S 1874 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EIA{CI'RICAL I'I[RppIT NO.
1874
HIl11.DING DIVISION APPLICATION/PERMIT PLUMnINc.-MECHANICAL
l`J
BUILDING I'ROJI?CT IDFNT'IFIGk'1'111N
BU1LOINGADIDItIiSS: - SANITARY NO. APPLICATION SUBMITTAL DATE
2 /8-0,,F- R&6/V4 k > e-u Pc/Lr�h/D
(IWNIRS NAMIi: PIIONCE CON'IRACIOR'S NAMIE LIC NO
Ro 2� �}tG` 4'z$-7 Z.5-07z- - ' N/C CON IRDI.0
�SID pECTIC�C`NN �c.�d6 u oGNO y3a t� ADDRESS:
. _ ❑ O
CONTAC: PHONE: BUILDING PEIiN11T INPO
�Oq CYANO �Q Z� ' Z ; ❑
Consultant Fees Paid by Applicant(initial) HLUG ELI b/ PLl1h1P I ;
,7 LICENSED CON TRACTOR S DECLARATION ARATION QTY 1 LGC TRIC PERNII`F " FEE I hereby ntGll dart :d 1 1 IChEFI )1 ' g - -v - ..JOB DESCRIPTION
ZoIZ
F+ 00 PERMIT ISSUANCE
RESIDENTIAL
in full force and effect rQ :
❑sErm. ❑KITCHEN REMODEL
GVU Lmenvc Clnl hicN APPLIANCES-Ii RSInENT1A1. ❑AUUIIIGN ❑PLUMIIING RI?-PIPE
[-ZM Date Convenor
Na,E• ARCOTFCFS DECLARATION ❑MULTI-UNIT ❑$TRUCTURAI.
4-p N PANELS MODIFICATION
N Z 1 understand my phms shall be used its public records
OZ�`� _ UI"Iu 21N1AMl'SI'HR10R ❑Cl]PANTY REPAIR
F BF--Ed Limmul l'mfewourill 201-1000AMPS IMPROVEMENT - ❑SWIMA1INGP0(lIS
OWNER-BUILDER DECLARATION OVER IINII]AhIPS ❑BATH RY:MOnI?IJRI?PAIR DEMOLITION
�J C�a 1 herehy of rra(I'd 1 an summa Goan the Cunoneou n Licen,eu Lnw It,,Ile
3 m U following inaction]031.5.Business and Pnd'essions Cotln An t t ❑01'1{lili
g recant.( yciyor cnunY SIGNS[LF.CI RICAL
F 0 N which requires a permit ut construct,alter,improve,demolish,or repnir any structure
f y� tic or hs isxtarn,t,also l.....lotslbsu"licanlfor such"moa n flea nignalelat"at l SPECIAL CIItCUIDMISC.
Ihathe is licensed pursuant m the provi.vinns of th,Centnclors License Law(Chapter 9
I+1�00 (OOmmcncing with Seninn]fN)B7 of Divisinn3ofthe Business and Pafevionz Gdcl nr TEMP.METER OR POLE 1NS9L COMMERCIAL'
d p�o t•L IMn he is exrntpl therefrom=it the basis for the illegal cxcmptina.Any violation of - ❑NEW BLDG/ADDITION ❑DEMOLITION
ISN, Section 7031.5 city any aPPllcam fill a pennn oinces the applicant Ina civil penally of POW17R DEVICES
> not more than five hundred dollars($500). ❑TENANT L3 FOOD SIIRVICI:
�Fd Los nwner it miss nt I11res with wages as dmf,sole el ulceration, S IMMINGPOOLEIECfRIC IMI'ROVEMIiNT
❑ PrnPu Y YmnP Y acs pcava
dolhewnns Code TheConnectors
on e hots License
La this. of appu.]fan owner
(if
63 m and Pdy'he co Code The C its the.rs License law dre.not apply e f owner of OUl'LI FS-SWI'I'CIE?S-FIXTIIIt F.S
3 OTHER
prnpeny who bullJs or innpnvev thereon,std who does Hoch work himself nr tM1rnugh
hiswa entployws,provided Far.inch ingnnvenanNu wnal immadnl or offend or NE RESO)1?NTIAI.Ii1.EC'FR SQ F-F
sale�If,howcvcu the build'mgor improvement is add withinoneyeoridic, EPletimt,the SQ.FI'.FLOOR AREA S/SQ.En
cr-builder will have the burden of paving Lha he did not build or improve for pur-
e rl h'ale.). -
is nwner of One pro,E ant exclusively nmvacling will IkenseJ enNractors In TAI: 1
construct the project(Sec.](M-1.Btuia.,cold PmRssions Coo the Contarm(a Li-
wew, awdws nntupply loan ownerof property who buddsnrimpaves thereon,and 'QTY. 1 ISItA11T• ,r FEE;
n...mails bu...It Project,wins a contraction,)Iwilool l Pmstmnt to do G,ubanor's
1-ircnse Law. PERMIT ISSI' NC
❑lam tpnJ .If do P C for this 1.111.
AIAER-DRAIVAkHNT- A'FI?R(1? VN.UA'FION
O run
C. WORKER:SCOMPENSAI'ION DI?CLARAT ION BACK FLOW PROTECT DEVICE
I l ereby auirm trader remdly of penury one m ole following ardirmiate, d
L3 1 have and will manudna CenillcateofGmcoad1. lbin,urc for Wn kcr'e C...... DRAINS-FLOOR,RIIOF,ANIIA.�N S'f(1121L 'I'YPI?CONS'IRUCTION
ration,as pruviderl for by Section 3700 of the labor Gide,for the performance of the
work far which Ibis permit is issued. FIXTURES-PER TIE
❑ I have and will mninhlln Worker's Cca,s na i l,.Oco cc,as oeyuirnl Ery Srrllon
370(l of the Labor Code.fm the witurmanec of the work for,rush lhk%psua as issued. GAS-EA.SYSTEM-I INC.d OUTLETS (ICC.GROUP APN
My Workers Contp.nsation Inaummsc wilier and Policy anther are:
Carrlur: Iblicy FROM
GAS-EA.SYSTEM OVER d OFA)
CERTIFICATE Oil SAI ION
RAht WORKERS'
COMI'IiNSAI'ION INSURANCE. GRIiASFl1NDUSTRL WASTP.INTERCEPTOR
BUILDING DIVISION FEES
fThlx eenien Dud nm becnnmlual II Ile pennn Ix fonmc hundad Jnllnra($IIXD
or Ens.) G-WER 'S N' PLANCIIECK FI',li 3 T (x�
Icenify hot in in pedomtanecnfthe wmk Rte whichhisIn permit is issueA,lshall SEWIiR-SANITARY-SNNM LiA.21NIIT
nounpdoy any person in any manner solabecomc.vnhjacnn the Wurkers'Cnmpen. 'NERDY FF.I? /2. / Z�
Oz action Lnw..ill Calilnrnlx.IJote WAI'1ilt HI3Al'I?R W/VIiN'I'll?LEC'FR GRAVING PEP
.Z-a Applicant
.�.a NOTICE?TO APPLICANT':If,after making this Cenlfwre of Exclnptinn,you should WATT?R SYS'FEM/fBEATING -
F leasntaa%ubjea Ra its woatars Gtmpen,xtal E pmvidntsol he Labor Gale,yna angst I'EE
forthwith comply with...It ponvmor nr this penal Shull be deco edrevoked. WAI'IiR SI?RVICE
aQ
CONSTRIJCI'ION LIiNDINO AGENCY NIiW I2ESIDIiNT1A1.I'I.M13. S Ur V•V�-r PAID
UQ I hereby alEmubaulere is.c...cunin.lending agoncy kadepedouncruo of Illk(,J' Lha RecoiplN
the walk for which this .it is issued(Sec,3097,Civ.C.)
Lender,Naane TOTAL:
L) Leadcr'.AJJr1s - 'I ODV„
'� y 1 renily Thal I ha c J Ih'. ppl I' J.t t that Ih M fsmml nn is
BUILDING HE 0 e
rF-a rot coned logical to comply with all city and counly I' I state I r"Ironical
ttlhe
eaming et OIY MECHANICAL PER MIT �' FEES
Zl O
U baiW O
geo stnon, rd heichy null - el Tn esofll city I FUPSEISMIC El: l
abnvnmcnllonM pmpcny for inslrmion pupxsres. PERMIT ISSUANCE O
(We)agree t.save,indemnify and kccp hnnnlu..v the City of Cupertino agains ELECTR0. E U
Enbiline,.judganenl...... and exycnses whluh any in any way uceaenguival suiJcily AlAIRORAOI)TOMIiCIT
in consequence of granting of pemd6 rLUMInrvc 4'E •3 s/J
APPLICANT UNDERSTANDS AND WILL COMPLY will It AL1.NON-POINT AIR HANDLING UNII ETD I0E)0ICFM) MECIIANICAh P
SOURCE REGULATIONS / V
'AIRRANULING UNI'I'(OVER FlFp)C17M) CONS'I'RUCTION'LAX
Signumm ofAppliwMCnmrnctnr Date EXHAusTH00D(W/DUCFI HOUSINGMI'FIGATIONFEE
IIA%ARUOIJS MA'1'I:RIALS OISCLOS(JRli
Will the applicant or future building nTupanl%lore or handle Introduces tnulcrial iA I ING ON I],(TO I 00.00c)It FU)
as dclined by the Cupertino Municipal Coal,Chapter 9.12,.and the IIcurh and Safety
Cady Scott n i 25532(u)? trial[NO UNIT(OVER 100,11011 BTU)
❑Yn 7 N VEN'I'LLATI ON FAN(SINGLE RESH)) PAID
Vine be
q
Willdun EPPllaaa..r IRoaa building by the ..use..Air tentmdaviel which BOILI?R-COMP(3111'OR 100.NIO BT U)
emit baveNow Dir wmaminamu us define)by the by Area Air Qm'ny Manogcane'tt 'O
OiwrinP
❑Yee 0 N BOILI?R-COST(OVER I00.0g)BTU)
AIR CONOI'I'I ONEIt
S have wildlife Cask,Serious 25505,25533
5,2553 annts u2553 .l eine mann that6u5 of the Cali- ISSUANCE IJATI% is
forma'do &Safety Gds,ca rental,
a po2553),I unJcntamd thatifthe NIiW RESIDENTIAL.MECf{, SQ.Irl'.
ntnMiltgdae.m"I cry hnvenlellom.don ltMntr lem11nainillty to..eaify ille nerapaatt
e quire ns Minh mus I poor rot lssuancc of a Gen rode of Occupancy
,- Owl cOaou(Iari,cJ agc d Date TOTAL: ISSUED BY.
OFFICE