S 1562 (2) P APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO ZBUILDINGPROJECr
F,CI'RICAL 1117811'NO
BUILDING DIVISION APPLICATION/PERMIT CHANICAL �J 1562
IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI"ITAI,DATE
OWNER' NAME' PH NE: O RAGfOAC NO:fSIC CONTROL#
\RCHITECI'IIENGINEER: LIC NO. )R ISYS: ❑
C 'PACT: PHONIi: C BUILDING PERMITINFO
pp//��
5'7 Q ❑ Consultant Fees Paid by Applica )At�tT � BLDG IH.IiCT PLUMB nDiCH
gV 56 s F ❑ ❑ ❑
LICENSED CONTRACTORIS DECLARATION QTY ELECTRIC PERh11T FEE
1 hereby uffrm thin I nm licenal under provisions of Chapter 9(enumerating JOB DESCRIPTION
WOO
with Sn"ism 71X3)ol'Divisi.a5 lal"the Business and Pfol"exdne,Cnde,andiny license is RESIDENTIAL:
F,� fall fotceand e0em, PIiRMI'f ISSUANCIi ❑SFDWL ❑KITCHEN REMODEL
i-UU Licnue Closes Li^'N APPLIANCES—RESIDENTIAL El ADDITION C1 PLUMBING RF,-PIPE
N a Date Contractor
ARCHITECPS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
FtiN Itmderstandntyplansshall tensed as pnldleneords PANELS MOOIIICA'TION
CZ-O UP TO 200 AMPS ❑INTPRIOR El CHIMNEY REPAIR
1-4FW Liccnmd Proleesl.mil 201-11X3AMPS IMPROVEMENT E]SWIMMING POOLS
�0IJ OWNIiR-BUILOIiR DECLARATION OVER 1000AMPS ❑BATH REMODELIRF.PAIR ❑DIEMOLI'I'[ON
d I hereby tiff...That 1 inn excneq from the Clamored.,',Licensee I.aw]or the . � � `. �
L 6 U following reams.(Section 70315,Bre,mt and Profession;CMc:Any city or county SIGNS ELECTRICAL ❑UTIES y AIA
3 w 1- whiell regnirex a pmntit m eloomi 1,alcor,improve,dinned ish,.t repair any stmeutrc U ,�•_--v
m70d prion l I: retireesIh III '1 li d0 II b 1'mleeua, SI'LCIAl.G1RGDI'IYMIgG. f
W} 'hath licensed p n th pro a lilt Contractile,1 1 (Ctrple,9
ep� (rnnncnc t6wth Seu'nn 7gll11 of❑'v sinnJ,OM1adea mv,and lr fv.'ne Cala)nr 'IEMr.MEI'CROR POLP.INST COMMERCIAL'
6 d that he is exempt dmabrom and tM1c basis for the alleged exemption.Any violation el" ❑NEW BLDWADI31'I'ION ❑DFM01.1T'(ON
Section 7031.5 byanya,plicam for apenditsubjects the applicant to a civil penalty of POWE DEVICES El TENANT [I FOOD SERVICE
.F.
not...re than five hundred dollars(&5(31.} IMPROVEMENT
�d Lmnwncrnfthe nu nn SWIMMING PGGI.ELE I'ItIC
W ce mill dotbesions Cade he Comment's
License Lnwbratffemd sotalate pply tour Bunions, ❑O'I'L{CR
1 m and I'r.ressi.ns Cole.The Com perio Lind of Law docs not apply tour owner lar Or71'LIffS—SWIT S—FIXTURES
hisproo ny who builds or vide't s t such improvements and d.ax m n wnrk bardeal o f ffided gh
his own employeese provided thm such entisoldw arc not immndnl lar nlfenJ for NEW RESIDENT IT,EL SQ FT.
sole If,however the bnilJing nrimprnvcmenl i>>nlJ within 00
SQ.PC FLUOR AREA LSQ.IeI'.
owner will have the burden of proving(her he did it holt'or intpnvu lino pro- PAID po ecofmle.). T !'6
❑ I,nsr of the property,am exelun:v^ly contracting with licensed comramors m TOTAL:
oneamt theop,,,j«t Ree.7044.Business sad rrom,xlme,Codc:)'TIn,Clammmorx L, - I111�e®
cense Law does not apply to an owner of property contortswho old,or improves amreon,and QTY. PLUMBING PERMIT FLEE APR 27
who com,nx for such projects with a contracmm m
rtx)licensed pureuato the Cora dur's
License Law. PBItMI lISSUANCE
❑1 am exempt under Sec. .B&PC for this nasionGillur wren i Bvu
Owner Card ALTER—DRAIN&VENT—WATER(EA) VALUA'T'ION
WO and,, COMPHNS,my on Dfthe fRATION BACK FLOW PR(TIECT.DEVICE
I hereby umnn under penalty of perjury nnc of the following declurudions
❑ IhaveunAwillmvinminn CerlifeuleofGmsenlmself-besuretiro Worker's CnnI, - 1)I4A1NS—FI,OOIt.120017,ARF,A.COND' SdORIES TYPECONSTRUC'HON
senor,as provided fir by Section 370o of the labor Gore.fertile p<rfnra inv of the
work for whlch Ibis permit is issued. FIX'I'ORES—PERT RAP
❑I have add will nine...ruin Wnrke,'e Cad,nsul'mn houmnee,uv required by Section
37110 of the labor GNe.for tile performance of the work for which this Penna is issued. GAS—EA.SYSTEM-IINCAOUTIJITS OCC.GROUT' APN
My W I,knr'e C.mpenxmion Inxuranee currier amd Policy
Carrier. Policy No&MA GAS—EA.SYS'I'IIM-OVER 4(UA)
CERI'IIICATH OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASOINDUSI'RL WAS E INTERCEPTOR
BUILDING DIVISION FEES
(TM1ix saadion ncM sol he c.mPlmedil the pennil is for nnc hundrM Jnllurs IS 100) GI11iA51?'TRAP
or le".) PLANCIIP.CK FEB
Icerily that in meperformancclaRhe work f.rwhich buit permit is issued.I shall SEWER—SANI'T'ARY—STORM IIA.200 Pr.
not drodnyany pmmn in any nmnbe,soax It,bm,medd l m the Wudmrs'G,mpan- ENERGY FEE
0 z sa'ion laws of California.Date WATER HEATER WNENT'IELFCTR
A,,b..ad GRADING FEE
NOT ICE TO APPLICANT: L after making lIns Cenifmae lar Exemption,you should WATER SYSTEMIIREATING
ISVolic subjemmthe Workee%Compensation pmvisilans of the labor Code.you must SOILS FEE.
fonhwidh amply with,uehprevision,orchis permitsh:Jl he deemed revokM. WNIER SERVICE
C1. 0
CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PLMB. SQ.ET, PAID
,7 z Dade Reecipt 11
V k bar
this pniIiAbcoivucun(See.i3097,Cingagency bathe performance of
Le work for which This permit is issued(See.3097,Civ.C)
u' U Lendels Name TOTAL
>s L) LenJc/s Ocnifys TOTAL
r�'s W I certify thin I have read This aPPtlemion and swm That the shove Inlinnnnlnn is BUILDING PUC
F`V4i cones.I agree to comply with all cityard county entrance,and state laws nlum,or QTY. MECHANICAL P12RMIT FEE
buildingcnn,arrainn,and hereby aulbnrize reprevemplives ofihix eirym emeruprm the SEISMIC FEE
above mentioned property for inspection purprnes PERMIT'ISSUANCE
We)agree'.save,indemnify and keep hannlev,the City of Cupertino against GLECI'RIC 1713E
l inhlliti .jndgmems,mats:cod expenses which 1114Y in any weyaccme againm laid City A[A OR OR ADD'PO MECH.
c.n. u
of the gmnling of thio Ixrn it. PLUMBING PGF.
In Acf NDERSTA SAN ELI.CO PI WIT11 ALL NON-POINT AIR HANDLING UNITTO 1g1XX)CFM)
SOLI, ,I'NLHER 1 1 MECHANICAL FBI:
p AIRMAN OLINO UNIT(OVER 10,000CIM) CONS'FRUC'IONTAX
Signature of AlIPlicanhCmmouyo, Dote iX11Al1S'1'HOOD OVIDUCT) HOUSING MI'TIGAT'ION THE
I IAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haearJuus limited HEATING UNIT(TO 100,130 BTU)
use dcfned by the Cupeninn Municipal Code,Chapter 9.12,and the Health and Sufdy
Cubit.Section 25532(0.^ II UNPIN(UNIT(OVER 00,000 BTU)
Nin E]Yes ❑NVENTILA'I'ION BAN(SINGLE RESID) PAID Date Recei"a
Will the applicant or future hdding oauPanl u.ac ot,mmuern.s devices which
moil haxmddus air contaminants as definM by the Buy Area Air Quality Management BOILER-COMP(3HPOR IOB.(XX)13TU)
Disaicd TOTAL:
❑Y., ❑No BOILER-COMI'0JV[R IIXI,OIXI N'1'rp
Etuvcbeadm,lmzmdumnen.talsrednitcani nnder Chapter GCarlo,95 of he CONDITIONER ISSUANCE DATE
learm Hwhh&Safely Cot Sections 8505.25533 and I!VOT I understand that if the NEW RESIDENTIAL MECH. SQ.Ill
building does net Coa ly have a Intend,that it is my responsibility to amity the occupant
.f the nequimmems which noir,he met prior',i"Idence.t a Certilie ne of QwaPaney.
Owner or mdhomed agent Dam TOTAL: ISSUED BY: Db
OFFICE