S 1787 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ULEC71 RICAL PEr`y�IIT NO
BUILDING DIVISION APPLICATION/PERDIIT PLUMBING.-MECHANICAL V 1787
BUILDING PRO..'-CT]DEN'Timm(ON
BUILDING ADORESSo �SAANI:1A:RY:N10P). APPI.ICNI'ION SUIIMI'I'[AL nAI'1'.
10 S LI . t C%C)--q�
OWNEN$NAME: - PHONE ('ONTRACI OR',CAJNIE ^ //! LIC NO, �j
$2'88 6 (}N lJ �-R UTAl�'o Avsg-. NIC coN'rxol.a
• ARC1 l l'I'1C'I IIIN(i INL;R: LIC NO: ADDRESS, m W In-,
CONTACP PHONE; BUILDING PERMrr INFO
M°l" ,AIOB -6343 ❑ Cunsullanl Fee.,Paid by Applicant(initial) I+IA�G— ❑: ❑
ELECT PLUMB NIECE]L?—
.]CENSER CON I RACCOR'S DECLARATION QTY. ELECTRIC PERMIT PI'il;
I heathy affirm m;n I an,licensed and,,ptovtsionx,,r Chapnr v commencing JOB DESCRIPTION
MCz with Scaion 91XX1)ol Division lel,hc Busi e,md Pmressinn.Cde,aMmy license is RESIDIiNT1AL'
,cc, PERMIT ISSUANCE
I-ly, in full forceaM entail. ❑SIq)WI. ❑KITCHEN REMODEL
CO Lrensecl,s" L 4hSB3Z
Q y APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
FZ Dam—��V Commm�,rQA:Jf MAUWCF!
yQ ❑MULTPUNIT ❑STRUCRIRAL
F - As shall
use DECLARATION PANELS
Z I undcrmunA my plans shall he used as public records CHIMNEY
IC REP
ON
ZOZF-C UP To 200 AMPS ❑INTERIOR ❑S IMMING POOR
F,n F-ty Licensed Pndessional 2111-I(XX)AMPS Ih11'NOVEMENT [3 SWIMMING POOLS
qq
OWNER-BUILDER DECLARATION OVER I(XXIAMPg ❑RATH REMODEIAHPAIR El DEMOLITION
C C Q 1 hereby nfR.n Ism I nm cacmpt from,he Contractor's Lic<nve Law Ra,hc
kCW following ren.w,.(Scai„n 911)1.5,13uxiness and l'motc%sion,Code:Any city or comny SIGNS ELECTRICAL �fyfIIER
W EE' which re e,a Femur toe a,nxnnm,alter,Enpmvu,tanolisn. a repair any vmdere
ku.0A print , ale, der,plicaml h acinver,l file—i,tiednilleama SPFCIALCIRCUIOMISC.
Ebythat he is licensedpursuant the pvvnmvfth Contractoev License Law(Chapter 9 COMMERCIAL
LL:�00 Isom n n6 'thSm 9(XMB fU rzin J fth H : ass II r Colc)m 1*12 RMELRORPOIEINST
6 d e C ,hut he lis clamp,,nemfnnn and the basis far the alleged exempt an.Any viola en of ❑NEW BhDG/ADDITION ❑DEMOLITION
-oe Sanlnn9031,5 by any applicao Fara permit sabjecOthc appllcmnm a civil penalty of POWI?x DEVICES ❑'fhNANT f_1 FOOD SERVICE
a roan dun t'ive nundred dollars($5110). IMPROVEMENT
ASO p Las nwnanllhe property,army employeeswldt wages as tbcirxolccarnpcnprironn, SWIMMINGPOOL-.IzC'I'RIC
F. will dn,hc work.find the stm.uru ix nm imenJal nr offered fonule(See 9Wq,BusivO, ❑OI111.R p
63 m and profusions Cala The Contractor's Liceme Low does not apply to an acme,of OU'ITISI'S-S FIXTURES 0 P1
properly who builds or improves tbemom,and who Jots such work himself or through
his own en,pinyecs,Provided that such improvement,are ma intended o offered for NIiW RESID , IAL li SV 1'I'.
sale If how r,the building or improvement issold within one ycmnfeennpetion,the SQ FT.PLOU1xn A�o MVJ 'Q.FT
crhand,will have the horde,of pro ing duo he did not bold oo impro'c for Ina J
posnol da.), v s 'I GrAm ,s
❑1,as owner of the pl,),vl um eaclusivcly aomm.isg with licensed comm.,,,n, �'17 VI. V,p.
onnct the project(Sec.9(W.Business and Professions Code:)The Commence%U.
sm Law does no,apply to unowner ofpmNrty who builds,,,inannwe,baccoa and QTY. PLUMBING PERMIT FEE
whn,vva,I,Ila,wmh prnjax,x ,ina c»mm.or X)licensed pu,uunuo the Comem or's
Liccmc Law. PERMIT ISSUANCE
F1 I.,it cacmptundc,Sea ,13&PC to, hismrnson
ALTER-DRAIN&VIiN'l'-WATER IIIA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTF,CE DEVICE ow O O
1 hereby uffimn under Penalty of perjury one of the following declarations: JJ
IhmcanA will mninlulnu Ccrliliea,e ill Consunl mscl(-inwre(ur Worker's Cnlnpen- DRAINS-FLOOR,ROOT,AREA.CGND, ,TORIES TYPE CONS'FRUCCl(1N
,,vam,ea pn'vldeJ fur by Semios 37a)oI the Loca Code,Ito the pednnnance of tiro
work fill which,his permit is issued. FI%'TURES-PGR'fKAI'
O 1 have and will maintain Wvrkerx Cmilenanion Insurance,an"moral by S¢ninn
37M mine Labor Code,for e performance of the work for which this permit is issued. CAS-IiA.SYSTEM1t-I INC.JOt11'LFTS � OC ,GROUT' APSE
My Woker's Compsmaden Insurance canierond Policy normae are: GAS-PA.SYSTEM-OVER d(EA)
fierier; Polay No.: S�pt..Q,iL.
cRIOTIFICAI'1i OI°EXEMI'I'ION 17ROM WORKERS' GRIiASININDUSTRI,WAS 117 PIT ERCIO'LOR
Co MpEN$ATION INSURANCE: BUILDING DIVISION HF:S
fFais%action need not he completed it the is torose hundred Jolla,($Ilpl GREASETRAP
or less) PLANCIIIiCK FEE
Icenifylhatinlhe peformancemmework rorwhich,his permi,is issued.l shall SEWER-SANITARY-SIORNI EA.200 14.
no,employ any fec on in any amener m as to Favorite subject to the Workcrs'Compen- ENERGY FEE
Z nation Law,nl Culirumin,Dam WAHEREE.x IERW/VENTIFLECTR GRADING I:EB
ZQ Applicant
y NCUICE'IOA'PLICAN'I:If.after making,hi,Cenifrmc of l:aen,plion.you.should WA'I 17R SYSHNUTRHA'1'ING
become subjea u,the Workcrs Compensation pmvidom b of Labor Code yon amst SOILS FEE
{ ,.., forthwith annPly with such pmvisi...or his permit shall b:decmN revoked. WATER SERVICE
1.1
a. PAID
CONS'I'KUG,TION LENDING AGENCY NEW RESIDENTIAL PLMR, SQ,Ill Dam xnaipt#
U 0 1 herehy anion thm Iham
e is a rnnsmtian ndo'agency lite the pert.nonce or
IIF Ise work Joe Much this Farrel,is isvied(Sec.JIM)].Civ.C.) TO'T'AL:
O U Lando%Name 'It)TAL:
}It7 Lenders AJJmes BUILDING HE
0. 1 certify that I have read,his application and late that the above infonnaion i.s
nF.y co.a.lagreea,complywithallcityandcountyordinance%and%latelawsrelatingo QTY, MECHANICAL PERMIT FER SEISMIC FEE SO
U Z hm'1tt111gcammlclion.anrDmrohy rntlhnnu rePresuntmivc,err Chia shy m criminals the
nnnvcman,ioncd prvp_.Y lar'rop"Inat InsTonas. PFRMH ISSUANCE ELIiCI'RIC HE
(We)itgs,to save,indemnify and keep Lanolcu the City of Copeman agavall
Iimbili,ieajudgmems.costs and cspemms which may in any way accmeagainstsaid City ALTER OR ADD TO MECH. PLUMBING FEE
in rossequcncx of the gmmiag mail,permit.
AifP. ANT USDERS'1'ANDS AND WIL.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CPM) MECHANICAL HE
S t'tC. EOUI TIONS,
b NRIIANn1,ING 11Nl'f I(1VIiR IILINN)CITvE CONN'I'NIIC'CION'I'A%
-rat�g
Signature ill AppEcanV...... err Data P,%IIAU$'I'HOOD(W/DUCT) HOUSING MITIGATION HE
HA9.ARUOIJS MATERIALS DISCLOSURE
Will,ne applicam nr fum,c buildingowcupent Invoice handle hazardous material ]ABATING UNIT(TO IIXLI011 BTU)
u,definal by,be Cupertino Municipal Calc,Chapter 9.Q,and,he Health and Sufey HEARING UNIT(OVER IdIL(X 0 BTU)
Cade Sculion'L5532(u)'I
C3 Yea No VI?N'I ILATION FAN(SINGLE RESID) PAI. Du¢ Rcccip,N
e Will the ap iicom or future building eccupall,use equipment or devices which BOILER-COMP CUP OR I(p.011f)BTU)
mit humorous air commitments as defined by the Bay Area Air Quality Management 'POl'AI-: 7-Sze
Dista.^ BOILER-COMP(OVER IIXLdIXI BTU)
❑Yes [D No
I Love,land darve odommaeaals,c t,under Cba far G.95 of the Cnll- AIR CONDITIONER ISSUANCE DATE
gnirenren p
rani' Ieahh&SaRty Ca .kctinns 255(15,2553)aM'_55Ji 1 unde,mnd that,If,hc NEW RESIDENTIAL NIECE I. SQ.Fn
but ling cs nal cumendy have a tenant,that it ism' onsibility to mody dre occupam
Sfl oft -,equ -are fa which mostemet paorm is a c fa Certilinroof Occupancy. T
o anea.ed agc,o nam 'DOTAL. IssueDNY: 1�e-” jqN7DRE_sa C
OFFICE