S 2626 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _
CI'PY OF CUPIi RTINO BUIUDING-EUEC'I'EdCAI, IFRMII No.
ItInI,DWG DIITSION APPLICATION/PERMIT PUUMBING-AIECHANICAU S 2626
BUIUDING PRHJI:CI'IDENI IF'ICAIION
❑111LIlING AcDDRIitiS: SANITARY NU. AI'PI.ICAI'I()NSURMI'I'I'AI.DAr[
O/�iS �L✓ZT144/t.Ecca
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ED
OWNER'S NAN1Ii: /� 1'HO 1' COMfJ���jCI'ON:S NANIG; LIC NO:
(D� `O� 57 2 NIC CONTROI.a
ARCHITI;CI7pNGINEER: LIC NU: ADDRIiSS: ❑
/1)14 ZOO 73 lh`Rnl cvparz,J.L,
CONTACD PHONE: BUILDING I'ERM1l1'I'INFO
J ❑ Consultant Fees Paid by Applicant(Initial) BLDG HIXCT PI.UNIB MCCH
/LtrLc� sbs-s5GI A /a] ,® ❑
LICENSED CON'HEACl'ORS DECLARATION QTY EUECTRIC PERMIT FEE
1 hereby afr m dim[am I;ceaved under low slop,of Chapter 9(coinmencing JOB DESCRII'FION
MMZ lith s��ti�n7gM)pd Uivision3 of the Bu,inmsunJ Pn,ies,ion,Cok,md my liecmc is RESIDENTIAL:
w00 µlull force and clleet '[ ' FERMI I'ISSUANGIi
in C O ❑SFDWI. ❑Kll'CHEN REMODEL
.`1 Li¢n,`'I �Lic.M �J a At'1'LIANCIiS-RESID1iMHAU ❑ADDiHON ❑PLUMBING R6PIPF.
F z w Doc- �� Cunni¢tor_
m61 ARCIIHITCI'kSIILCLAN I' CMULTFUNI'I' CS'1'RUCfURAL.
F,p m PANELS MODIFICATION
m z l n ffermand InY Nan,shall be oven n,public records
OzU11102N)AMPS El INTERIOR CCHIMNEY REPAIR
h+��I, Liaised 11 1 erchawnal 201-1000AMPS IMPROVEMENT �SWIMMING I'(IOLS
F
X'il:c,dU following peachy hlon that
ision t I ifArltu n'i�nnd he Contra ON' OVER IIxLt�MI'� �(THIEALL If RIiMOI11iLIRleI'Alk ❑DI'.MD1.1'TIGN
w Iracmr',Latest law lot he ❑OfIIIiR
rca
x Cole Any city or county SIGNS IiL[C'1'R1CA1.
913"f- which....elan II Ixnnit.........true..alai,imp T.dumulixh,gr n,an any xtmclone Cx
�7Vt< purl I '-. .dw - I d IPIi, tl bpermit l fl -8 d7 t om SI'ICIALCIRCUI'IIMISC
�,y>. Ihatl I Ipnu tt d P +n Id C t I 1' (Chniom,9
pe et a 11
Q°,m 8 J Sect 711m11 fll sit I of ltua nes, JP +less into Codehr '1 EMI'MCI1R OR 1'01.1 INS'r. COMMERCIAI:
e.p.o K that hu is cxclun Ihcmtrom z I the ka,i,ko the ad,vd-co,nion.Any violation nlz:47
NEW BLOG/ADDITION C DEMOEAT10N
fal�N Seclirn 7031.5 by any applicant lin a Permit subjects the applicant to a civil penalty of POWHK DEVICES An ❑TENANT ❑TOUDSERVICE
nn,more than live hundred do1Dn O5gp. IMI'ROVFMENT
=C 1]1.unxoerol heprnpenitnrnty employees with......%twiranle compen,amon. SWIMMING PCOU pI.I!CI'RIC f')k
F- will Jnthe work.and lhezm,cture is not ina�ndedofotictbd for sale(Sce.701,1.Business V [I OTHER
3 w and Promoions GATT: Me Cnmranor',hiceme taw Jos nm appy m an nwnef of OU'I LETS-SWITCHES-FIXTURES
property oho build,or impmvas ar mon.and who does such work himself or through e
his own employe,provided that such imprinanem,am rust intended or oBemd for NI7W RLSIDINI'IA,EI.LCTR SQ E9'.
sale ll;however. building or impnmc
wcntiswa
ldwithinneyeaofcompletion.Ihc SQ,Pr.IJA(Ik AREA SISV�IT.
conamoloulder will have the boNan of pmvin8 that he did net(wild or improve torpor-
,..1,i
orpur-
pom.,sale). TAI
C 1,as owner of the pro,ii an exclusively contracting with licensed commcan",to
coaaruct the pr9ec1(Ste.9(U4,Busines,and Ihufess{ons Cade:)The Contractors LI-
n,a Law does not apply to an owner of props,who builds or improves thereon.and QTY PLUMBING PERMIT FEE
who contracts for such projecn with a contractor(s)licensed punuanao the Contractors
I.iccnse I.aw. PERMIT ISSUANCE:
E] 1 am exempt under Sae. .B&P C for this remon
ACI ER-DRAIN&VEMI'-WATIiR(EA) VAL-US]]ON
Owner tae
WORKER C(llY 11:p our10N DECLARATION BACK PLOW 1'H(YI1!CI'.IIIiVICIi 7000
Ihereby:dlinn ender pen;Jty nl'perjurY one of the fallowin&Jeclarmionr IM1
0IhavennJwlll inuinmhmnCcniticinm,fConxcnDo,olf-insure for Worker's Csmpen- DRAINS-19L(llt.kU(Ih.AR1iA.GOND' ST(1k11iN '1'YI'EC'11N"IItUC'DON
s,tit i f miS , 171x1 0 I M C I ( Ih p f the 7,
ark, 1,10,111i,p t I. FIN I'URIS II;R TRAP
❑ I h 1 ',If maintain W k :( I r I y it by Section
1700 0 I i...Colu.1111'fell TrulanOO 0Itl l,lor whichtlispnnd is macd, GAS IA.SYS'I IiM IINC JUU'I'LI?'I'S OCC,GItUUI' �AlI
N
My Worke, Canlxn'u I-invoCeear 'rad ltlicy webr are.
Carficr: Policy No.: 'AS-LA. ' '1ild {O
CIiR'1'I1lCAl'Ii01'liXI;M1'IION fzROM WOKKLK.S IiAS INDFL' L WA:I'1 IN'rli 'E' IR
GOM PI',NSAIIGN INSURANCE I{DILOING DIVISION ITIS
(I his sectionn-dn Ite,omplecd it,he,ion i,for one hundred Jolla.,1$11x11 iv, S"1'RAI'
or Iv,) rr 1'I.ANCHECK ITE
Icenilythm in the perhur Dance of the work kovbich thispermit is issued.)shall SENIf N A Y P .2( 'I'.
not anpiny a yP� � ny mu rue ait lyty5�me suhjecun the Wodeti Compen. ENERGY FIJI
,z ,amine lay /�'a /� 7 WINE ER HIiAI Hk WINTHN17I71.ECl'
zApplican� GRADING FEE
y NOTICE I0jA 1 `�m inking this Ceniftnte of Exemption.Y.should 'ySTENT RIiATINC, SOILS Ilili
? become wblect o the Worker',Compen,arnn pmvi,ions of the Labtn Code,you moa
fonhwith comply with such pmvi,ions or this permit ehall W damned revrkcd. WATER SI;RV1C-1i
EIJI
7 Z CONSTRUCTION LENDING AGENCY NEW RF-SIDFNTIAL PLMH. SQ.ITT. PATO Receipt p
U O 1 hereby xflinn Ih:n there i,n construction lending agency for pctfnmwcc of
V. F the work for which thio permit ix issued(See.3097.Civ.C.)
C) U lander,Name 'rfrrnl.:
Lender,Address T( r
BU
a I certify that I have read this application and state that the above information is DING L
F' fA comet.1 agree to comply with ail city and county nrdidences and ante Laws reining to QTY. MECI IANICAL PERMIT EE
U Z building consttnction.and herebyathorue represenmtive,of this city to enarupon the SEI$N11 PIiC
obwanncminncd property for iml+caimm putprv,cc PERMIT'ISSUANCE! C xIQ ED
(We)agree,,)wve,indemnify and keep h:mnlea,the City of Cupertino against EL[ ERIC 19,11,1
hahilitit,"migmcou"Insand e,cn.wx which maymany way accrue agaimuaid City A ITT R(OR AIIII TO M I:CE 1. PL MIiENG THE O
in m-ocnee of the"ami.,(If this 1111111. '
API'1�U.Nifir�.,RSNIIANI)WILLCOMI'I.YWITHAI.LNON-P(IINT Alk HANDLI NG UNII'(10 10.k)0CIM) MIICII �NICAI.IPLSOAIR IIANDLING UNI'I(OVER IIidoCl'M) CONST RUCIION'1'AX
nntmctr Oar EXUAUg'I'I IDODIWIDIIL'I) HOUSINGMI'1'1(IA'I'I(INI+I7E
IIA%AIIDOIIS MAI'Iik1AI.S DISCL(IS(JRE
Willlheapplicunt or GltumbuiIk1u,o,,u, toresrhandlchvmfdoaxmacral UIiAHNOUNI'1'1'OlkO0(X)13UJ)
if,Jefinal by dm C.,arduo Mnnicipul Coda Ch,le,9.12.;rad the Health and Safe,y
Calc,Section 25532(a)7 DEAL ING UNIT(OVER I00j),xl Ifl'U)
Ej Ve, 0101 No V pi I I.A'IION FAN ON INGUI:RF51 D) PAI[) Date Receipt M
. Will the applicant or woe huildio,necupant use c9m,mOm or device,which BOILER-C(IMP(3IIPOR 100.000BTU)
cion hazarri air conmrroun ,as defined by the Bay Area Air Quality Management �(H'+
Diane,' ROII.ER-CON['(OVER Idd.kjG BTU)
C3 Y, No
I have mad the bvadous materials requirements under Chapter 6.95 of the Cali- AIR CON LAI RISER ISSIJANC17 DAI'F
firm TO II Imb&Seley Cm+d,5 ions 255,15.25511 and 2553,1.1 undentaal thin if the NI w RLlIDIiN'FIAC NEiCH. SQ.171'.
taildi dm tmmlyh vc mnant,mhm ItismYte,ry,n,ibility to anafy the occupant J —�
of mem temet pduns i„mnce of a Certificate of Oaurynr'l
riecJ a8vnl Date TOTAL: ISSUED BY:
OFFICE