00010163 (2) APPLICARTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 00 /O 63
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT'NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S
BUILDING PROJECT IIIEN'1'IVICATION
BUILDING ADDRISB _ / SANITARY NO. APPLICARONSUBMITTAL T)—An
l 98 (S ,Sled V///(�/ryW/ Z-
NERSNA F,: PHONE: TRAC OR' N Mii: LIC NO:
\/1 Ini - -W5 8 NIC CONTROL
1RCHITECOENGIN6ER: LIC NO: lRNx AR1x)-q ❑
CONTACT: PHONE: BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
MUCH
ID ElL_ ❑
LICENSED COW]RACTOR:S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby m rio'hart 1 ant liaised under provisions ofchapter 9(cormar ung JOB DESCRIPTION
WoZ IhScclinn]INNgof Division3nf the Nueinnsand droll,cion Code,. mylleenw:ix RESIDENTIAL:
WOO wt PERMIT ISSUANCE
FW. full foac and ellen. _ a � ❑SFDWL [I KITCHEN REMODEL
a F- n
QUV LrecnuC • —Lica gppLlANCliS-RESIDENTI []ADDITION El PLUMBING RE-PIPE
F Q,U Date Comraclnr
❑a, ARCHITEUI';S DECLARA'DON PANELS El MULTI-UNIT ❑STRUCTURAL
Z FO h� I understand my plans shall he axed as public records MODIFICATION
OZ�-� UP1O200AMPS ❑INTERIOR El CHIMNEY REPAIR
F s?F'W Licensed professional 201-IOOOAFIPS IMPROVEMENT SWIMMING POOLS
x C y' 1 hereby off rat that um lu'n rER firm
he Canna DECLARATION
Licensee Law for the OVER IOW AMT'S ❑BATH REMOUEI/REPAIR DEMOLITION
Y d O following reason.(Section 9I13L5,Huxinecx and Pnoic,sions Code:Any city or enumY SIGNS BLF,C'IRICAL ❑OTHER
WIII
O` which reclines a permit to mmswcn.,doer,imprwc,derni repair any,m¢ture
U.
prim hs its issuancqulw mquires Ne,pplicant fmsuch permit t.file.signed statement SPECIAL CIRCULDMISC.
E }�
that he is licensed pursuant to he provisions ofthe Contractors License Law(Chapter 9
y ppp0 (commencing with Section7000)nf OMlsinm 3ufhe Business and Prof cion,Cmc)or TEMP.METER OR POLE INST. COMMERCIAL:
i yto,c
o p� hat he is u-nm Ill,mirmn and he basis for he alleged exunptinn.Any vlobninn of ❑NEW BI,DGIADDITION ElDEMourrION
W..y
Section 7031.5 byamyapplictim for.permad,u cert,theirpr cant ivil pcnalnyof POWER DEVICES 0TENANT ❑FOOD SERVICE
not more than five hundred dollars IS5 W). IMPROVEMENT
R=C ❑ SWIMMING POOL ELECTRIC
_ will do the work,and theawrc cwis net imendednrnllered fo...le(Sec.Y044Barinus ❑OTHER
�ti13m and Professions Calk.'1 he Contractors License].no does not apply no an owner nr OUTLETS-SWITCHF.. FIXTURES
LL property who builds rn improves thereon,and who docs such work himself or hrough
his own anployms,provided that such improvements art not intended or offered for NEW RESIDAINTIAL !CIR
sale.If.however,the building or improvement is sold within one year.f completion,the SQ.FI'.FLOOR AREA SISQ.FT.
ter-Wilder will have the burden of proving that he did not build or improve for Fur-
pnce
1,a,owner of he Prupeny,am inclusively Ondlecting with licensed orameturs m TAL
construct the project(Sec.](W.Business and Professions Codec)The Common's Li-
cense law docs nm apply to an owner of pmpeny who builds or improves hereon,and QTY PLUMBING P MIT FF,E
who contracts for such pmjec¢with a nhlamons)licensed pursuam to the Contractor's
License Law, PERMIT ISSUANCE.
E]I antumpt auditSec .B k I'C for this mason
ALTER-DRAIN k VENT-WATER(1!A) VALUATION
Owner Doe
WOR KER:SCOMPI!NSATION DECLARATION BACK Fl.ON'PROTECT.DEVICE 500
(hand Waffrmnude,doa pirCmJtcalcul jurymWol calnnme fommio,Workrut Cu
❑Ihave otdwillforby nection3catcof the Labor
trCod.f or the Worker'sceoflin- Il1tA1N5-PLOOR,ROOP.ANBA,CONU. STORIES TYPI!C(1N5'I'RUG'I'1(JN
-tion,,s pmvidhi for by Sermon 7]l10.f the Latin CuJc,for the Performance nl the
Iyf'which this maintain
porker Il%TUR6S-PER TRAP
QYI hove and will maintain he pedur Compensation h eW orlon,,as required by Section
3]Wuf the LnMn Cole,lin the penismmnce of he work for which obis permit rsis,ucJ. GAS-EA.SYSTEM-1 INCA OUTLETS OCC GROUP APN
My Workyyrtrt�� n summa aria unA Pairyn
Crme':y Policy No.:�r'+�(1f - GAS-EA,SYSTEM-OVER 40A)
CERTIFICATE OP CXEMPTION FROM WORK17RSI GREASEANDUSTR,WASTE INITiRCEPI OR ` VJ
COMP12NSAI'[ON INSURANCE BUILDING DIVISION FEt3
D'hix section need not be completed o ffie permit is roma,hundred dollars($IUB) GREASE TRAP
or Tassel YLANCHECK PEE
I cenify that in the performance ofthe work l orwhich lhispeonit is issued,l shall SEWER-SANITARY-Sr FORM EA.200 Fr.
not employ any person in any manner.at as or become,ubject at the W..km Co.,.-- ENERGY ITT!
,Z ration laws of California.Doe WATER HEDUIR W/VENDE-LECTR
ZApplicant GRADING FEE
y NOI'IC1!'TO APPLICANT:If,aper making his Certilicam of anno,rnn,you should WATER SYS'I EMG RF,ATING
live se subjcm to the Worker,Cour"i'mion provisions of the Labnt Code,you mual SOILS FEE
D-1 ronhwith comply with such pmvismnx or this penin shall be deemed revoked. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID
U0 thereby affimtllummem is.construction lending agency forme perforrimmor Date Rcmipta
LL F he Wok❑t which mix puri I is issued(Sec 3097.Civ.G)
Lender's Name TOTAL:
Lenders Address TOTAL:
G I cenify that 1 have mad this application and.ante that the above information is BUILDING IRE
concur l agree or comply withal cityand catim ondn,nees and slate law,reining to QTY. MECHANICAL PERMIT FEE
U Z hbddingcmuwrdun.and hereby nnm(Mir.e mpre,entatives ufthisduy or enternp,n the SEISMIC FEE
above-nuennioned property for inspection purposes. PERMIT ISSUANCE
(We)agree of eve.indemnify and keep fannies,me City of Cupertino again.,, ELECTRIC FEE
Iiabilitics,judgmenns.costs and eapenms which may in any way aecme against said City AIERORADDTOMECH.
PLUMBING PGE
in consequence M the granting of his
APPLICANAUNDfRNDS AND WERL
L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,IN0 CFM)
SOURC MECHANICAL ITE
-d71 AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
reo
SigwmW211 mractor Date VV FiXHAUST HOOD(W/DUC) HOUSING MITIGATION FEF;
I AZARII(IIJS MATERIALS DISCLOSURE
Willtheapplieant nr future building occupant smreor handle ha.Nousnmterial HEATING.LINE'1'(10 Ig1.hN1 BTU)
as defined by the Cupenino Municipal Cale,Chapter 9.12,and the Healh and Safety
Code,Section 255320)'! HEATING UNIT(OVF,R TELL BTU)
❑Yes VENTPAID -
1� ILATION FAN(SINGLE ftES1O)
Will he a licant or future boldin n use equipment or devices which Orate Receipt a
pp dby he
.Air n BOILER-COMP(3HP OR IINLUW UTU) ./
.it hamNous air c.maminams as Jclincd by the Bay Area Air Quality Management TOTAL:
District! BOILER-COMP(OVER FEB."BTU)
❑Yes
I haveral the huraudons nntteriuls re is under Chu¢.b 95 of'he Cmi- AIR CONIII'1'IUNER ISSUANCE DATE
yumenten p
forma Health&S ry Cale.Sections 25505.25533 mrd 25534 1 understand thin if the NEW RFSIDF.N'I'IAL MECII, SQ.FT. D
buildingdrc an tlyhaveamwm,than it i,my respnability to notify the occupant - �'-- Za
ofthe«quir whim must bcmet prion.i....ms,of a Crnificam,pp��ac� y.
/\ G7—/ w
Omncnnam r n Dire ICTAL: ISSUED BY: 9
OFFICE