S 1027 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI RECAL PERMIT NO,
BUILDING DIVISION APPLICATIONWERMIT PLUMBING-MECHANICAL ,$ " 1027
BUIhIIENG PROJECT IDEM['IfICAT[ON' J
SANITARY No. APpLICA ION SUBMITTAL DAII
ILDING AIIIIRL•SS:
�o u�o Fe tb
ERS NAME: PHONE: C N'I'RA OR'S NAME LIC NO: BIC CONTROI.4
LLP lyes 33-oto •u� Im•o5'tfW rn� /A•e'• ❑
AR ITEC)'/l; INE R. LIC NO: ADDRESS:
CONTACT: � PHONE BUILDING PERMIT INTO
r I�� �QO5`w/� 6;
Sb)4&7—
to IM
❑ Consultant Fees Paid by Applicant(Initial) LDC ELEC rl� MECII
L10ENSId)CONTRACTOR:S DECIARATION G QTY, ELECTRICPERMIT FEE J013 DESCRIPTION
I hcraby affan thus I an diccmcd mods,provision,of Chaple,1)1cmnorati ng
Zwi,M1 Sedion]IXNI)nl Division 3 nl the Business and Pntlisin Is Code,and my license is PERMIT ISSUANCE RESIDENTIAL:
��� i ❑$FDNC ❑KITCHEN REMODEL
full force and effect.
QFUU License Class I.Icp APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-I[PH
bQS Uam Contractor ❑MULTI-UNIT El STRUCTURAL
ARCHII'IT=DECLARATION PANELS MODIFICATION
N 1 mndcr,lood Iny plane.ball be used m public nears
OZ-� US'TO Nat AMPS [_1 INTERIOR CHIMNEY REPAIR
�. a Licen.Id Professional 201-H)DU AMNS BATH R EMIDF [I DEMOLING POOLS
; OWNER-BUILDER DIiCLARATION OVER 1000 AMPS
[3 BATH REM(lllliURfiPA1R [I DEMOLITION
W 6 I berth,affirm that 1 am c®ep,from the Comenchus License Law for the []OTHERKOyU fullest,maser,(Section 7031.5.Bull....and Profusions Cash:Any city or carry SIGNS ELECTRICAL
W 3 W h which rcyuiro,a parent to colosm 1.alcor,improve,demolish.or repair any swcmrc
point to it, e he Tp,I mmf air lu fl ,rdsmtemcal SPECIAL CIRCU I VMISC.
$.r�,j•] that he Is I erewd!pursuant tthe provisions ofth C t'aclor s License Law(C hoptor 9 COMMERCIAL'
W SCO (co gwth Section]0010)ofDvs J ofthe Business and Profession,Code)or TEMR.METER OR POLE INSf. C1 NEW BLDG/ADD
c.a c Y that he exempt therefromand thebasis f m alleged exemption Any violation of ITION fO1.IT10N
Section 703 L5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT FOOD SERVICE
m mom than five hundred dollars(551101. IMPROVEMENT
F-
=Opt.as menerof the Papery,or my employee,with wages as their side compcmomen, SWIMMING POOL ELECTRIC OTHER
P. will do the work.and the structure is not intended or ofiered far some(Sec.]044.Business OUTIJSI'S-SW1'TGHIiS-ITX'I'11RIi5
W and Pride—,,",C d.:The Carantean s Lieeme Love dans not apply w an owner of
L Property who builds or improves ihcrcom,and who doe,such work himself or through
his own employees,provided that such improvements me not intended or offered for NEW RESIDENT SAL F.LF.CTR SQ lT.
SQ.ITT PL(IOR AREA SISQ.Ii
sale.IL howeve,the building art improvement i,sold within one year ofpro ve fon,the
wrier-builJcr will hate me buNen of vi
prong that M did nrn builder improve for per- ^
po.cof sulc), T(lTA 1: 1_ D
1,us owner of me pmpeny.con exclusively roof ruining with liccu,al aaatecmrs m
con,lrum the prnjm(Sec]044,B.,incs.and Pnd'ensiao,Crde:)lue Cen,ramor.e I,i- FEE
cense Law dee,not apply to an owner ofpmperty who build..,Inpmvex merum,and QTY. PLUMBING PER OCT 15 RECZ,
who contracts for such projects with a comm rmr(s)licensed pursuant o the Contractor's
License Law. PERMIT ISSUANCE CITY
I..exempt under Sec. .B&P C for this reason I I
ALTER-DRAIN&VENT-WATER(IA) trap IJNr l
Ow Dac V
• W( ER'S COMPENSATION DECLARATION HACK PLOW PROTECT,DEVICE
1 hereby affirm under penalty of Perjury one of the Billowing declarations:
❑1have.nd will maintain.Ccriftcme of Consent to self imam for Worker'.Compen- DRAINS-FLOOR.ROOF.AREA.COND. S"IOR11S '1'YPECONSTRUCI'1(lN
sation,as provided for by Section 371 of the La on Code,for the peifommnee of he FIXTURES-PER TRAP
work for which this permit is i.aeed.
❑1 have and will maintain Worker's Conpenxmion Ins.mnce,a..rcyuircd by Section
37N)of the Lubar Cade.for the performance of the work Rn which this Purmlt is k,ln. GAS-FA.SYSrEM"I INC.401JTLITS OCC,GROUP APN
My Worker',Contpenetlaohoomerec earner and Policy madlerare GAS-FLA.SYSTEiM-OVP.R4(IiAI
Cartier: Policy No.:
CERTIFICA'IZ OF EXEMPTION FROM WORKERS' GREASUINDUSTRL WASTE INl'ERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(ltiszxtionneWmulTecompleed ifmcamait isforonchundreddollan(SIM) GREASF,TRAP PLANCHECK FEE
artless.)
I¢nlify,hat In the perfonnansv ofShe wurk lo,whicb this permit i_,issued,l shall SOWER-SANITARY-S'IORM HA.2(X)PT. ENIiRGVITiII
not employ any penan in any moaner so as m beeolum subjculla the Worker'Compen-
O Z notion Lows of Califumia.[)air WATER IWATER WNENT/FLECI'R GRADING FLE
O Applicant
Z .N. NOTICE TO APPLICANT:If,ufe,making this Coni&ae ro(Exemption.Ind should WATER SYS'11:M?REATING SOILS FEE
(^ become subject to the Worker's Compensation powisda,of the Labor Cole,you must
wti lanhwith aonsPly with.mebpro,Wonsor this porno,ehall be deemed revoked. WATER SERVICE
Q
CONS'1'RUC'1'ION LENDING AGENCY NEW BESIDES'1'IAL I'I,MI{, SQ.lal'. PAID Uu Rc' rip
Z I herebydfrn that mem is,comVac,ion lending agency for the Plefomtancear
U
W 0 me walk for which this permit is issued(Sec.3(1],Civ.C.) 'TOTAL:
Om
U Lenders Nae TOTAL:
U lanler's Address BUILDING PER
1 certify the I have read this applirmian and some Ont,the abase infomtatiun is
to career.lagree to comply with oil city and anunyo,dinancuand state kov,mlodngmo Q'EY. Mh:CHANICAI.PERMIT FEE SEISMICITE
U Z buildhtb'cnnswniun,and hereby authorize reproscmmivus al this citymeno,urym the
above-mentioned property for inspection Emposca. PERMIT ISSUANCE 171-EMRIC FITE
(We)agree to save,indemnify and kip harmless the City of Calved.against
limili,ies,judgecens.costs and cxpenu,which may in any way acme gaunt said City ALTERORADDTOMECH. PLUMBING FIiIi
in c......ence of the graining of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT(TO 10AX)CFM) MECHANICAL Itlili
S LATIONS.
/O /j' � AIR HANIl1.INC UNIT(OVER It1,IXXI CFM) CtINSTRUCT11lN'TAX
ogvmm of ApplicandCnmmctor 47 Dam EXHAUST HOOD(W/DUCf) HOUSING MIITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE: HEATING UNIT GU I(1.fNN1 BTU)
Will the applicant or f Iron Wilding midpoint store or handle Intonations material
a,ddinesl by the Cupertino Municipal Code.Chapter 9.12,and the Health and Sufcty HLA'I'INC,UNIT(OVER 1(1.1(X)let U)
Code,Section 25532(0)! PAID
(JYe, Fol No VEN"ILLATION PAN(SINGLE RESID) Dore Reveler#
L&vs�
WII the applicant or future building receptor use equipment ordevices which BOILER-COMP IJHP OR I(XO")ITN)oux air onmantina ax ax defined by the Bay Arca Air Quality ManagementTUInl,:
BOILER-C(MP(OVER I(1,(X1BTU)
es UNo
AIR CONDI'IIONEK ISSUANCE HAW
ve Mud the haautdn,v mucenWs quirtnncnts under Chapter fi 95 of the Cali.
h&Safety Cedc Sections 25505.255]3 and 25534.1 understand that if the NEW REi[DENTIAL MUCH. SQ.IT.s cox Carmody have a mnam,the h is my responsibility m notify the secupoldromen l which must be met prior m issuance of a Ccnifcam of Occmp.ory.whoiacd.gam
Date T(l'IAh: ISSUED 1{Y:
OFFICE