S 2593 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - .BUILDING-ELECT RICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 2593
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANI'PARYNO. APPLICATIONSUHMHTI'ALDATE
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PHONE:
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ARC]IIfiCT GINEER:
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CONTACT. PHONE: 6UII,DINC PERMIT INFO
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O /0 j—'fl?o ED Consultant Fees Paid by Applicant(Initial) (it DO'ELECF PLM
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11//1144
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE 40
I hereby affirm that I den licensed under powision.s or Chapter 9(commencing JOB DESCRIPTION
CZ,
With Section 7000pdDlvintan3 oche lousiness and Profo,samo Code,andtny nanse., <Z j ^ RESIDENTIAL
WOO PERMIT ISSUANCE J k-'
F W r toll Poreeandeffecl. � ❑MFOWL ITCHEN REMODEL
�U License Class Lic.4 APPLIANCES-RESIDENTIAL. ❑ADDITION [_3 PLUMBING RE-PIPH
Z Data
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ARCHITECPSDECI. ( I OMUUTLUNI'r [I STRUCTURAL
F O
coPANELS
ZOnz Iundersmndlnyplansyhullhnusdaspublicrernnh MODIFICATION
OX O UP'10200 AMPS F1 INTERIOR El CHIMNEY REPAIR
[ti�Iqq'W Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS El BATH REMODEL/REPAIR ElDEMOLITION
Q 1 hamby affirm Thal 1 am veenipl font the Contractor's License Law fee the
j(O at U rollown,reason.(Section 7031.5,Baine„and Pofosonst,Code:Any city oremnly SIGNS ELECTRICAL ❑OTHER
W 3 W y which requires a permit to construct.alter,impose,demolish,or repair any structure
prior Init,isuunee,o6orcquirestheapplannlforau.IipermittoI!Ice'ignel'Pitement SPHCIALCIRCUIT/MISC.
that he is ficersed parturat to[lie provisions of the Contractor s License Law(Chapter 9
aCa]a/d� (ecmme. M P.ing with Section 700(hol Diviorm3ofthc Bovine,,and Prol ..Ions Code)a '1 EMETER OR POLE INS'L COMMERCIAL:
G LRL o C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
k m W Section 703L5 by any applicnnl fora permit subjects the applicant In a civil penalty of POWER DEVICES
SW"w ❑'CENANT ❑FOOD SERVICE
not more than five hundred doll.,5500).
C Q ❑I,asownc,,fthe properly,nr an,amployce,with wages as lhcir,on,mr creation, SWIMMING POOL ELECTRIC IMPROVEMENT
A p., wdldomewmk,andthe stmewm'oiatinlendcdaran ..6l'orsale(Se,.7044.Rosiness O ❑OTI LER
W"'I m and Profession,Code:The Corm tar's License Law does not apply to an owner o OUTLETS-SWITCHES-FIXTURES Z
pmpcny whe build,or Imprnwe,Ihervon,uad who doe,snch work himself or though t
his own employees,provided that such improvements are not Intended or offered for NEW RESIDENTIAL FLECTR SQ I7.
Win.If.however,the holdingorlmpravcment is,old within one ycarofcomplction,the SQ.IT.FLOOR AREA S/SQ.EP.
owner builder will hove the barren of proving that he did nm build ornu ove for par-
poor of rola.),
1,as owner of the property,ran exclusively contracting with licensed contractors to LAI
instruct Ilse p jcet(See.7044,Retires and Professions Coac:)The Contract(,,',LI- -
rseLawdoesaotuppiymaa owner if property who builds or itnprovcstheremn,and QTY. PLUMBING PERMIT FEE
whocortmds for,uehprojects with oeo marou(s)I iwn,elpursumt tothe Cenhacter'c Ig
License Law. PERMIT ISSUANCE
❑ I an,exempt under Sec. ,R&P C for this reason
Owner Date ALTER-BRAIN&VENT-WATER fEA) VALUATION
WOR oge,,COMPENSATION,1.,one
DECLARATION BACK FLOW PROI'LCI'.DEVICE 2�
I hereby andwaffirm vain aCenuhyofp juryonenfthe il-ons re for arece loon
DID
❑.a...I have and will maintain ection 370nch 0 w,ha Consent Code.for the Worker',Coinpon- DRAINS-FLOOR,ROOK AREA,GOND' STORIES TYPE CONSTRUCHI)N
,shoo,as provider for ni Section 3]110 of the Labor Code,for the performance aRhe
E]I have
which end
sinis permit is issued, I§XTURES-PP.R TRAP
❑I hove end will maintain Wnrk.4 Campen,mien Insurance,m reyulred by Section
3700 of the Labor Codonfortheperrnnn nceopheworklivwhichthispermiiisis,ued. GAS-EA.SYSTEM-I INC.4OUTLETS to OCC.GROUP
J%
JjPNO�
MY Wode p t tion is once trrier Policy
Pohay n ppeJ �py q� (%
Carricn� PoliNFRO /!tib /tib�7 GAS-P.A.$YSTEM-OVER'4(EA) - �1
CERTIFICA'POP HX. PTIONFROMWORKERS' l Z
COMPENSA'1]ON INSURANCE GREASE/INDUSTRL WASTE IN rERCEPI'OR p R ^ '- F ILDINGTHVISR)
(This section reel nm beetmpletnd Hurt permit is forone hundred dollars(5100) - '--_11-----
,in live,) - GREASB'BAP 117 NCI IECKFEE
I ecru l'y l hal in brepefmmonec of the work for which Ion,ahpit is issued,Is hall SEWER-SANITARY-STORM EA.200 Fr.
nm employ any pent in any meaner ne ns m herr a,object 1.no Work...Cro per- RC � 83J
Zz ,.tion Laws of California.Date WATER HEATER WNENI'/ELECI'R
Applicant i 'I I)INGFEE
F-I rte. NOTICE TO APPLICANT:It,door making this Ceditiam nr Exmnpdon,you should WATER SYS'I EvITREATING .S PEP. -
become subject I.that Worker s Compenemi(,n provisions of the Iarm,Code,you must
LT1 rnnhwi(h cnntply with such pawkine,or this pernal Ball be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMy. SQ.Irl'. PAID
L) O I for
rte Nm therehsue (Seddon len ding agency far thopeHormanceef -AT--
Receipt
ti Iba work for which this permit i,Issued(Sec.31197,Civ.C)
l"oWC) (ti Lender's Address TOTAL Lender's ss - OT
1 canify That 1 have read this application and store that the above information in _ BIIII P.F.
0.-i l�/J uttact.1 agree m emnply with all city and.limy nNinnncoe and see laws relating m QTY, MECHANICAL PERMIT F,EE
V Z. building construction,and hereby andmorire repvorearlves oldies city to enter noun the SHL
nho....caramel propony for inspection Purnn,es. PERMIT ISSUANCE
(We)agree to nave,indemnify and keep limitless the City ur Criterion options BLFG PEE
liabditics.judgmenu,lints and esper.e,'Incnnay in any way accmeagximla.id City ALTER OR ADD'I'O MF.CH, t
In consequence of Mooing of this permit. PLUM NO FEE
APPLICAN'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNH(TO 10,000 CFM)
SOURC. ill,ItL/A,F )NS. / MECHA CAL FGB
AIR HANDLING UNIT(OVER I11,001CFMI CONSTRUAtIONTAX
Signvlure nfAPPlicn (,Vora / 1 to EXHAUST HOOD(W/DUCT) HOUSINGMITIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Willthe opplictinlnr future building oceupam sM'e or handle mornieu,material HEATING UNIT(1010f1,000 BTU)
as defined by the Cupertino Municipal Gide,Chapter 9.12,and the health and Safety
Code Section^_5532(x)'! - / HEATING UNIT(OVER 100,1911 B'PU)
Ye, JB O
'` VENTILATION FAN(SINGLE RESID) PAID Dns Receipl4'
Will the applicant or furore building occupant me equipment or device,which y0ILH12-COMP DIE OR IfN),IHHI BTU)
,mil bomNous air mai minum,as defined by the Be,Area Air Quality M;magetnenl OF
Di,Incl'!
ElYe ROILP.R-COME(OVER I(111,(N111 RTU)
AIR CONDITIONER
I have readthe l -W at ids avalumareark istater Chapter 6,95 or the Cali- ISSUANCE DATE
knome Health&Sultry Cod,,S t 55115 25533 ad 25534.1 under,tandqui ifthr, NEW RESIDENTIAL MECH. SQ.ler.
bulrgl h t hit it y , -Allyl Ffyti Punt
(,fdan"o n. oro'ummae of a Can'hc.teo eco y.
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Owulhnn a cel I D 'I'Ol'AL: ISSUED BY: r
OFFICE