S 1356 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F:LRCI'NIC.\I. PEIT NO.
BUII,DING IIIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1356
BUILDING,PROJECT IDEN-F1F'ICA'OON
BUILDING ADIlRliS$: O SANHARYNO. APPLICATION SUBMITTAL DA'I
e
OWNER'S NAME. 1 P CO RACFOR'S LIC NO:
NIC CONTROL#
'
ARC]IIT FC'VENGINEEK. LIC NO: ' AILD SS' ❑
e
CON PACT PHONE: RD H.QWG PERMIT INFO
7 /� Consultant Fccs Paid by Applicant(Initial) ,LUG ELECT PLUMB MECH
SQ 7 '7 ❑ ❑ ❑
LICENSED CONIRACfO DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm mal I am Ecem,al sad pmvisiodx of chapter 9(comme.cing JOB DESCRIPTION
Oat win Section 7000)ofDiviaon3ofthc Busincsh anA Prolessinn,CMc,andaryliecnsc is RESIDENTIAI:
410# I'F.RM1'I'ISSUANCE
F u:•
in force and etl°rf'/ '7 ej ❑SFDWI. El KITCHEN RISMOUEI.
aUU License CL ss LLYl3_L Lic.p APPLIANCES-RESIDENTIAL El ADDITION ❑PLEMBING RE-PIPE
NQ a Dotc CnnII'dclnr
Fly ARCI IfVECT'S DECLARATIO PANELS ❑MUITI UNIT ❑STRIICTU AL
z Oy ZV. I undcr,mnJary phmsmall beavel spohlie recnrJs M PION
Qz-q UP'T02WAMPS ❑INTERIOR CHIMNIiYRIiPAIR-
F�FW Lic.n"dl'nmlcssinnal 201-100DAMPS IMPROVEMENT El, 1IMMINGPOOLS
AYE; OWNER-BUIIDISR DECLARATION OVER IIgq AMPS [I BATH REAfODEIIRIiPA1R �Df?M01,1'fION
yy a a Q I hereby affirm that I am exempt form the Crntre.r',License Law for fc
%3 G u following rcesan.Necuaa 70315,H.siea.c,and Pmfcoio.,Code:Any city of county SIGNS ELECTRICAL ❑0711ER
WU.h which minifies a permit to concoct after,improve,dmnolish.or repair any structure
f'�O5 prixtits issuance.also requires PPI' II chi It flsignedstatement SPE,CIALCIRCUIT/MISC.
ji hal her,licensed p..0 It lir p o ft ContraI L (Chupwr9
W aOC (commencing with Sinton 711811)of Division 3 (the Bu%ine%s dprf ms Core)or HEMP.METER OR POL NST. COMMERCIAL:
a a c a Phut he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [IDEMOLITION
af y Seaman 70315 by any applicant fora permit ada,,o the nppiirma to n civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE.
am more than live hundred dollar,($50B.
F Z Y IMPROVEh1EN'f
�Q ❑ L.rowner ol the pro pea%or is not intende wifwngus.sale( ere cost[it tion. SwLMMLNC I' LELF.C'1'RIC
�p..� will Jo the work,and Ocstructure is not intended on,RereAfoesalc lSccJMY.liuhincss ❑OTHER �y
4x13
to and pourc%sion%Calc:The Contractor's License Low does not apply to a xner of OUT] -SWI'TCI{FS_FIX'I'U .Ir
property wba builds o m,o u therein,and who dors such work hiet,el no it
his own employees,provided that such iinpmvemcnm am not intended or oR.md for NE) ESIDENTIAL ELELTR 'Q FI'.
safe.If.however.the building or improvenam is sold within one year ofcompletion.the SQ,A�I�FIR�ME1 b/SQ FF.
owner huddler will lune he havica of proving that he did art hand or impnrvc for par- r�RR ere Affil
ptoe ur sail,).
I,its owner of the prapeny,am exclusively contracting with Iicenwal contractors to T[
consumer the project(Sae.7DUL Bmine„trod Prfasionx CodeO•Dine contractor,l,6 I CITY Uf VUmn I II\ )
nm Ww doe,a.,apply ,,an.wnerof property who builds.,improve,thereon,and QTY. PLUMBING PERMIT
who acaha-vmh ptojet wit a confmtlo(s)l acirved par.aattn the Canfmcmh
License Law. PERMIT ISSUANCE
I ata exeap,under Sec ,B&P C for this reason
Owner DateALTER-DRAIN&VENT-WATER IEA) / �JALllg40 ,
�///Cq l�J\
WORK ER:S COMPBO
NSAON DECLARATION BACK FLOW PROPECT.DEVICE �
Ih M1y ff 1 have i Try eo raj ry fth moll gJ F fmh
(] JI - t C Ce rt1 t fC at)%eir-mrstare f W ke .Campers- DRAINS FT(K)R,ROOT,AREA.GOND. S kIES T UCI'I(
,raio,a,provided nix by S 37000Th I'h Carl,li th p,! ace nl the /
M Ih K hlh.M1 I : J 19X'1QR1.B-I'ER'fRAP
1 have.Lind willod,for he pe or Compensators work
hi h this extuire
by Section
My%Oahc,Conla,Cale.fon I...move cancer and olio lbr which this lnnnit is issued. GAS-EA.SYS TEM-1 INC.40UTLE"
(K:C GROUP ANN
MyW sf-s. pcn1, Insurance carrier and Policy un :
Carrier. -fliar -Policy Nu.: � V0,50-7 GAS-EA.SYSTEM-OVER 4D'
CiRTFICAOPEXEMPTION WORKERS
�_3
COMPENSATION INSURANCE
GREAS[%INDUSTRL WAST NTERCffTOR
(flak seclion mrd not heaa. IctW if the foroachundncJJnllam(SIWI BUILDING DIVISION FENS
p pcn.wm GREASETRAP PLANCIIECK FEE
or less)
Icenlfy lhatin manyfnnran, ,,,toba' memichthispermit isismed.lhallfor, SEWER-SANITA -STORM EA.21X1 FI'.
nm employ tory#,conn many tnanncrw ns m hemmesobjcet to time WmkcM Comrya- ENERGY FEIi
0z sation Laws of California.DamWAlldk MEATIWN1:T /ELI!CI'R
z O Applicant -N
M NOTICE TO APPLICANT t If.eftennaking his Cenifcamof Ewrr,lion.You.should WATIik SV TliNVfREATING
a > become subject to the Workses Compensation provisions of the La1wr Code,you must SOILS 197E
Omhwith ean.ply wit such prvisiomor ti,permit shall be deemudrevoked WATRVICE
z CONST RUCTION LENDING AGENCY NIi RESIDENTIALPI,MB. SQ FII PAID
V0 I hearbyalliim fa,lam,ka r„ttaru m lending agency(..tire pertormance al to Receipt Of
[I. P the work far which this permit is iswedSer.3097,CivC.)
0V lender's Name 'TOTAI;
Under,Address TO'YAL
Fr" Q I crony that 1 have read this application and state that the alone information is BUILDING FHE
7h conevu,Iai I...on.ply withall city and county radio.....and-stetelawsrclutingm QTY. MECHANICAL PERMIT FEE) Z building construction.and hereby notion,representatives ofias city to cmeraboade S17ISMIC FEE
uMrve-mentioned property far inspection purposes.
I Wcl agmema:rve.indemnity trod keep ltumdess the City nl Cupenlno against PERMIT'ISSUANCE ELFCI'RIC FTSE
Iiabilitics,judgment,costs and expersev which may in any way acct,again,.vad City ALTER OR ADDI G MECH.
in asequence of the granting of this permit. PLUMBING FEE
APPL'T UNOERSTAMJS AND WILL COMPLY WITH At.].NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE IiGILATIONS. MECHANICALFEE
AIR HANDLING UNIT(OVER Ill—WIND CON.STRIIC'1'ION'I'AX
Signature ofApplicam/Cmrb. ter Date EXHAUST HOOD(W/UUU1) HOUSING MI'fIGAT10N FEE 0US MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING IINIT(TO 1 10.011U)
it,defined by the Cupertino Municipal Cale.Chapter 9.12.and the Health and Safety
Cade,Section2553200^ HEA'L'ING UN Tf(OV E W.000 IITU) its
0Yc, ONO,
t VENTILA'1'[ON 111/SINGLE RMID) PAID
e Will thea applicant or furore building - Date Rmeia a
pp gby the B use equipment a or Marro which BOILER-CO OHP OR 100.800 BTU)
mit hvadnus air contaminants as defined by the Bay Arca Air Quality Mawgcment TOTAL:
DislnCl^
0Vo, []No ROILEN- OMPfOVEItIW,INNI R'I'U)
I hav,"ad'he ltu.....i rnuacrial,mynlmntuam under Chapter 6.95.1'the Cali- AIR/ NDITIONER ISSUANCE DATE
forma Health Or Safety Code.Sections 25505.25533 and 25534.I undemtand that if the N RIiSID1iN1'IAh MECN. $Q.FT.
hullding Joe,not currently have a tenant,that it is my responsibility to hourly are rreupant
of the rmptifumems which must M:and prior e.insnunw n!a Ccaificmc.f(lmupuncy.
Uw.eooramhnri rd agent Dame 'TOTAL: ISSUED BY:
OFFICE