNVICfi
nt marc than five hundred Aolall($5nd, IMPROVEMENT
-JdQ
1,ib.the work.
the pn,pcny,nr is not lnyce.vi oroneollaxihcir, Sole campcnsint,, SWIMMING I'ftOl,Hl. IC
F- will dntnlions Coda,
Me nareipnnumended nr owdo l'mot apply 9814, weer es E]OTHER
6'3 w and property
who
Calor inip oyes th ren License laws such
not apply to if owner of OUTiCI'S-SWITCH -FI
his me who buildx or videdvex t thereon.and who dew such wnrk deed m or throughdfor
his own employees.provided that zu<M1 impmvaircnrs um not intended or o((crtd En NEW RILSIDfiNTIAI,F.LEC!'R I°I'
sate.If,howocn the building or iniptoament ixsold within Ane ycaror completion.the
SQ.FT.D CH)H AREA ASQ.Fr.
n-builder will have the huNcn of proving that he did not build or improve for put-
5;=�
,),a TOTAL'
❑ 1.as owner of the l I l,I r.Ibs,,aly.braIwhl J imarloor,la
tet nh FrLr,cl(S ,7044 I1 'u�.andI r... w6'ode:,the C fivars 1. `'�
.e Lt J Iapply f 'Ifp 1 ry 1 build p It n std QTY PLUMBING PERM1 J FEE
who contracts for such projects with a contract (0 fumed personal the Canma,ba'x
License Law. PERMIT ISSUANCE
❑lam excmPr J un er. •Sec. Dme.RB PCfnr @is mason
ALTER-DRAIN.@ VF,M'-WATIiH)PA) VALUATION
owner,
VAR REE S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under pennhy of parjnry one nithe following declarations:
❑ I have and willTitillation oit CerWicatcut Consent Innall-rour"fnr Work...Canteen" DRAINS-FLOOk.kOOEAREA,COND' S'IDH11i$ 1YPHC(1NS'I'HUCfION
Sudan,as pmvideJ to by Scaion Coo of the Licher Code,botbar,parhaman¢of the
work for which Nis Drink in Ixsu d. FIXTURES-PER TRAP
❑1 have cad win toaia do Worker'"campen.amian Imuranm,a:repaired by Section
3700 of he Later Code.for t he Ndamerneeofthe work Tor w hich IN.,permit is I...ad. GAS-PA.SYS'I'FM-I INC.4 OUTLEFS OCC.GROUT' AI'N
My Workeh Com,nisal on Insamnce earner and Pat icy number arc:
Corm"" Policy Nn.: GAS_PA.SYSTEM-OVER 4(12,7
CIiUIFICATE Of EXEMPTION FROM WORKERS' GREASIYINDUSTRI,WASTE INTI:RCEITOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('I his Icarian need bat be cumpleed it he Pcmal it fanmc hundred dollar,IS 1(0) GREAS E'1'RAP
1'hANCIBiCK Plil[
I cranny that in lM1c perrnrmummrfthc wnrk for whiNt(h:xpermit is i.aual.l shall C. SGWIIN-SANI'1'ARV-STOkM I:A.21X)FI'.
Aar employ tiny pcmon In tiny mm�n
it, uhkn ae enc Workcoi Cnngwn- 51jN a Illl?
0 Z sauna Laws nfC i Try,.lJ: y illi Sy>,a'✓let{ WATER IIM'll?R WIVGNT/I?LECfR
ZO Applicant--cciid �fJ�' FJr/LY OGOVCswwl 1 GRADING l9ili
I
(Al NOTICE l'O I "ICANr:If,after making Ih Cenificate of Exemption,you should WAI'F.R SYST13d/fREATTNG Is., SOILS FEE r
f become subject to the Workers Com creation pmvi.iam of the labor Code,you most
fadhwith comply with such provisions or this semen shall he deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. I-AID O
I hereby Biebl that them is a.......ro,;jI la jr,Agency rte The Parrnrmaneeof Ins Receipt U p
W. F 'lie work rte wbmle tma p"rtnil is issued tsea,van,civ.C.) rcrinl
C) Ll Lcnder'x Name
I<bder's Address TOTAL:
H.1 I reedy that 1 have read this application and state that the above in ormation iI BUILDING IT
a
F' Ii'lZ correct lagmetommand with all city and cnrmyorative,o.and smm lawsr,martha QTY. MECHANICAL PERMIT PI:Ie SEISMIC ET'
V Z building cenmrvdinn,and Mmhy amhove rcpmxmaives of thi.citym ender,mar the
above"mentioned property for impaction perryeun. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,Indemnify and keep han dies the City of Cowman against
labilifle,jadgnmms,....Sand expense,wbichar,many w:ryaccme against said City AIA 17R ORADD'10 MECIL PLUMBING PRE
to nn.'nence of the gnnaing of this permit.
APPLICANT UNIIIIRS'I'ANDS AND WILT,COMPLY WITH ALL NON-POINT' AUR HANDLING UNI F(IT)10JI00 CIM) MECHANICN.ITEE,
SOURCE RI:GULA'1'IONS,
AIR HANDLING UNIT(OVER IOMM ChM) CONSTRUCUON'1'AX
Signature of ApplicadiComrecmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
INYARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building omcupnnt store or handle hamrdous becrial HEAT INC UNI"r G 0100,00 B'1'U)
as dcOntd by the Cupertino Municipal Code,Chapter 9.12-and the[]earth imd Solely
Cudc,Smlo.25552304 HEATING UNI'P(OVER 1(X1IXN)BI'U)
❑Yes ❑NaPAID
VEN'IILA'I'ION FAN(SINGLE KCSIO) Uvm Hxeiplg
Will the applicant al hirer"building occupant use a,donent or device,wbicb BOILER-COMP(JHPOR 100.000 B'OD
mit M1aaardoux air conwminants as defined by the Buy Arca Air Quality Management TOTAL: M O
Dievin9 BOILER-COMP(OVER IW.IXX)BTU)
El Yes C]No
I have read(l mentions materialI" ts under Chapter 695 of the Cali- AIR CONUrrIONER f� ISSUANCE DA�Tj/,
hamairt Health NoSafety C } a 2550525511 bod25534,1 understand Into it the NEW RLSIDIiNI'IALMECI. SQ.FI'. �
n 'Id'te docs not currently havea brain,lhart e any'�P ubil'tyt 'fy nee "Imo Ot O
of the re0uini which most ne ten Prior to i"ana'e of a cradwam it 0....anay.
Owner or authnrimJ agent D:ncTOTAL' ISSUG�BY: ��- `
OFFICE �-