00010126 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY [JOU U If 1L(49
CITY OF CUPERTINO � - BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION[PERMIT PLUMBING-MECHANICAL SOoo�
RUIIJ)ING PROJEC I IDl.N dF'ICsM ION
SANHARYNO. APPLICAHONSUBMIi'ITL DAi
BUILDING ADDRI?SS:
/057'f CA-,
OWNER'S NAME: PHONE: C' 1"RACfOR'S NAME: LIC NO:
Itis -57 `^ ' ` �a/�1 Q IUNIC CONTROLp
�
CHI'1'FUPUNGINEIiR: LIC NO: ADDRESS'. V,-�./ fl fllh¢� �Jl��'`� ❑
CONTACT PHONIi: I3lJILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant QDllial) BLIIG ELECT PLUMB MFCll
rot. as3-ob�� ❑ ❑ �— ❑
LICENSED CON']RACE ORS UI!CLARATION QTY ELECTRIC PERMIT FEE
I thereby aHbm that I ant licensed under prowi.simrs of chapter o mmnme,heing JOB DESCRIPTION
MW=Z with Section 9(Xq)at'Dmond 3ol'the Business ad Prommi...Cala and my liceme is RESIDENTIAL'
WOO PERMIT ISSUANCE
in full fore,vnJ effect. � ❑SlllWl, ❑KITCHEN RIiMODEI.
QUV License Class Lic.n pPPLIANCGS-RESIDEN"I'1AL ❑ADDITION BYtNMl31NG RI:-PIPE
I Zyl Date Cotnraclar
N6L
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
F o,Z I u odernnmd my plan,,hall be used no public.,adx MODIPICAI'IUN
OZ-� UPT02r0AMP5 ❑INTI?ItIOR ❑Cf11MNIiY REPAIR
H.CLL: Licen.xeJ Professional 201-10(X1 AMT'S IMI'ROVIiM F.NT SWIMMING POLLS
Y OWN]?R.BUILDER DECLARATION OVEB Hadd AMPS ❑BATH RILMOUFL,REPAIR DEMOLITION
C Q 1 hereby aRm+that 1 am exempt Curacao,Contractor's Liennu Law for the
xD5� E U fallowing reason.(Section 9031.5,Business and Professions Code:Any city or county SIGNS IiLFCI'RICAL ❑OTHER
Ia13 W f" which require,u permit In c.nsim,r,ahcr.Improve,demolish,a repair any structure
E-'LLC� prion t ': I. y ' rapplicationI Ips tt Ed signed,tvtcnen SPECIAL CIRCUIT/M1SC,
fly
bar too I Ip alt In p rtl Contractors L I' (Chapter9 COMMERCIAL'
W E00 (commencing with Section 70(a))of Division S of the Business and Profess Ca1e)or TEMP MITI HR OR POLE IN:y'.
d a c 5 that he is exempt therefrom and the Luis for the alleged exemption.Any violation of ❑NEN'BLDG/ADDITION ❑UEMOLI'T'1(lN
-,� Section 2031.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER AM",
❑TENANT ❑FOOD SERVICI!
or mare thim Ove hundred dnllan(551101 IMPROVIiMI?NT
~ C E]I,mowncral'thc pmperly,nnny chnpinycev with ingots a,their-le compensation, SWIMMING POOL ELECTRIC
ywill dn,M1e work,nnJ,M1usimcmrc i.ani imcnJW nndlkrcd far s�la(Sa.9(Uq.Business ❑DTIII?R
3 m and Professions Calc:The Comrnaro ,License Law docs not apply to an owner oC OUI'LI:TS-SWITCHCS-h1X'1'URES
pmpedy.)on build,ur impmve,thereon,and who dues such work himmif ur through
his nuv employees.pmvidd that such impeovemems arc wt intended art offered for NEW RISIDHN`IAL ELECIR SQ IT'.
side.If.however.the building or improvement is sold within one year ofenmpletion.the SQ.Eq.FLOOR ARBA SItiQ.FT.
owner milder will have the burden of proving that he did not build or improve for our-
pow of sole.). I DIAL
❑ 1,as owner of the propcny,um exclusively Contracting with licensed convnnar,m
construct the pn+jcet(Sm.9014,Business and Prafcxsions Code:)Unit Cantan
nor',LI-
ccm Law does not apply to an owner of properly who builds or in+pmves daemon,and QTY, PLUMBING PERMIT FEE
who Connote¢for such prejecls with a commctons)licensed pursuant to the Contractor's
License law. PERMIT ISSUANCE
Fl I at exenhPt under Sec. B&P C far'his rcanon
AI,TIR-DRAIN&VENT-WA'f17R(EA) VALUATION
Owner Dale
WORKERS COMPENSATION DECLARATION BACK PLOW PROTECT'.DIWICE
I hereby affirm under penalty of perjury,one of the following declinations:
I have and will maintain a Campeau,of Consent tosclf-insou far Workcr'x Comped- DRAINS-FLOOR.ROOF.AREA.GOND, STORIES TYPE CONSI RUCTIO
s tion.as Provided for by Section 3900 of the IaMn Code,for the performance of the
-i
lot who'his pelma i,issued, FIXTURES-PER TRAP
,ave and will mnintnin Wnrkcr'x Cninpciuuliun Insurance,Ea h m0+ir,a by Semon
3700 of the lrMn Code.far the perincomem of the work for thispermit is issue). GAS-IiA.SYSTEM-I INC.40IJTLETS f)CC.GROUT' AO�
My Wnrkkyy Cnmppcc syp carter end l'nlicy nunilt
Cmdrw,0 bf J1L„�nl e.wae\ Policy Nn.:IJ 11nf�i542S8 GAS-EA.SYSTEM-OVERJIEA)
COMPENS119
ATION
FROM WORKERS' GREASIIINDUSTRL WASTE I JTHRCEITOR
COMPENSATION INSURANCE BUILDING DIV ISIDN PEES
CI'hl,xme,ion need.,or lx+corepleted i Dha permit L for ane hundred dulls.($1W) GRP.AS13'rNAY
rtes ) PLANCHFCK ITiIi
leerily that uOhe,iLeaancenflhor
e wk on.hich mr,N,ni,is issued,tonal SW Ff.EWER-SANITARY-STORM EA.2
nemploy any pecan in any maer nnso ass to become%objecnn the Workers'Camped- GNIRGY ITE
o
ot
Z lt..Lawn of California.Dam WATER HEATER WNESUIULLC R GRADING ITE
zO Applicam +
Vl NOTICE TD APPLICANT.1[Caen making this Cc....to,of the
Exemption,you should WATER SYS'PIiMlfRLA'1'ING
a 5 hecls,a Com,uhthe Worker'Cnmm,muni, pnmit hal of the Lam a Code,you mux( SOILS PEIi
fodhwith ttnnPlywilh such pn+vixiunsonhispermit hall be deemed evoked. ,ERVICIi
OPAID
CONSTRUCTION LENDING AGENCY NEW RE,SIDHNITTAL PLMB. SQ.IT. Date Receipt#
V0 I hereby atfinn that hen is a construction lending agency for the performance of
L4 F the work far which this,Iro mit is issued(Sec.3199,Cie.C.) ^ �� fTOTAI-
OU LnWcr',Name 'TO'TAL: i e ' I
Lender's AAAex, B ILDING hUEr-Z] u n
1 1 eerily that 1 have mad this application and state that the above information n
Flip catect.I agree n+comply with all city and county ordinance,and nate law,relating to QTY. MECHANICALPERMIT FEE S ISn11CPis
C,)Z building can,vawi.n.and hereby aelhonrereprc,emmives of Nis city to enter upon the
above-mpropertyinncdproperty for inspection purPhxcs. PERMIT ISSUANCE �tCfR J::
(We)agree hose,indemnify and keep harmless the City of Cupertino against
liam itlm,i rueno,cosuaad expense,which.hay in any way accme against said City ACR7R OR ADI(TO MI?CI I, I ' MII1NG Hili
in onsequenecof the gaming of t ' Parini(.
APPLICANT'UNDERSTANDS U WILL COMPLY WITH ALT.NON-POINT' AIRHANDLINGUNIT('1010.000CFM) � TjANICAL FEE
OURCE RLGUI O .
/_127-0d, AIR HANDLING UNIT(OVI:R 10.000CFA) CONSTRUCTION TAX
Signa c can oro,. a Dam EXHAUST FOOD(WIDUCT) HOUSING MITIGATION FFP
HAZARDOUS MATERIALS DISCLOSURE
Will ihenpplican,or future building(rccupant store or handle hwnrdousnamnodl HEAPING ON]'1'(TO RX)-(XX)BTU)
a dcf,ntJ M1y IS Cninn Municipal GWe,Chupldr 9.12,and the HealthHealthovd Safety
Cde,Section 25539upcx)2 HEATING UNIT(OVER IIX),(Xq BTU)
❑Yes ❑NnVI3NT11,ATION FAN(SINGLE RGSIDI PAID
Dare Raeipt p
Will the applicant m mount,building nuupimt use cgnipnsm art devices which
-
hvurJnm inu
11.1 Poo,
air comamn,x to,ddefinedm
by the Ituy Arca Air Quality Mngcmum BOILER-COMP(3HPOR BXkq)BH'HJ) 'ITYTN:
ureal UOILI!R-Comp(OVER RXkgX)B'N)
Lh�vc
❑No
AIR CONDITIONER ISSUANCE DATE
he hwNot numrials rcyvirtmcros under Chvptcr fi 95 of the Culi nlc urns 25505.25533 and 25534.1 understand thatHthe NEW RESIDENTIALMECH, SQ.IT.ry to 'ika,m,,mulaility,,n...ifthesccmmll
wM1n' ohmpnmmixsuuncy ICcnlfcmefOuupuh¢yo7- TOTN.:d agent Dam ISSUED BY:
OFFICE