S 1866 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-,USE BALL POINT PEN ONLY
CITY OF CUPERTINO - - BmLDINC..ELECfRICA], - .' Pe IT NO
BUILDING DIVISION APPLICATIONIPERMIT PLUMB Z-MECHANICAL ' 1866
JIUILUINGTROJEC'T IDEN'TIF'ICATION,
BUILDING ADDRESS: SANITARY NU. APPI.ICAI'ION SUBMITTAL DATE
1� �`1 -i-• � ?— 1 -`18'
ERSNAME PHONfr. CO TRACTOR'S NAME: LTC NO
9(Q— Ino (� l �n 9U( NIC CONTROL#
•,ItCIRTEC'IIP,NGINE LIC NO ADDRES" f0�� J ❑.
CONTACT - PHONE: - t=, •BUILDING PERMIT INFO _•
❑ Consultant Fees Paid by Applicant(Initial) BLDG IiLEC' PLUMP MECH
Fr;nA- ,;253-061s - 4�d ❑
ITCFNSFD CONTRACTORS DICIARAI ION- - QTYv fEI F.CI RIC PERMIT.{• • I'. ,PEE+
I I by a ll d B I r d d p f Ch,a 9( Coca, i. .,+ + „•+ + . +. JOB DESCRIPTION
Oo'Z won iths i 9Wo) fT son M1<ItheBusn and Pm(axs'ansc,«lc and nyl ce e �� � RESIDENTIAL:
H full to"and clleet. / PERMIT ISSUANCE -
U U License Class L-- lw 2 5 ❑SFDWL El KITCHEN RF,MODEI.
�LicH
F 7-1 a] Dom Counted, APPLIANCES-RESIDENTIAL ❑ADDITION '. i$IrhtlhNXMC.AFKPIFIi
-
V,ii,z> ARCIIITEC'I"S DI?CLAItA'TION e ❑MULTI-UNIT ❑MODIFICATORAL
Z O4 P 1 undetstvnd my Plvne shell he aced as Public records PANELS - MOUIP 'f10N
UP T02UU AMPS
O zp - - ❑INTERIOR El CHIMNEY REPAIR
lY f al
BUILDER DECLARATION 201-1000AMPS IMPROVEMENT ❑
SWIMMING POOLS
< 1 hereby ff 11i I i form line Contractors Corso Law for he OVER 1000 AMPS pJgnn R:MODI: /RRPAIR
[I DEMOLITION
y(�0,U following reason (Section 90315.IT Inco an 1 I r le.', A y ay or County SIGNS ELECTRICAL ❑OTHER
,which no,dirs,v Permit to Coronad,vltar,ii 11v dem IIs mpmr any etmemrc
FP�O`9 prior KiNissuance,ulsoreyuiresthe aPPliumt for such Pent so,ecdsmtentem SPECIALCIRCUIT/MISC.
W, Wel .I' d1 t bittern, ftl C I (Chpter9
��Q (wn g 'tlS t 7000) fD ' " 3 ftl l3 . :: 1 'C,de),r IBMP MP,TP_It ORPOLEINS'E COMMERCIAL:
d ly c C Chet 1 exempt there m v,d the basis f the alleged exempt m. viol firm d - ❑NEW BLDG/ADDITION ❑DEMOIA I ION
K m W Section]IBIS by any appb,ant for o permit subjects the npplicant K a n er a iy of POWER DEVICES
W^an ' ❑TENANT ❑FOOD SHRVICF
�x� act the T' hundred dollar,(5500).
fp p PdY Y PIy 0 age tl : I 1 SWIM11MING POOL F.LF:CIRIC IMPROVEMENT
H
will the k and the structure t t dd B If (S 44H T s ❑OTHI?R
{ai13 anA r f 's, rve Cndu.7h Conlraen rs Loss,1 nw docs nm apply m v, r eP OUI LETS-SWI'TCIILS FIXTURES
�' .. pmpctly who built/-w nr intpRrvnr themnn,and who does ouch work hhn,,11 a,through
his own employees,provided than such impmvenmnts are not intended or offered lot NEW RESIDEN'I'I AL ELECT R SQ IT,
sale If,howevcm the building(it mli ornentlssold whanone ycurnfeomphdon,lhe - SQ.IT.FLOOR AREA S/SQ.PI'.
cChuEder will have the burden of proving shad he did not build or improve for pur-
pusenrame).
❑ I,as owner of the propfaF ata exclusively contenting with licensed contractors to 'I'OIAL:
Consumer tn project(S 7044 Brounness EmitP I Code)]'hCoutoein,Li-
Case
+ Loss does not applyI al'p p ly he h 11-a i pno,ex" Incona, ,d QTY PLUMBINGEFRMITy J,'i' fE8'
whnctlaat for such parl with o cottratns)lcnsed per vu to lire Continuous „
License Law. I PIiRMI'f ISSUANCE ��
E] I am exempt trader See. .IT Ad C banns K+son ' - -
O"nar Date
- ALTER-DRAIN do VENT WA'I'ER(ESO VALUATION
WORKERS COMPENSATION DECLARATIONHACK PLOW PROTECT DEVICE (-/(.. 0
go
I Ih by B Wunder pe rJlY dpeE ry flh f IIwin6, I +r(
[] I Time and will maintain v Certificate ofConescorto self-insure for Workers Coiped, DRAINS-FLOOR.ROOF,AREA,CONT. STORIES TYPE CONSTRUCTION
onso,vs provided far by Section 3701heLnbnr Code,fort he pednnunnceol'In, - -
work folwhich this ponniti+ie.nad. FIXTURES-PER TRAP
ave t it will mainein Wmkev's Comtmasudm,Insumnec,is resound]by Section ”
3900fd 1b Ced,fordid pT anee(Ads,work let is'�a,d. OAS F,ASYsHF.M I INC401-TIHIS - OCC GROUP APN
M'W. .C . t carr d Policy I W,
Curr Y I Policy N .'Z N� ; GAS LA SYS'I EM-0VER 4 TO)
CTRL IFICATF 01 Ll tMPIION 1 ROM WORKERS
COMPPNSATIONINSURANCF GREASGINDESTRL W,ISTEIMERCEPD)R -
- -( ii-C,nn,eed unbec,npleteAdthe pemit'of..rte hundred dal[i,(SHq) GRICA # BUILDING DIVISION E.IaS
or Ices.) SEWER-SANITARY-
fRAY - A' ' PLANCHECK FEE
Icenlfythin inthe performanceoDs towork
becfor which this the Wosrc,ual,Ishuli SEWER-SANITARY-STORM FA.2fNl FI'.
note ply }pc:on y � sties to h subject'.❑ Worker,C pen- � ENERGY FEE
Z vatit I I Caliloar,Dole WATER HEATER WIV0 AMU
Q
Applicant ( GRADING OBE
NO'OCE IO APPLICANT If after making this Certifcme of Eiaconnum.you should - WATER SVSTHM/l` P INE
Msome subject to the Worker's Compensation provisions of the Libor Code,you mustSOILS FEE
LTI forthwith amiply with sch provisions or this permit shall be deemed mvoo d, WAl ER SERVICE -
Q
.a7. z CONSTRUCTION LENDING A agency NEW RESIDENT I'I,MB. SQ,PT PAID
UO hereby affirm leading agency fonhcperfnrmmnec of Date Recc�pt#,
C) the work rot wend{dos permit is issued(sec 909].G¢C) ,
Lendd,Name - TOTAL:
C) benders Address �_ � 'I'0'fAL:
a1 CodifyGot lhave read this appicatimandust ifforthe abovef .f ' - r ICAL BUILDING FF.I
.F.t v1 er ne t I's t pp with-ll ity d ty d' d same 1 fin
b t Y: MECHA
QT , NPERMIT +� " FEF 4
building co,smcio, and honImes
ey agent"d elean utend
Ins City to pnn e • i. SI?ISMIC FEE
'" oboe i Ip n)f P f 1 m PER
MI
R ,.r. ? ' •.I
(W)a,,C tec sa' indi vi fy nadT p lnmdrydui
ess the C' of Cupe ,o ugnxt PMl'I'ISSUANCE ELECT RIC PEE ' /
Iiabilihes,judgmm.ts,Costs and expense whim may in any way neemwgainstsamCity Add FR OR ADD Tn!vIHCH. /S
in sequence of the grantin of this permit _ PLUMBING FEE' ll
APPLICANT UNDERST DS AND .CO PLV WITH ALL NON POINT AIN HANDLING UNIT(TO 10,000 CFM)
CE RF S. MECHANICALANICAMECHANICALFEE
.. OO
• l6i Al AIR HANDLING UNIT(OVER 111,111111 CFM) CONSTRUC'TION'1'AX
S" auaeol'AI Infant/Comms T [),,to EXHAUST'IG0D W/DUCft IIOUSINC MITIGATION FEE
IIA%ARDOUS MA'I'EIiIAI.S DISCLOSURI?
WIT the n,Tiwm or future building d,t,,nt glue or In cle hazafdoux material I MATING UNIT'(TO 100,000 BTU) -
as defiord by the Cupertino Munldpal Cod,Chapter 9.12 and the He:dth and Safety
Code,Scanlon 25532Qp? HEATING UNIT(OVER 00,000BTU)
❑Vex C]No VP.NTILAHON PAN(SINGLE RESID) - PAli) -
Dam lC,Cd,#
Will the appheeaturfuts esdere lding by plic BayAse I ea Airi plity Miceewhich BOILER-COMP(3HPOR 100,000BIL)
emit hnznnlous vin cenmmimm�s vs dehnwl by the Bay Area Air Quality Munagemem
District? ,f �letl _ - BOILER-COMY(OVGIt IW,OfN1 B'IUJ
❑YC, ❑No
'
AIR CONDI T TONER
Ik Ith hazard t -I. I t. d Chfi,95 f@ Cli- - ISSUA D/�)y'E '
Than,Hiarlil,A,SaddlyC d Scefle.,25505 25533and25534.1 anderat I 0caffde NEWRESIDHN'I'IALMECH. SQ,EI'.
build' b not curnntly b' en n.n',n.th'n 'try respane'hd tYanoi ly the na.Pau (l ,
of the ixyuimn]cuts which must be and pn'orto issuance of v Ceniticam of Oecol,ur,"
Owner or author odd agent Date - - TOTAL:' ISSUF,DRV: ` z M/` —T
OFFICE