S 1979 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EC,,rIR{CA{, Pe IT No.
BUILDING DIVISION APPLICATION/PERMIT PLUMPING-MRCHANIC,,I. � 1979
IIf111,UINC I'Rll.p?C'1'IDI!N'I'IPICA'I'ION
BUILDINGADDRESS: SANf1'ARYNO. A1'PLICACIONSIl11MIMAI.DAIT
p ZjGI D2�l�ff � (n . 5 _
OWf'WySJIIUNIi. & ')Nolo C' NAND /x 1. )'
L'e-fX�F - a NIC CON I'Rod.p
�I ARC({I'IECTIENGINEEW LIC NO', Up I]y[ay: 7^ ❑
COMAM PHONE 13UILDING PERMIT INFO
-/" '^ / ❑ Consultant Fees Paid by Applicant(Initial) dLI){; ELECT PLUMB MECCA
LICENSED CONTRACTOR'S DECLARATIONQ'TY ELECTRICPERMIT FEE /tom-jam
I herchy aroma Ina,l at licensed ander Plasmis of Chapin (c
9 m nnimoing JOB DESCRIPTION
❑=Z with Seetlon]0000o1'D slnn Aid he Budnessand preensions Code idnry Iseme is �J �O RESIDENTIAL:
woo FERMI'C ISSUANCE; 3
in full force and WOO. ' m,> ❑SFDW'I. ❑KITCHEN REMODEL
E.
QUV Leen *" Lica APPLIANCES-RESIDIiM'IAl. ❑ADDITION C]PLUMBING RE-PIP(!
F Z m Dam O Cnmrecmr
soak' ARCHI I'EC'S DECLARATION ❑MULTEUNIT ❑STRUCTURAL
Fpm TIAN1i1S MODIFICATION
ZO Z=Z I understand ton,plans,hall he used as public records 111'TO 200 AMPS
RIOR ❑CHINI,NEY REPAIR
F�FW Limmcd!Professional 201-100AMPS IMPROVEMENT E]SWIMMING FOOTS
�Y§� OWNER-BUILDER DECI.ARA'I'[ON OVER 1(XN)AMPS L1 BATH RENT( PAI DChfOLI ON
G 5 Q I hereby affirm that I um cxcmpt from the Cmdai,o is Lierme L aw for the � T
X C'a V following reason.(Section 7031.5.Business and Pr'fessi'ns Cale Any city or"'only SIGNS ELECTRICAL LJ QTHF® —O
W 3 LL N which"vim%a permit to commuct,altcr,improve.demolish.or repair any suueme h
F�06 prior to its issuance.also requires the applicant for such permit file a signed emrtment SPECIALCIRCUHUMISC.
that he is licensed pauuem to the pmvoiamafine Contractors License lawfehaptarq
Ixy,C�p Nuount.o ng x'ith Section 70001 ofDivision T of the lousiness and Ptofcssf'ns Cadc)or 'HEMP.METER OR 1,01.1; COMMERCIAL'
a d 5 that be is exempt therefrom and the basis for the alleged exemption.Any%illation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Senior]'31.56 1 )
W_y yn�r applicant permitsun ecu the applicant dtvcivil peatah'nf I'UN'C:R UI!VICIS ❑TENANT ❑FOODSERVICE
not more than five hundred dollars($5W). IMPROVEMENT
=c 01.as owner ofthe pre,ent,or my employm%with wages as their sole compensation. SWIMMING POOL ELECTRIC
F will do the work,and the suacaum is net intended or offered for sale(Sec. Business ❑OTHER
W 3 m and Professions Cods.The Contractnex License Law does nal apply to:m owns of OUTLIiCS-SN'ITCHIiS-0'1%TURES Z 0
0. property x hit huids or improves thereon,and who does such work hamxelf or though
his own employees,provided that such impromment%ort not intended or uttered for NEW RESIDENT[Al.I?I.ECTR SQ IT.
,.10.If.however,the buildingorinmmvemedmould xithirtorm year of completion.the SQ.FL MOOR AREA $ISQ EL
nerEmlder will have the burden of pnn'ing that he did not build or improve for pur-
pose of ve.). OC 0
],,as owner of the prope,,,am exclusively contracting with licensed contractors m
cows the project(Sec.]ILI,Business and Promotion,Code:)The Connector's Li-
ceLaw does not apply m an owner of property who buildx or imprnvs thereon,and QTY. PLUMBING PBRMIT FEF.
who co strias for such projects with a coanccarpl licen.aed pumas tothe Comracmre
License Law. 1117RMI F ISSUANCE
I am exempt under Sec. .IT h P C far this reawn
AI1TER-BRAIN&VENT-WATER(PAT VALUATION
Owner Date
• WORKERS COMPENSATION DI!CLARKI'(ON RACK FLOW PROTECT.DEVICE
I hereby infirm under penalty of perjury one of the following declarations:
I haveand will antimain.CedificuufCo—soraself-in,cre for Worker's Cninpem DRAINS-FLOOR.ROOF,AREA.COND. WGROIJI CONS'I'RUCI ION
salon,os provided lar by Section TIM ot'the Labor Code,far the peri nm;mce at,he
work for which this perinu is issued. IgxTORES-PER TRAP
I have and will maintain Worker's Contpemmion Insurance,ns required by Section
110(lofthc Lna,y�Ypl�t Co( �I,�anjh�c perinn0 c of the work fuVola,yyrr"�gwhhi}icch�jjt�axp Rl�s imi//mme. MS-I!A.SYSTEM-I INC.400fLETS OCC, AYN
My Wo(�C!y�yy 1 Policy No, J ` • !9- • � GAS-PA.SYS'I'ENEOVER 4(EA)
CarriereQ:'U' V
5
CI?R"rIPICAD!OP EXEMPT ION RANGEROM ORKERS' GREASE/INUUSTRL WAS I'I! 'ERCEPIYIH
COMI'ENSA'TI(1N INSURANCE LS
(IM1isxectlon need ria,bv,olv,laed itdiepern'uls loonchundreddollurx($100) GKEASE'TRAP rLsx) PLAN1 soi fy ohm in the perlonnreoll he work fop which t hi s lienot is i sed.l shad l SI:W I!R-SANI'IA -S'I ORM EA.21X11°I'.an"ni11 "ca",1ny ' M1 bl nloticWorkcr¢Ct gxtn RNER
z Orion11 a I WATER HEMI" WIVI NIIELEC'I'R
7z Applicant GRADING TiF
q h NOT IGL'1' APPIACA 1.II sr . 0y tlis Cc-'I oro o f Ess rip,.....yo, shoo Id WIM 1.14 S 'I ENUTRIA'I'ING
F` ha'me subject m the W x Cmnry_nanlon pm s rax of the labor C 1e.Yot naw, SOILS I I
F-I
Imr,hwith onmply with s Provisions in Too pcnnt shall ba dectued revoked. WAIT: SERVICE
0
Ro CONSTRUC'TIONLENDINGAGI?NCY N RESIOEN'HALPI.MB. SQ.I'L PAID Date Rcocipta
Uantcrchyalirm,hat muuanennstmeion landing agency the pet forgo aT
6d the walk for which this pen ut is isnucA(Sac.TMJ],Cie C.) '�,
F
Leader's Name Y e'1 TOTAL
Lcndr-Adresa TUTAI,:
6. I'emly Ina,1 lune read this upplicntiun and ,am Than the ahuve indonnauan i� BUjosiILDING :E
enrc.Ll i'me ,,comply with all city and county rmllnunce,and stall lawsrcLGng to QTY. MECHANICAL PERMIT D
Uz buildingcnnswetiun.and herchy matiorim representatives ol"this city to enter upon the SL:M1
adxnonmmi'ned pnapeny for iopcct!on purrynex. FERMI PISSUANCE ELECTRIC IEE 3 O
(We)agree msnrve indennnify and keep ha ndOo,the City of Cupenina ugninst f )
Ilalnlais,judgnents.co.sts and expenses which may in any way accruengaio,said City ALIER ORADD'D)MFCH. (,IJI VI' PLUMBING FEE
in .sequence of the gadding of this land
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]f('1010.0y)CFM) MECHANICALFEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER I,LIXXI CPM( Q)NSTI{UCI'ION TAX
Signature of ApplicanVCnnvanor Dec EXHAUST 11000(W/DUCT) HOUSING MITIGATION FEE.
HAZARDOUS MST ERIALS DISCLOSURE
Will the applicant nr future Wiliito,weepamt Hamar handle hmcdmmnumriad BEAT ING UNI'I(TO 100.000 BTU)
as defied M1y the Cupertino Municipal Code,Chaper'1.12,and the health and Safely
Code,Section 25512(.)! HEATING UNI1'(OVER 100.0)(10 U)
0 Ye, ❑Nn PAID
11 NO 11 A'ION IrAN(SING o RILSIU) ]—)all Remid X
• Will die applicant or!Imre building occupant use equipment or devices which
emi,haeaBOILER (THl' R 100.IX10 BTU)
ourds air contaminants as defined by the Bay Area Air Quality Management )TA :
DisWc,t BOILER-COMP VRR 100.00011'1'U)
❑Yn E]No
I have read the hvaNtwx materials mataireasnu under Chapter 6.95 of the Cali" AIR CONDI- )NIiH ISSUANCE DATA
farnia
AT-
fomia Hmhh k Safety C de.Section 2550.5,25531 anal 255.14.1 understand that if the NEW . HENTIAL MECH, SQ.FT.
building does not currently have a tenant,that it is my aespomsibility to nsnify the occuparn (((
of the"tairemems which must M met prior to issuance of a Certificate of Occupancy. rys
0.m Oa authomcd agent Date TOTAL ISSUED BY:���• O
OFFICE