S 2884 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.PUBui RICAL PBRMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJF,QI'IDEMrffICA ION
Nl11LDING ADDRf:SS: /� JV—/0-2 NO. APPLICATION SUBMITTA DATE
Lkr
OW i `�T!///.n 0 'S NAME: LIC NO:
/N✓, P4 i�Aw
N/C CONTROLp
ARC 1 'Cf E [//�/Ii GN: a LIC NO: ADDRESS: ❑
CON"IACp W// /��PH//.OJJBUILDING PERMIT INFO
NNE:
�/'7 /�/k� ❑ Cnnimitant Fees Paid by Applicant(Initial) BLDG El I= PLUMB MECH
LICENSED CONTRAC'[OR'S DECLARATION QTY ELECTRIC PERMIT FEE,
I hereby report that I um licetead under provisions of Chapter 9(commencing J D SCRIPTION
05z with Section]IX10)nf Divisir,n3nfdhe Business and Professions Caole,and mylicense is RESIDENTIAL:
�o In full litrc,aad effect, I'IiRMIT ISSUANCE RESIDENTIAL
WP ❑SPDWI. ❑KITCHIiN Rf.MOI31iL
�Ur, License Clues Lic.p APPLIANCI-S-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
NQW Dan Contractor
bo O ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z Oyyz+ I nndcrsaedmy Placa o,ll he used tw pablirrecords MODIFICATION
O--4 UVT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
fs�x,F.W Licenced Professional 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
FiR-1 OWNER-IiU1LDT:R DECLARATION OVER Flat AMPS ❑ REMODEI/REPAIR ❑DEMOLITION
0.' Q I hereby air ani that I oat exempt Irate the Contractors Llecnse Law I'or the
a O a V bdlown Section]031.5,Business and Professions Cale:An t d OTHER
la.�( gmaasoa pe y can or county SIGNS[LECTRICAI.
tJ C F' which requires n permit re quires the alar,improve,demolish,on repair any amcmre
�� prior In its issuance,nun requires the applicant for such permit to file asigned statement SI'I?❑IAL CIRCUG'/MISC,
o no tm ehe is licensed priauant mEm provisions of the Contractor's License Law(Chapter 1)
W�00 (cotmnenaing with Seetioa]00(Bof Divieion 3oan
fthe Bminessd Pndr,,dons Corl 'I IWR METER OR POLE IN" COMMERCIAL•
:i Iy O p, that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEN'II.DG/ADDITION ❑DEMOLITION
'aW! N Section 7031.5h,myopplicunt hoes permit adr,Ix l he applicant ma civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
�zQnot more than five hundred dollars($500), IMPROVEMENT
❑I,mownerr,f the prnpenY,nr myemployceswinhxmgesaz theirsnie compensation. SWIMMING PDOI,E R
E IO will do the work,and the structure is not intended croffered torsule(Sec.](WJ,Busineee ❑OTHfiR
,,
d 3car
and Profecdons Calc:The Contractors 1 iceoe Law doe,mot apply m un owner nl44 OU'f1.E'1'S-SWITCHES-FIV109
property who builds or improves thereon,and who does such work himself or through
his own employer,pmvidd thin.each improvemcros are nm intended m oRc J fur NEW RISIIIEN 1. '.ECTR .V 14.
sale.IL however,he huilding or improvement is sold within one yemofeamplction,the SQ.Fn FLOOR ARG $/SQ.Fr.
po.m-huilder will have the hwNcn of proviny that hu AIA not lauld or improve for par-
ofxalc.).
❑1,as owner of the property,am exclusively conmeting with licensed connector,to UITAI
conaruat(lie project(Sea.7044.Business and Professions Court,The Cuntrad'a,Li. D D
term Law JoeX aot apply loan owner of property who builds or improve%mentor,and QTY. PLUMBING PEI IT FEE
whoroments forxuch projects with acenauctoge)licenaml puntmnuothe Conmaelors PR 1 2 19 9
License law. PERMIT ISSUANCE E.
❑ In ampd mode,Sri. ,1t&PC En nis me...a
0 At ACIER-DRAIN A VENT-WA1 11R(L'A) VALUATION
Date
WO ER'sCOMPENSKNONDIiCLARAI'1ON BACK filPROI'ECT.DEVICE By
1 hereby affirm nada peulty of)erlary carol the following drelarutions
❑Ihave wdwill muimninu Ctnirevdatf Cnnsennn.cdl-..,.pelta Wnrkle,Cnmpem DRAINS-FLOOR.ROUR AREA,COND. STORIES 11 I'YPEC'(INSTRUCHON
sodium,as provided for by Section 37W of the Labor Code,for the performance of the
work for which this Permit is issued. FIXTURES-PER TRAP
❑ 1 have anti will nmlrmin Worker,Cmnpar atimt insummce,sex required by Section
3700 of the Labor Cale,for the performance of the work for which this pemtil is issued. (IAS-EA,SVSTIiM-I INC.4011'TLE'fS OCC.GROUT' APN
My Workers Compensation Insurance carrier and Policy nambm etc:
Carrier: Poticy No, GAS-EA.SYSTEM OVER 4(EA) I �
CHNU IPICA'1'E OF EXEMVI ION FROM WORKERS' ORP.ASI%INDUS'I'It I.WAS'i'Ii IN' CIA'fflR
COMPENSAT30N INSURANCE BUILDING DIVISION ITES
Thissectinn need Bat he rame,nedarhe permit is turone hundred dallas($100)
or less.) ORT:ASF:TRAP PLANCHECK ME
I candy thutin the lttrfainince of the workfor which this permit is issued,l shall SEWER-SANITARY STORM G.2W Fr.
not employ any proem in any manner ser as to Manu subject in the Workers'Compo. ENERGY hili
Zz smion Luws o(Califomia.Data WATER HEA NENT/ELEC R oe
O APplicunt GRADING FELE
y. NOTICE'IO APPLICANT.11',arm making this Cenifirade nl'Exemption,you slmulJ WATER limWI'R EATING
become subject ,,the Workers Cmnpmsmian provisions of the I.1w Cotte,you roues SOILS PER
forthwith comply with such provisions or this permit shall be demand revoked, WAT SERVICE
Q
p" CONS, LENDING AGENCY EW RCSIUENTIAhI'hM11. SQ.FT. PAID
.`J z Use Receipt#
fJ O I hereby airmuha ad,i is a constmcti30 IcnCi e.agency for the pceformanre of
F the workbr which this permit is issued(Sri.lrH],Civ.CJ
0 I<nJer's Nume TOTAL:
C.) Lender's Address I(yTAI: -
} BUILDING FEE
0. I certify than 1 have read this application and atomm
that the above information is
In correct.l agree m comply wish al any and county ordinances and satm laws relating eco QTY, MECHANICAL P17RMIT FEE
U z building construction,and hi authorize represcouttiva,or chis city to ctncrmpnnnm SEISM R:FIAT
u alcove-mendionul pmpeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless Ne City of Capacitor,against ELECTRIC 12C
habilitit,Iudgments,enstsind expensee which may in any whynecme agai ns(add City AUIEROIt ADII'IOMECH
ire quenceof the granting of this pertnil. PLUMBING IEEE
AP AN'T UNDF'.RSTA NDS AND WILL CONIPLY WI'I'II ALL NON-POI N'I' AIR HANDLING UNI'1'(TO 141KK1 CEM)
S 'F.REGUL TIONS. r MECHANICAL FEE
AIR HANDLING ON]r(OVER 10,000 CFM) CONSTRUCTION TAX
'ignamm of APPlir UCitarmt Date 17XHAUST HOOD(W/DUC ) HOUSING MI'TIGAT'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theopphront nr home building occupant aorto,bundle lmnmdnu,male,inl HEATING UNIT('10 l 00,80 If'I U)
as defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health not Safety
Calc.Section 25532(a)] HEATING UNIT(OVER 100.31PTU)
El Yes ❑No PAID
VENTI LA)'ION FAN IS I .LF?RESID1 Dm ceiptp
'. Wg11 the applicant of fore building pecupem use equipment rr devices which
emit Imitations air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP( PORIN)JOB BTU) TOTAL:
District'!
E]Yes ON. IfO1LCR-CO 'IOVIil111M1,INXI BTU)
I have read the homrdoecmaterial,re4uirem , ohmenty under Chapter 6.95 of the Cali- AIR CO IIIONLH ISSUANCE DATE
t Iicalth.@Sal'cty Cade,Satinnc 2550.5,25533 and 25534, andeutndifthe NE tf:SIDEN'I'IALMP.CH. SQ.En
b ng does net currently has tamamLthat id ism,mspieihilitym notify the aeration,
sew ichor d tpd t uamcenfa CeniGcat fffJe paw
Owner nr uuthori dagant �Iline TOTAL: ISSUED BY. a
OFFICE