S 1568 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY��Tp' CUPER'I'INO II1111.I11,NG-I'.Lf.C'I'RE GAT, PliIT NO
i' BUILI�NGDIVISION APPLICA'I'IONIPERMIT rLunlBmc.AncunmcAl' 1568
BUILDING PROJECT IDEN'PIFICA'PION
BUILDING ADDRESS. SANI'T'ARY NO. APPLICATION SUBMITTAL DATE.
-:22600 t/ .1 U4N �Q G°k err/Nal l%�-
UWNER'SNAM': OM 3(s[ /� CONT' . O C.Ii! C CON L�3'8 6:!;-IB NIC CON'IROLM
HITELT/LNUMbbR: LOU NO: ADDRESSqqr J Li
oSoS 6are.c L e 616a C'G.
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) HhD(; EI� PLOMB MECH
LICENSED CONTRACTOR'S DECLARATION 1 Y ELIiC`FRIC PERMIT FEE 'I E
I hereby affirm that i am licensed under provisions of Chapter 9(commencing Q JOB DESCRIPTION.
D=Z with Sen...7XXBof nividnn 3orem ImMumsamd Professions Code.omd my It..is RESIDENTIAL
Fac in lull force unJ cffcm. ` S� PERMIT ISSUANCE ❑SFDWL I]f(1'ICHENRBMODEI.
�UU License ClaS5Y5 r Lio.N `�r"`
Had Dae 1��'' ?�^� Convenor T APPLIANCES-RESIDENTIAL []ADDITION IMBING RE-PIPE
ARCHIT[CT'S DIICtARATION ❑MULTI ANTI S'I'RUC'TURAI.
Z p H u Z 1 margo nd my plans shall be used as public rerord, PANELS MODIFICATION
OZ4O UP FED 2(O A MIR ❑IN'HER]OR C1 CHIMNEY REPA IR
F'3 F"w
Licensed Profesxiowl 201413fIt1AMHS IMPROVEMENT C]SWIMMING POOIS
�Y OWNF,R-BUILD.iR DECLARATION OVER 10011 AMT'S 131INHIRE DEIJRE I (]DEMOLITION
a:cCd I1y� hereby affirm that I am exempt front the Contractor's License law Rome 1y�G U foolmsm n.(Nation 7031.5,Business load Prafmsiom Code:An t t ❑(rififf ^ ��
X e toes^ Y ci y or conn y SIGNS P.LF.C'I'ItICAh A
w3oy
which requires .. construct,,It p d I'1 p, Ystmuurc V . \ „/
��Nd pre: t t :: t 'I: y ' 'pr imo II ftp rs I'I y dxtatcmml SPECIAL CIItCUI'I'/MING. -1Q ���-J
that(commencing
a PSomnnn0m provso ra 3the Cnmmn r Lan:cla (Chapter9
(cat he I,ingwit therein urn and of basis
rmic dBusiness
reel emend Pr,A.,ovi lotion r TEMP.MEIIiIt ON PO INS COMMERCIAL:
6 a c C That he is exempt therefrom and the basis for the alleged eminant to Any violation of ❑TNEWEN HLDG/ADDITION ❑FOOD .1 TION
RVI
2m net m don. by any harp licantrs($50rmil xnhjensthe applicant nsacivil penalty of POWER UIi C' El TENANT [I FOOD SERVICE
t more Nan five hundred Dollars($5(X11.
IMPROVEMENT
d ❑ Las owner of the papery,or my employees with waKmmthcir sole amtpeusalimn SWIMMING t .ECTRIC
will dothe work.mnd the Iontumistal intended ar^!!earl fmwle(Sce.10Jy,Business ❑OTIIIiR
R�13 and Professions Code'1 he Contractor's L'iecn,e Law does not apply to an no net or OUTLETS-,6I'1'Cfl FIX'I URIIS
CC
property who builds or Itnprovex Raman.and who does such work himself or Inrough
his own empluyas,provided but such improvements are not intended nr Offered for NEW RESIDENTIAL HLE SQ FT.
sale.If.however.the building or improvement is sold within one year ofcompletion,the SQ.Fin FLOOR AREA $/SQ,FT.
will have the burden of proving but he did not build or improve forpur-
mmntdsaleJ
owner . P A 1 D
❑ 1,as owner of the property,am exclusively contracting with licensed contractors u, TOTAL:
mxenm Iles pr Jet Xee.1WQ B.,iness a nd Pndes,inm Cccc:)I'he Cammemr's],I-
cc seLast does I l opfly m on owner III ou,Iry who build, aiogmwes Nebo,and QTY. PLIJ MBING PERM IR' FEE
who contracts file such projects withe emnl,bals)licensed purouumwtno Cammenr's APR 28 Alp
License Law. PERMIT ISSUANCE Alp
❑ I am exempt under Sec ,Il as I'C far this moven )N'
Owner [)ate AcrER-DRAIN h VENT-WAfLR RAI IJmvi'11fvy
WORKER'S COMPENSATION DECLARA'T'ION BACK FLOW PRCGECI'.DEVICE? 2'S eee?
go 1 heluhy nl'finn under penally ceps Jury ono of Inc fidlnwiuK Nnlurainnx:
I have and will maimnin aCertifeateiRmscntmacl r-insvc lin Worker's Compen- DRAINS-FLOOR,ROOF,ARHA,COND. STORIES 'TYPE.CONSTR IJC'1'I ON
cation,as provided]or by Section T1011 of the labor Code,for the performance Of the
work for which this pemtil is issued. IgXTURES-PI?R'IRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3100ofbc LaArt CtOe,forthe performance of the work fervehich this Permit xissucd. GAS-EA.SYSTEM-1 INC.i OUTLEi;S OCC.GROUP APN
My Wader's�p�penylion.! t cr and Policyn bra ver9.�
Carries ,s r�C-OM/ln Policy No.: GAS-EA.SYSIEM-OVER 4EPA)
C13RI IFICA'I'S OF HXI:MPI'ION FROM W ORKIiRS
COMPHNSKI'ION INSURANCE GREASH/INIPL S'I'RL WASTE IN'I FIRCHPIY112
BUILDING UI W SIGN pL'[kS
(Thdc,ctlnl.awon.,be completed il'the pcnnil is union,blind,.],],,]lots IS 100) GREASETRAP
or IensJ YLANCHIeCK IIiC
I ernify that in lneperfomanemdthe work(orwhichlni,asuret ix i,,m L1,mII SEWER-SANI'T'ARY-STORM P.A.21X1 Fr.
mol employ any peon in any manner so as it)hecnme subject as the Workers'Crimper- ENERGY FEE
OZ Satinn Law,of Coiburnot Date WATER HEALER WNENT/ELECIR GRADING PER
Z Applicant
re, NOTICE TO APPLICANT'.If.after making this Cenifiel Of HacmptmI,you should WATER SYSTIiMO RHATING
abecome mhlcct m the Wild s Contponnminn provoioes of the Labor Code.You mune SOILS IB3H
w fonhwilh comply with such pmvi.mos ar do,pcnnil shall be deemnl invoked. WATER SERVICE
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
U 0 t hereby affirm that Nem i,a condim lot lending agency fon the perrarreare of Dom ANY"
the work for which Ibis pmit eris issued(Sec.3091,Civ.C.)
Its F' Lenders Namev III T(TrAL:
(J Lender's Address TOTAL'
aI certify Thal I Mrve read this application and cum in,the above information is BUILDING ITE
r) Z) correct.l agree ill munPly with all city and county ONinuncenund peso lows rclmingm QTY. MF.CI IANICAL PERMIT . I-F
Z building construction.and hereby authnrw representatives ofthis city tocnarupon the SEISMIC FHI
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hornless the City of Cupertin,...fast ELECTRIC hili
liabiliticojudgments,costs and expense,which may in any way acerae against said City ALTER OR ADD TO MECL
in c
omequence rl the grunting of this pcnnil. PLUMPING IgiE
APPLICANT UNDERSTAND AND WILL COMPLY WITH ALL NON-POINTAI R Ii A N DI.I NO UNI'r(101 Wild CFM.
SOU-- EGl1LA1'ION, MECHANICAL F.F.
^AJ /_q�_?e AIR HANUI.ING UNIT(OVER 10,000CFM) CONS'IRUCTI(. TAX
Sign a of Applient/Comommr T O` Dole 17XHAUST 11001)(W/DUCT) HOUSING MI IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
N911 the applicant m future.wi Wing Occupant dome,handle It...Mo.,macrial 11FATING UNIT(IO 100.000 BTU)
rax defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)iHEATING ON(I'(OVER 100.000 in
E)YO,
VENTILATION PAN(SINGLE RI?SID) PAID
Ilulm RacPl q
Will dths clifir contcaut aminants
More buildefined cerupby
meaAirQu Ordeviceswhich BOILER-COMP OliP OR 100,0X1131 U)
ail havardous air conbminants as defined by the Bay Area Air Quality Management \ TOTAL
estreat
E]Yes BOILER-COMP(OVER 100,000 RTU)
AIR CON DITIONEk
Ib tthe h b �t uls I ' I le Chapter 695 Tris COl'- ISSUANCIi DATE
torme Health N Safety Code,Section,Z11101,11111 d2111LI d f d'hot tIne NEW It13.SIDHN'I'[Al.it SQ,FP.
hail l' avert t hal tl y .p :inblyl tfydnaclpa
ofN I w tan t. m fnC rtiwre Itkwpaney
Own
!d.,cut Date TOTAL: ISSUEfl11Y:
OFFICE