S 0963 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
' CITY-0F CUPER'fINO' — BUILDING.ELIICrRlcnl. PERMITNO,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING MECHANIcn1, O O A C
,� rf,BUILDING PROJECT IDENTIFICATION'': t lJ �7 V
' BUIf2DING ADDRESS:c/ JJ}'/Jg/r "SANITARY NO. API/'h{yJCrA�1TI-OIN SU rAdITTAI. AI'li
OWNERS AME: �ON�I:r'. / Y ' CONTE TOR' ME, LIC N(�' NIC C(INTROLin
�ARCHITECT/LNGINI EIL LIC NfI �"� AD R+SS;, � ' ❑
"O TACT: PHONE: / 1//I 1 ":i'_ +BUILDING PERMIT INFO'
/1�. _ .Z/ C7 '7 }, ❑ Consultant Fees Paid by`Applicant(Initial) HLUO ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION- QTY y ELECTRIC PERMIT" ; iz FCE.
JOB DP,SCRI ION
�pO wI11B croon AlIXp ofDivision fidlbe Bus d Pifivoina,Coca.radio,he se 11PERMIT ISSUANCE RESIDENTIAL' .
��P In 1,11
p r ❑ADEFT. �r��,I,TCHr'N Rrnaonra. '
FZW fele ca" APPLIANCES-RESIDENTIAL ❑ADDITION s� .JMIiI NO RE-PIPE
0<a RCHITECTS DECLARATION - ❑MULTI-UNIT "LJ� SI UCTURAL
.p-D In PANELS
z o un zndemtand my plum shall heroes] .puhl'emmrdx - - - " MODIFICATION
oZ4- - UPT0200AMPS El INTERIOR CHIMNEY REPAIR
F N�Ep"W Licensed pul'esxinnnl ,201=IIXNIAMPS IMPkOVP•MF:NI'"" SWIMMING POOLS
W OWNER-BUILDERfroDECLARATIONCLARATION OVER 1000AMPS- []BATH REMOOBIJREPAIR El6EMOLI'I]ON
hereby.form that 1 ul.5 exempt i,un the Co.too,C's License Law for the _
a V Section 9031 5,Business and Rofesdons Calc:Any cit,o,county ❑CI HER
following sives a.( ) n a Y SIGNS ELECTRICAL '
3Wy whih y 'e: permit l .t " h p demolish, repairY struclure
prior to itticomance,also q 'he
If such mu II . I mmenl SPECIAL CINCUIT/MISC.
thalh I' dp,m II m pro,in'son:ofIh C I Int License
Low(Chapter 9 _ _ -
. � q0 (coopmereir,still,Secti mMu ofDivisi i of th ❑ ,awsmal ViaI'...mtc Code)or TEM P.ME FER OR POLE I NST. COMMERCIAL;
F y m y that he is uempl therefrom and the basis for the allegN'excmplion,Any violwmn oI _ - ❑NEW BLDG/AUDITION ❑DEMOLITION
X W Section 9031.5 by troy applicant Far a permit vuNects the npplicanl to a civil penally of POWER DEVICES"
LLI^p1
El
t l a "I'nm f hundred
pmd lxd.ndollars
y II :(y$500p)
ly th g Ih 'r l pc. t A , ❑TENAN
T '
FOODSERVICE
SWIMMING POOL ELECTRIC IMPROVEMENT
w 111iOTHER
t I '
and P'pv, ,
Code Th Cumonvors License-L does ma'pply to a.evore,of OUTLETS-SWI'TCIILS FIXTURES
prop nY who hands or approves thereon,and who does such work masseur or through
sown Fimplayste.provided Ihot such Improvements are our imanded or offered for NEW RESIDENTIAL ELFCTR SQ -
sele.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOORARHA ,$SQ.FT.
tan lauodcr will have the burden of proving tl t he did an build or improveur par _
Two ofol ) ® "
❑ I c f(h ......Iy clue IY I g "h licensed I I s to
mBIITh pj t(S 'IB14 B IPf:: :Cal )ThGIt L' !'� '
La d t apply Loan aware of property thruilds or improvq thereon,and QTY PLUMBING PERMIT,} +'.FEE
whocerapireasrhpject. 10ucoitaem(s)Icen.edp II lhConn t s
License I w PERMIT ISSUANCE
I exempt rude,Sop. B&P C for this.",, �SJ
ALTER-DRAIN&VENT-WATER(EA) i VUI ALUATION ` -
Owner Date CC1V Ur. .
d WORKERS COMPENSATION DECLARATION BACK FLOW PRGFLC L DEVICE
i n h ,v loan under penmly of of j y n f the roll g d I tions:
❑Tho ad a 'moi to Cert 3700 of t a If'm f N ke mance
DRAINS-FLOOR,ROOE;AREA,GOND. STORIHS^. 'IV PECONS'fkUCTION
trump as pn viffid f e by Section 191111 of the Labor Code,for the perfo mnnw of the - - -
nrkfbr,wndwillmaintainWxned. FIXTIIRF,S-PF.R TRAP
use'ond will maintain Worker's Compensation Insurvnce,as ruryireJ by Section - -
370()of"he Lubar Code,fonhe pciformlmccol the work for whish lbi.peintit is icsared, ,GAS-EA.SYSTEM-I INC.4 OUTLETS - QCC.GROUP APE _
My Wn kr/�Cninpenryt Inset e r and Policy nap ttp ye \ 0
'
Car is, ...Ti1A /Jc a rticP lm,No.: UU l'f V U CAS-EA.SYSTEM-OVP_.R4(EA) `
•�� 'CERTIFICATE OF EXEMPTION FROM WORKERS'• - '
COMPENSATION INSURANCE GREASIJINDDSTRL WASTE IN'IERCEPi'OR
BUILDING,DIVISION FEES_ _
.. (Thissmrion need not be Completed 11 the perndt is Forane hondreA tlnllulx($11q) GREASETRAP
orleo.) PLANCHLCK I+LTi
I certify that in theperrormonccofNe work for which this Permit isixsua6 l shall SEWER-SANITARY-STORM PA.200
not ply yP.:nn yna c :ovIb bj Imthe Workers Cnmpe" -
ENERGY FEE
p '.Ap t L fC IYar Date
- I WATER HEATER WHEN UTILECTR
art cat _ GRADING FBI. "
NOTICE TO APPLICANT If after making th s Cenil,oro or Eve Bpi v you should WATER SYSTEMOKEATINGG
bocomb subject m the Worker's Compensation provisions or the Lobar Code,you must _ SOILS FEE
wGLI forthwith comply with such provisions or this permit shall be decymd revoked. WATER
W �" ' nWATERSERVICE
CONSTRUCTION LENDING rCY NEW RESIUFN'1'IAL PLMHSQ,FI, PAID
UOThfirm thatN r ' moaswi dig.my[ Ih pufrmancenf Dam Rccoiptp
the work for which this I is Noted(See.3197,Cie.C,)
,
•O l"I Lenders Name N TOTAL.
y U LendersAddress, TOTAL
ti1 nfyd Ilhaveread his application ad late Pride,'h elf of n' , ; P ; nBUILDING FEE
it)
gt comply all city and county ordinances state mining FEE","
) t txt IR
V 7buildingconstmeton and h mhy auhorse representatives of Los citytoenter upon the . I ; ' SEISMIC FEE
abovemcationedpmpenyfor'nsputonp rry:
-
PERMIT ISSUANCE
(We)agree to save,indemnify and keep harnless the City of Cupertino against ELECTRIC P ?
liabilities,judgments,costs and expenses which may in any way accme against said CityALTERORADDTOMECH.
in emisec rve of the granting of this permit. PLUMBING FEE
gn
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT'(I'O IO,oco CFM)
SOURCE REGULATIONS. _ MECHANICAL EE
AIR HANDLING UNIT(OVER 10,00d CFM) CONSTRUC'rI NTAX
Signature ofApplicant/Coutimem , Dote EXHAUST HOOD(W/DUCT) HOUSINO'MI'I'I ON FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will theappliurnl or future building occupant smmorhandle hazardous material HEAPING UNIT(IO 100,60f)BTU) t
as dcflnrd by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety -
Code,Section 25532(u)? - HEATINGUNIF(OVCH100,000131U) -
E]Y , CINo _
Will _
I VENTILATION FAN(SINGER RESIFT PAID pate Reccipl# -
the or devices which BOILER-COMP.c+HP OR IXI,IMII BTUI
emit bouradons or,conmminonts as defined by the Be,Arco Air Quality Management _ TdI,AL,
DimrictE - - BOILER-COME(OVER I OPT01 BTU) '
III ]No _
I hay rend the humNn"muledulsre Is under Chapter(.95 of the Cull- AIR CONDITIONER ISSU IJATI:
yuiremcn p
fund.Hem" &Safety Cade,Semon.25505,2.5533 and 25534.I understand that Firm NEW RESIDENTIAL MECH. SQ,EF.
ouldingd ancurm yhuvea anf thm It
my re"amihilityto notify the scrapum
ofthe req me sw , a f{im I issuanceefaCentre
(lw r an
hon,,Kim tc (� TOTAL: ISSUED BY
OFFICE