B 0651 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO • BUILDING-F.I.ecPRICAI. PERMIT No,
BUILDING DIVISION APPLICATIONIPERMIT
PLUMBING-MECHANICAL
IFIC t 1
ItU11.U1NX:PROJECI'IDEN'1'IF'ICATLON NO
AP7
SANITARY NO. APPLICAI'I(IN 5013 M111'PITh ILCI'I
BUILUING AUDR135S'.
Cbz r- � Q
OWNE Mi: Pire C
TRACTOR'S NAME: S ! LIC NO z NIC \ CONROLa
HITT! II:AGI EER: LIC ADDRESS:
COM Jy!QNA S' S /a v "70 BUILDING PERMIT INFO
�� y''ro ^b / ❑ Consultant Fees Paid by Applicant(Initial) BLLDDG/ FIXC`f. PLUMB - MECH
Y' �
LICE I
ID CONTRACT R'S DECK RATION QTY, ELECTRIC PERMIT FEE SOB DESCRIPTION
I ion VX:Jl iron Division
I alts Ile ensd under provisions m',Cola, 9l,yylimuse is
W�2 with$cc'iun JlXXp of DivisionJaOhc l3uxinms dnJ l'mfessianx Gtdr,unJ myliccnsc is PERMIT'ISSUANCE Ra I ENT(
ly5� in full tamarind eBccl. .FDWL ❑KITCHEN REMODF1,
XU� Lams Class I.ic.a APPLIANCES-RESIDENTIAL ❑ADDITION CI PLUMBING RF,-1'11'1:
<Z, Ilam Convector ❑MUCH-UNIT ❑S'TRULTURA,
ARCHITECTS DECLARATION PANELS MODIFICATION
zOZt2z Imou,undmy planedual hrmernspublic records UPT02WAMIS
❑INTERIOR ❑SWIMMING
REPAIR
P A,f.W Licensed Profesninnal 201-IfKOAMPS IMPROV F:MIiN'I' SWIMMING POOLS
G
OWNER BUILDER DECLARATIONOVER I000 AM1'S [IHATH REMODEL/REPAIR C1DIMOLITION
K C Q 1 hereby aBma that I um exempt from me Cum'
nhawrc Lmcnm law for the ❑OTHER
�;LL U following reason.(Section 1031.5,Business and PnsPosions Code:Any airy o"county SIGNS ELECTRICAL
� which requires a permit to amnswcl,eller,improve,Jcmnlish,or rtpan any xWcwre
F_.u]�.] p,nrl t I, require,'h applicant for suchpc its fl signed statement MPI:CIALCIRCUIT/MISE
F.ny mat he i,lima,ailp tt the C t hr',1 Low(Chapter 9 COMMERCIAL
W X00 (enmm,nstngwim Smuch7mM)ot D .nnJ fth li : ssadProm CodOor TCMP.MIT HR OR POLE(NST.
a a e
that he is exempt therefrom ad he basis for o,alleged cacmpliun.Any violation of ❑NEW BLDGIAUDI'TION ❑DEMOLITION
�m Section 1031.5 by any applicant for a permit subjects the spplicanuo a civil penally Of POWER DEVLCIiS [I TENANT ❑FOOD SERVICE.
not more than five hundred dollar($Ap). I IMPROVEMENT'
ZQ01.as owner offle prop,",or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC C1 OTHER
C � will Jo the work,and the mnmmre is not intended or offeml for sale(See 7044,Business
LL
and Pmilexainnx Gxlc:'Chc Cnnmucnnx hiccnx Lnw ares Mat apply et nn nwacr of OU'ri-Eis SW" ICS-FIX'I't1RES
13 pmprny who builds nr impmvcs thcnon,and who Jncs such work himsdl nr through
his own employers,provider that such impervemenu art not intended or alTrred for NEW RES 1.EL SQ ET.
sale.IL however,the building or improvement issold within one year of complaian the SQ Irl'.I'L�(�IOR AREA USQ.IT.
-builJef will have the burden of proving that he did not hold or improve for Pur- i S�
O,a ). TOTAL: `-���^�- V
,o 1.o Ih prop nY 'sly t 'i g with I 1 t t rs m 0//
nal Int p.,,act rsr munwidl1 Codeorncart .an V
ase W Jc:On applYt f properly h b IJ: p .the and QTY. PhUMBI 'ERMIT FEE
whoconlown,for such pm)c rl wnh o nnttmams)licensed pursuant In the Common"'
License law. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER ICA) VALUATION
r
Data
c WORKERS COMPENSAI ION DECLARATION BACK FLOW PRUI'FC'L DEVICE sJ ✓✓'s
1 hereby affirm under,gnahy of Worry one of the Iidlsnving declaration,
❑IhavemW will maimaina Cenifcatc of Cmnsennn nelGinsurefnr WmrAcrx Compen- DRAINS-FLOOR.HOOF,AREA.COND. STORIES '1'YI'Ii CUNS]'RUCTIUi
satimn,as provided far by Section 3100 of me Labor Care,far the porfommim of the
work for which this permit is issued. PI%TIIRES-PER TRAP
1 have INN will maintain Workers Compensation Insurance,as required by Section GAS-EA.SYSTEM-1 INC.4Ol1'll,lrl
91Wo1'the LamrCode,for the perfonnarm of the work hir which this pcsnifls issud. OCC.GROUP APN
My Weeders Compensation lnnionme comer and POlicynnmhrrme: GAS-CA SYSTEM-OVER 4(HA) -
Calver. Policy No, jJ n f
CERTIFICATE 01:EXEMPTION ATOM WORKERS' GREASMNDUSTRL WASTE:INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION PEI!S
(This sectlounedno'be completed if Ne penant is forms,hundred dollars;($100) GREASETRAP I'1. C E'K 1T:E y
les")
I"artily that in the per(urm:umc oftnc work fur which this p,nnit is ln5uer,lshall SIiW[R-tiANI'I'ARY-STORM ITA.21X1 FT. 11 li G P1317 m
nut employ anY Iwnan in any nmilecr w as'o beantte euniecl w me wnn.ud Cmmpem 1
Z cation laws of California.Dale WATER HEATER W/VENT/ELECI'R I NG MIE
O O APplicam I
Z' NOTICE TO APPLICANT:If.ager making this CeniOwte of Exemption,you should WATER SYSTEMiTREATING SOIL IEE
[-� become subject to the Workers Compensmton provisions of the Labor Cache.you must
W0 Bmhwilb comply with such p000kons or this permit shall he deemed revoker. WATER SERVICE
CONS'IRUCL'ION LENDING AGENCY NEW RESIDENTIAL PLM SQ.En PATI
I a _
Date Receipt x
UO IMrchY alRnn@m mere isanmmmnion lending agency aha perntm'ance of
W Pthe work for which'his .it is isrver(Sec.EMP.Ci,C.) TOTAL:
O U Lenders Name TOTAL:
W hander's AJJreax n(mmvtion is E.
BUILDING FE
ps I artily that I have read mix application Mad awes that the about i
F-I N cnrreel.In In cum mall ail Icuunl dlnunccX andoam lawvrclaing to TY. MECHANICAL PERMIT FEE SEISMIC FEE 4
gree pYwi Yum ynr Q
U Z building ennsm¢tion.and Mmhy.aumnriee represemmives of mix cirymenmrugm the F,
donut+nennomid property for impection Purposes. PERMIT ISSUANCE ELECTRIC PER ly
(WO agree m save,indemnify and keep hasnk,the Ery of Cuprninn against
liabilities,judgments.ensu and expenses which many in any way want,against said City ALTER OR ADI(TO NIECE 1. PLUMBING FEC
in consequence of me granhir,althis pesni'.
AVPLICAN'f UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO I(,IXNI CIM) M ECfIANICAI.II!H
SOURCH REGUI.AI'IONS.
AIR HANDLING UNIT(OVER 10L(XX)CFM) CONS'TRUCTION'I'AX
Signature of Applicant/Cmntraoor Uate 17XHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE Q
HAZARDOUS MATERIALS DISCLOSURE.
Will me applicant nr future building occupant store or handle irritations material HEATING UNIT(TO Hp.000 BTU)
m dermd by the CapcnlnO Municipal Cale,Chapmr 9.12,and the Hcalm and Safely ,BATING UNIT(OVER 1000M It U) ///���
Coda,Smik 25532o)Y PAID /.[�
El Yes (:3 NO VENTILAI]ON PA N(SINGLE RESID)
Dxm Rcaip'a a
Will the applicant or futum building occupant use equipment or devices which BOILER-COMP(3HPOR RM.00013TU)
nil hazardous air contaminants as)dined by the Buy Arca Air Quality Management TOTAL:
1'stficl'.' BOILER-COMP(OVER 100,000 BTU)
❑Yes _I No
AIR CONDI'I'IONEN ISSUANCE DACE
I have a,ad'M haode,Sections
2 5 5.15533 ualan under553 Chapter 695 of me Culi
building
Health&Safety C,ba Sections 25505.2s toy and 255)4.I unraddy h thus if as NEW RESIDENT MECH. SQ.17.
buildingduns est,which haveI nut prior
istoyof a Cendy iofnotifythepancyam
of du:requimmenu which must R met poor m issuance of a Cenifcme of(kcupancy.
Owner or authorized again
[)all TOTAL: ISSUE[)BY:
OFFICE