S 2375 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OI'CUPERTINO BUILDING.RLF,C'I'RICAL PERMIl NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2375
//.V4A� BUILDING PROJECT IDEMI'IFICA'1'ION
BUIIDINGADERESS, SANITARYNO. APPIACA'I'ION SUBMITTAL DAI'1
590 a � li�
OWNE SIN " x QJ 7PHONE CONT' OI'(SN . .N
//��`'�yQQ87
/ NIC CONTROLp
ARCHITE '/ENGINEER: LIC NO'. 5 . ❑
CONTACT: PHONE: - '{' HUILUINC PERMIT'INFO'
❑ Consultant Face,Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�,f ❑ ❑ ❑
LICENSED CONI'RACFORSDLCIORATION QTY - GLECfRIC PERMIT FLIT
I h L y n r, that 1 r' d 1 I i rh'tpnr 9(a..............g t - ,• JOB DESCRIPTION
LaoZ inlet 5 t' 91x10) ID tof thv llus .,andlr Ic-si sC,Jquul mYl cin se is
u ,g PLRMH ISSUANCE RESIUF,NTIAL:
F�.. .n roll force nnJ elle lx�"� ,e �`� `� ❑SFDWL ❑KITCHEN REMODEL
�UU L:ccnm!gY �./ Lee4 APPLIANCES-RESIDENTIAL ❑ADU177(IN ❑PLUMBING RI7.11IPE
v Zuj Date ./� 7� Commetar
ARCHITECTS Minot ❑M111T1-UNIT El STRUCTURAL
p,.D to PANELS
z O v Z I o n l,nmmd my plumc.chull br used ov public records MODIFICATION
02=0— UPT0200AMPS El INTERIOR ❑Cl IIMNEY REPAIR
ra01 ut Licensed Profcssima'l 201-IIxIBAMFS IMPROVIDENT E]SWIMMINGPOOLS
9'u •,A OWNER-BUILDER DECLARATION OVIiH IIxx)Ahf PS ❑BAFII RHMODEIARITA1R ❑UIiM01.1'1'ION
4' 6 I hereby ammt thin 1 am exemm
pt form the Cnraem's License Law far the
W 3W U frllnwing ndeant.(Section 71111.5,liusimesx and ProreW.re,Code;Any city or county SIGNS HhP.CI'I<ICN, COTTER
0 NQ which rcgnire.,.penult m c.n,rmeL Ater,improve,demolish,or repair any>Irnedure '
OJ priortoiB issuance.also rd ices theapplicaut fat3ucn fail to,Men signed ata¢ment SPECIAL CIRCUIT/MISC.
bathe is Metaledpon,an„nn the pnnl.iomrfthe Cunuuaar's License Law(Chapter 9
apo (annmeesong with Sectinn 70(Xbol D,vision Sof the Resines,and Professions Coca)or 'I'EM It MET HN OR POLI:INS'L COMMERCIAL'
d e c that he is exempt therefrom and the basis for the alleged exemption,Any vinWtian of ❑NRW BLDG/ADDITION ❑DEMOLI'1'(ON
Salina 90315 byany applicant fare permit ynbjet(rthe opplicunp
tn,aeivil multyof POWER DEVICES
tot ' 7ENANT ❑FOOD SERVICE
oat morerade lift hundred dollars y chi).
IMI'ROVI:A1EN1'
QI]I,as,nvncndthe pmpeny,onnycmploycrswiW wages astheir uJt rompcncaion, SWIMMING I'OOLIiLECfRIC
O will Jo the work and tau stmauvc is art imtndtd or n0'urcd frrsWe(Sa.7f)14,Iktxincvs ❑O"fI IP:R
W ac and profession,Cotte:The Crntmctnr',License Law doses nut apply m an t was of , (IU'f1.ISf5-SWI'TCIIHS 'TURES
13—
pmputy who builds nr impmvm thou and why n,are do wad mal u,A1 through
his awn navac the anviokdding that snchaimpnwcoldw thin nal Iyear(if m nl tion.fur NEW RESIDHNTIAI ?L :R SQ PC.
sale.If.however.the building rrimpmvemem is sold within one year of completion.the SQ.I�I'.FL(kA ARE $ISQ.HI�
er-bsdlJcr will have the burden of proving that he did nm build or improve for put. JUL - 11999
❑h as owner of the properly,oro esclusively contracting with licensed contracmrs w 'IY)I'AL.
,nrtmat the project(Sec.9144,Business and Przdrolics C,.[cO The Cartmmars Li-
,e1.awchic, npply I,,nnoweerrf pro,rtywI hdIdx,rinynoves rbma•on,amt QTYJ. r�PLl1M IIN4111712101'1', .F.Ef.
who contracts for such projees with a rantwmr(c)licensed purwaa0r the Conitci
License Law, PERMIT'ISSUANCE
❑ Itmeacreptundrr Sec ,II&1'Clafthlxreasmt
' Diane, Dute A Ek-DRAIN&VENT-WATER(1?A) VALUATION
• WORKIiIi'S COMPENSATION DECI.ARA'I'ION BAC NLOW I'ROI'I:C'K DEVICE
1 hereby affirm under penalty of perjury one of the 4dhrwmg declarations M x(/V
I hevu and will namtaima Certificate of Consent o self-Imaru for Worker's Camper- DRAINS- .OOR.ROOF,AREA,COND. STI
I OR] '1'YPH CONSTRUCON
satins,as provided In by Section 3700 of We Lrhnr Code,lin da perfnrade ec of IM
rk for which this permit is issued. FIXTURES-1'17 TRAP
I hnvr and will maintain Worker's Compensation Insurance,ns reymired by Sectinn
39xlofthe I.id, ,We,ialhe no reticent he work fnrwhlch dth pemtit 6iscued, GAS-HA.SYSTE INC.4 O'IIjUS OCC.GROUP APN
My works n Cenr �n a d Pnlic'nu
Crvidr:
day
No.. `r�"k�xx S-EA.SYSTEM-0 4LEA)
CERI'IF tl'a OF E%EMP1 10N FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSERI.WAST NPERCEPTOH
BUILDING DIVISION FEGS
('Thix,ationn boot lx conq,lcmd il'lhcptmtit lx for unu hundred dnllnry(51(1111 GREASETRA P-
or less.) 1'LANCHECK PEE
I crnifythw in the purlbrmnweefthe work far which this pemtir it issued,ICInal SEW17R-SANITARY-STORM EA.- )III'.
mploy any per any............as m beam: .mbjat m the Wndurs'Cwupai ENERGY ITH
nett nun in '� c
,Z cannot laws of C:Jifnmia.Date WA I'17 HEATER W/VENT/19.FCR
Applicant GRADING FEE
ICE 9Y)APPLICAN'1:11,alter makmgthis Cenifitareof H odo,tio 1,you xhardJ WATI!R SYS'I'f?M/I'IiBA'11N0
F b afunb subject to the Workers Compensation pms sions of the Labor Code,you must SOHS PER
Isla r>-t InnM1witn comply with such provisions or this permit sM1all be JcemeA revoked. WATER SERVICE
aQ
CONSTRUCTION LENDING A NEW H[SIDIiN1'IAh FEAR. SO FT PAID
� z Inerrny arrrrn Wm there iane,nxwaban lending
montg ngdm.r rah e lomat.,,
s„ nr _ Daeipt
ate Hx
mCry. -
U O e wok for whist this perch is issued(Sr,3097, .C.)
0 F' Lenders Nate TOTAL:
V Lerdar'x AJdresa - 'DEAL:
F0. 1 eerily War 1 have read this application and state thin the above infor ntiion is i / a, BUILDING PEI!
pp correct.l agree to comply with all city and county ordinance,and state laws relating too QTY. MIiCHANICAI,PERMIT, Nlili
V Z nmiminge,nsmtmiun,and hereby authorize rcpresemntivc nllhis city mentis.,no the SEISMIC PER
uMrvo-montl,ned property fir inspection purposes. PFRMI'I'ISSIIANCIi
(We)agree m save,molland king,M1amJcas the City of Cupertino agairot GLI?GIRIG IFC
inhilities.judgmeds,c...1,and,speasex which may inuny way accoeagaimt said City ALA ROR ADD TO MSCI 1.
is,,,.,mance of the gcauting of this pdrea 1. PLUMBING p17E
APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO 111,1X%1 CFM)
SOURCE GU IS. MECI IANICAL FEE
ARI{ANDLING UNI'1'(OVBR IOIxq CFM) a
CONSTRUCTION TA%
Signaarv,d A,EV,m/C.d...... , Doc EXIIAUSTII000(W/UUC'I7 HOIISINGMMIGNIHONFEE
HAZARDOUS MATERIALS DISCLOSURE n
Willthe applicamar famed bmiliing,acupantsrreorhendle h:vardaun material HEATING ONI'f(TO 100,000 BTU)
ns defined by the Cupertino Municipal Cod..Chapter 9,12,and the hector and Safety
C,Ju,Section 25532(a)? HEATING UNIT(OVER 100.000 BTU)
C3 Yes E)No,
VHN'I'ILATION PAN(SING I.Ii RES IU) PAID
Dam I<ceciptp
Will the appldrum in future building occupant y A co Air Qu nr devices which
it hnzorclnus air cnmumintna ax JcBueJ by the tiny Arco Air Quality Mumrgcmen BOILER-COMP(31{P OR IW.IXIII RTU) 1'O"IAL.
District'
❑Yes (-1 Not BOILER-COMP(OVIIR 100,100,0001111J) g/
Ihere rent the hamnlec,mammals reyuimnans under Chaparfi95,t the Cali- AIR CONDI'I'IONEIt •T ISSUANCE IJATE
fomin I car &Safe Code.Saurus 25505,25533 rad 25.5.4.I international if the NEW RESIDENTIAL MECH. SQ,PT.
nrWdi se - rnrn lyltuftnm rt,maru iamvpamxn,ifnym.adrr and Inmt
of th�nems so W mud 't prion,issuance of a Ccnificx�,I J1Ccup��/ljl y��
Own out ze, ,�rea 'TOTAL: x 19SUlil '�/I/-r/
OFFICE