S 1220 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RICA I, Pcigir NO. 1220
ID1II.UING DIVISION APPLICATIONAIERMIT PLUMBING-MECHANICAL l`!
BUILDING PROJECT IDEN'I IF'ICA'I'[ON
BUILDINGA .tiS:
MSS: SANITARY NO. APPLICAI'I)N SGIfMI'19'AL DN Ii
O R5 nMli: �- I'IIONE: C N'IHACCURI
' CONTROL#
9 NA 11i: C NO: � 6
NIC
J ❑
.IARCHITFCI'/ENGIN[R: LIC NO: AUD ILS.': 1 ❑
CONTACT: PHONE: 1l P13ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CON'TRACTOR'S DF,CLARICION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION41 O
1 hereby affirm that;.,,I licensed under visiens paof Chapter 9(commencing
'0ZO with Sen.alkokOdDivision 3ofthe Buvinessand Professions Cale,andmY licensees PERMIT ISSUANCE RESIDENTIAL'
CU� G:Il torenand et ct. ❑SII)WL ❑KITCHEN REMODEL
aUU LiccnvoC Li'.X APPLIANCES-BI'.SIDFN'FIAL ❑ADDITION PLUMBING RIbI'll'E
Zy) nr
�k NN((CIIITFCfS UIiCLARA )N ❑MULTI-UNITSTRUCfURM,
PANELS
PAIR
O o V)Z f under.end m as shall be use blip a cords UP TO 11X1 AMPS CHIMNEY CATION
p ❑IMPROVN ❑SWIMMING POOL
NCj
I�4 t:W essinnal 201-10MIAMIS IMPROVEMENT SWIMMING POOLS
C Q 1 oercM1Y uffirm that,am NER lemmPtl from Lm CoAI mm rot's License Law fill the OVER Inu AMPS ❑BKI'H RIiMODI?UREI'AIR ❑DEMOhITION
j,; a U l lowing mason.(Section 711315.Business and Pafensions Cade:Any city or county SIGNS ELECTRICAL ❑(YI'HER
W 3�in which requirev a fernier ,cemaucr,Biro,improve,dernolish,or repair any sweturc
L.'Oy prionoll i....nce,ala"reluirel theopplicant fo onelb crntitw Bleasigncdstatcn cut SPECIAL CIRCUIT/MISC.
fr�}'c that he is licensed pursuant provisions ofthe Con-raters license lnw(Chapmr9 COMMERCIAL'
W0.'ap Rommencingwith Section 70710)of Division 3ofthe Rusinessand Professions Code)or TEMP.MEDiR OR POLIi INST.
C.y o C 1hm he is uompt therefrom and the basis lin the alleged exemption.Any violation of F1 NEW BLDG/ADDITION LJDEMOLITION
W N Section 7031.5 by any applicant for a permit subjects the npplicmn to a civil proal-y it POWER DEVICES IiNANT ❑FOOD SERVICE
on than five hundred dollars 1$5(001. IMPROVEMENT
rn m
�1,asoxnerofthe property,or my employees with wages as their solecompensation. SWIMMING I'OOLI.1 CfRIC
will do the work,and the structure is not intended or offered for sale(Sm.7(HS,Business 01 HER
C F'o owwr OUTLCIS-SWITCHES-FIXTURES
�3hc propand I il&,Conaeb c i t snl o lots t k "In at
his
n b 'Idsor p tb d h e ern x Irxthathb
nsemployees.Pa idd that n inproormem,are ma it d d or offered rat NEW RrtiIDENnAL Md CI'R SQ rr.
Sala If.however,the budding lir impmvemetn is sold within one year ofrompletion.the Sp.ITT 1'Ift)OR;kR A S/SO.tell
-milder will have the burro
den of emoting that he 11-11 not build or improve lou pur- r
fetercal sale 7. IOTAI;
C] I.us ownerof-be prapcny,am exclusively contracting wit h:live he Cn,ntmr,ms m FEB 9
tun r r the import(Sec 71001 Business d Pr f.. ins Cod )The Contractor'. I.i- r
ccoLa d not apply ian of progirry,who builds or improves Beacond QTY. PLUMBING PERMIT FEE
WI rearact,- ::ela 1 t in It coat t (0 licensed n D the Cent Tis CITY of VUr-Chll
L'm tec La PERMIT ISSUANCE
❑I am exempt under Sec. .B K 1'C fnr this reason
ALTER-DRAIN AT VIiM'-wAi'IiB UTA) VALUN"ION
Owner Dam
WORKER COMI'I7N56rIUN DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affnn under inanity it Fe m,enc of-be findewmg dmla tionvi s.
Ihm'e and will mutmaina Cenifica¢or Conserv mwlGinsore lin Worker's ComPcn- DRAINS-FLOOR,ROUR AREA.GOND. STORIES '1'VI'Ii CONSTRUCTION
varier,as provided for by Section 3700 of the Labor Cale,for the performance or the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will muinwin Worker's Cbef,cosation Insurance,as required by Station
3700 orthe Lubar Cale.fnr the Emformanm afrhe work ter which this permit is issued GAS-IiA.SYSTEMI INCA OI1'I'LRFS OCC GROUP AYN
My Worker's Cnmpemauun ranc;Iemmcr and Policy /
Citi nice Policy Na:r- I eveQ �Cy.— GAS-r:7,.SYSTEM-OVER 4 IPA)
C IFICATE OF FXI!MI'I'[ON FROM WORKERS' OREAS1IINDUSTRC WASTE INI'ERCGPTOR
COMPENSATION INSURANCE BUILDING DIVISION FIAiS
(Thin section need not bh comple d if the permit is Ionone hundred dallrn(811X1) GR ll IRAP PIANCHECK PGC
ar Iesn.)
Ioyanythmian in performance ol he as
WkfmwbijM1 thispermitWoris kers'
ounce- SEWER-SANITARY-STORM ISA.2(NI FT. ENERGY FEE
not nnpiny:uty Pc:xan in any mm,,T::e m lscconm.vubimue-hc Wnekeri Campcn-
z cation Wwsof Califnrniu.Dam µ'AT HR 1117ATER W/VIiN VELECCII GRADING FITE
OZi O Applicant= .NOTICE TU APPLICAN'C If,after making this Cenificae,of lixcmpoon,you should WATIiH SYSTEMO-BEATING SOILS PEE
[-� mcome sehico m the Workcr'S Compensation provisions of the Lubtr Cale,you men
a .Innhweh cateply Wim such pb,v sions or mix pennh shall be me, rd revoked. WAIIiR SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW BP_SRESIDENTIAL,PLA1H, SV.IeI'. PAID —Date RaeeiptX
UQ I herehyaffirm that then is a construction lending agency forme performance of
W F -be work for which this p 1111H is iawred(See 3097,Ci¢C.) T 'AI.:
Isnder.s Name L:
} D.1 I<nder's to
Asidreas BUILDING FEE
R: I cenify that I have read this application and state mat the ane information is
NN (omen.I agree to comply with all city unit countyuminunces and emm laws relating m Q'IY. MECHANICAL PERMIT II:E SHISh11CFEB
U b;:0ding.t::svactieq and hereby antherian mprccmanves of this city m enter upon the
above-mcntiencd property ter inspection Parpe,es. PERMIT ISSUANCE p.1icTB1c IBili
(We)agree to save.indemnify and Leer harmless me City of Cupertino against
liahilities,judgments.toys and expemee which may in any way acerae against said City ALTER OR ADD'COMECH. 1'I.UMBING hili
In lit
....m g
a of the running al mil Pcnno
APF "�UND131lSI' NDS AND WII,h COMPLY WITH AI.I,NON-I.OINT AIR HANDLING UNH'(DO Il1.IXN)CFM) MECIIANICAI,I:IiB
RCE RI JULAT
AIR HANDLING UNIT LOVER IILINX)CFM) CONSTRUCTION TA
x nfAPpllonl/Cuni''/ , 6rR— ~).the EXHAUST Root,Vi HOUSING MITIGATE) 11717.a HAZARDOUS MAI ERIALS DISCLOSURE
Will the applicant or furore Wilding:cevpanl store or handle haraNnus:material IIEATI NO UNIT 0O 100,00013'1111
as defined by the Cupeninn Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.00o BTU)
Cada Sev'lion 25532(a)I
[]Yw [:1 No VENT H.Ad ION PAN(SINGLIi RLSID) PAID
Uu-c Be ipt p
Will the applicant coma or future Wilding thyme
B use equipment or Evia -which BOILIiR-COMP IJIiI'OR IIXLINXI R1'U)
mit hmaNnuv ter comnminnms av JcOned by the Bay Area Air Quality Managemem TOTAL:
Digrinl NOILIIR-COME'(OVER Immo)BTO)
p Yen F-1 No
AIR CONDI DoNER ISSUANCE DATA:
I have rod the h one,S s tion,2 5 5,25533 un under Chapter rou of the if the
former Health on Safmy GJe,Scaiom 255!05,2551)and 255341 I,,a by d tout if the NEW BILSIDENI']AL MECII, SQ.17.
,Ifthe cedocsnotcurrcnily Lave n okayIonil Iv:nyrcslrsf I ClIfi usamitytheamapvm
of the rcyuiaincnty which natal he n:at prior to inau:n¢x of a Cenilirvtc of Ott'upancy.
Owner or authnriecJ¢gem
Doc TOTAL: ISSUED BY:
OFFICE