S1900 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull)ING-ELECTRICAL PE IT NO.
BUILDING DIVISION APPLICATIONIPERNI T PLUMBING-MECHANICAL 1900
BUILDING PROJECT'IDENTIF'ICAT'ION
BU1LDINGADDI SS'. SANIT'ARYNO. APPLIGVTON SUBMITTAL DATE
l D �-� ppq v 3 --q
OWNF,R' A. H: ^� I H NI—� COW, 'f NAR: ^� Lie O:
{/Jv/ 4f OP/F/�}) Is(N(vFT_ 11'VTI S NIC COYfROLa
ARCHITECT'/ENGINEER: LIC NO: f V.,)r f / • �, ❑
CONTACT: PHONE: U *tal) ---
BUILDING PERMIT INFO
7 7 fl7 Z ❑
Consultant Pees Paid by Ap ❑O P.0 r PLU MECH
LICENSED CONTRACTOR S DECLARAI ION QTY. ELECTRIC PIiRJOBS DESCRI7 ION
- w 1 h by tf th t 1 f d d p : of Chapter (comm Ing
7 ma r nXro) fD 3 ld I+us dPirtle...Ots Code and license ESIDENTIAL
FW in full force miCis ]cit PERMIT'ISSUANCEUfullfAce (tea 0 SFDWI. ❑MICHL REMODEL
--- APPLIANCPS-RF_SIOLN'f1AlADDITION ❑I'LUMHING RE-PIPE
aleTSin QaCum
ULTI-0NIT ❑STRUCTURAL
ARCHITECTS DECDECfARA'f10
F,p y PANF.IS MODIFICATION
Z O y Z ]understand my plans zhall M used s public records
pZ�❑ UP T02(XIAMPS El INTERIOR [I CHIMNEY REPAIR
F.,W Llce.sed ".Ed..ional 2111-I(XOAMPS IMPROVEMENT L]SWIMMING POOLS
Qytz.�.t OWNER-HUILIAHR DECLARATION QVIIR If00 AMPS ElBATH RRMODIiI./IFPNR 0 H OIJTION
C C Q 1 hereby affirm that 1 am cxcntpl from the COTIoul dds I.kmtxe Law I'ur the _
X 6 U fallowing teas...(Section 7031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
E' is re I nt conmmcl,alter,int demolish,.r repair- t dare
quires a.,Anti prove, any s m
WQ pot I t '.: elsrequires- the f such Permit flsigned:Ptumcmt ` SPCCLII.GIRGHi f/MISC. �.�
}�
thin he licensed ., aa.the p o: fIh C t I r License Lo (Chapter9
IW Q000 (com enctngw to SectionIIXXI) ID siou3 fIn B : - ndP f :Code)Or TEMR MIUER OR POIIi INS91 COMMERCIAL:
C L e e1 that he is exempt therefrom and the hnsis for the alleged exc npI nn.Any x olio o t of ❑NEW BLDC/AUDITION El DEMOLITION
W Semon 703 1.5 nyany applicant i n.moltsubj,cO thenpplicunt io a civilpamltyof poll R"I2VICLS ❑TENANT E3 Tool)SERVICE
not more than five hundred dollars(S50p.
=6 Las owner ofthc rt.orm'cm lu mcs with wa their role cam tion. SWIMMINGPOOLEL ERIC EMfiN'f
� W � pmpc Y > P Y gcs us pens° []OTHEROTHERTHER
F will Profession,
he Certain,
LiniOn Law
triply to ...Business
22 3 m and oty who ba Cade The n,,,Ski
als License law doe,not apply to an owner of OUTLET:S-SN'ITCt R-Ph LS
his ov y who hutch.or impmvc,therch i and who docs such work himself or through
his ova employees,provided that snch intpmvanems create intended or Offered for NEW RESIDENTIAL F.LLCTR SQ IT,
aibe
lc.If,h.wcvcr.She i ldaderito couent i,s,nld widn"on.ywnof enn"I'S i.So
SQ.IT.IT.00k AREA 5/SQ.FT.
mnId,,will huvc tnc maken of.toting that he did not build nr impmvc or put-
pow
u-of,aTe'r Tarn-.
Fl 1,as owner of the property,am exclusively contracting with licensed cotntucusn to
construct the project(Sec.TIJJ,Business and Professions Cede:)The r-moun ors l.1
ase law docs not apply to an owner of property who builds or impmvcs,thereon.and QTY. PLUMBING PERMIT FEE
xboeonnacts for suchprojects with u amtmcdmi,)licensed pursuant mthe Comrnnnr's
Linin Law. PERMI I ISSUANCE
Iamaxntplander See ,li&PCfst Ito .asi
AUI HR-DRAIN&VENT-WATER(LA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION MACK FLOW PROTECT.DEVICE
I hereby affirm under penalty or pe jury ne of the fallovin6 disdamtions:
I haveand will ntaimain a Ccuificate of Consent to self-insure for Worker s Contpen- DRAINS-FIAOR,ROOF.ARE ON D STORIIS 'FYPI!CONSTRUCTION
sail...,as.....filed Ibr by Section 3700 it She Labor Code Ibr the perfomtanccof the
work for which fits iw-rain is i,sucA, FIXTURES-PER TRA('
L✓T'rs and will maintain Worker's Compensation Insurance.its required by Seetiun
3900 of the Labor Code,for the perfnnnunre of the work for which this permit is issued GAS-EA.SYSTEM-I INC.J Ol1TLETS OCGGROUP APN
AtY stink r' G��n{'� }tQ�i9�l I:iL^icr and Policy nwnMr
Catrier. Q1((s�c� Policy No. fiAS-IIA.$YSTEM1I-0VIikJIG)
CEH'I'IFICATE OPSA I[ONINNSURANCIi FROM WORKERS' GREASIIINDUSTRI,WASTI71 NTF.RCEITOR
COMI'ENSAI'ON BUILDING DIVISION FEES
[Unk,erinummd not be cmnplamu if dictin,is firarta hundred dollar,SI(Xl) GRIiASIT IRA.
or less) 1'LANCHECK hili
Icerdythal in theperformauceuf the work forwhlch this permit is issued.Ishii] SEWER-SANITARY-STORM EA,20X1 FF.
t employ any.conn irony manner so as ao became subject m the Workers'Cnmpery ENERGY FEE
no
zZ cation Laws of California.Date WWI ISR HEATER WNENT/ELLCTR GRADING FEE
0 Applicant -
y
NOTICE 10 APPLICANT If.after staking this Cef ideate of Bxemptioa you should WATER SYSTEAIG REATING SOILS FEE
tN� hecome,object in the Worker's Cntnpunsmion previsions of the labor Code,you nmxl
fnnhwuh,utnely with such provision,it thix permilsnall lw dccatnd mvokN. WA'T'ER SERVICE
W Q PAID
CONSre,isarRuci SON
Onto LENDING AGENCY NEW RESIDENTIAL PLMIt. $Q.Pr. Date c unN
U I hmeby allithi that islued(See.30lendingagency for the performance of
the work forNa which This permit is issued lgre.309),Civ.C.) TOTAL:
F L d n
led :AJJ TO
TWU� 1 n'fythan lh doh: Iph,d d:Porth uh b -nfrm tonic IIUIhDING PI'li
.Hs h
cou,",I gon,i I cy ,m;111 't,.t I cOmm,codi ,,and 7 i f ws ref f g'It QTY. MECHANICAL PERMIT FEE SEISMIC FEES
U Z becldit6cemimutiin, ad thereby autinnio,repucrorl'c'utd ily loubler t pot the
above-mentioned p.,,by for inspection purpxseo. PERMITISSUANCE ELECTRIC FEE
(We)agree at .-,indemnity and keep h.nnle,s the City of Cupertino again%[
habilities,Judgmmnts.costs and expenses which may in any way accrec against said City ALT ER OR ADD TO MECH, PLUMPING 1:E12 v
inc.emqucnce of the gramir,of this permit. nn �1kk
APPLICANT'UNDERSTANDS AND WILT.COMPLY WUH ALL NON-POINT AIR HANDLING UNIT(TO 10.X10 CFM)T M tl v MrCIIANICAWIRi
SOURCE REGIII.A'1'IONS.
AIR HANDLING UNI'I'I OVIR 10,000 CFM) CONSTRUCUON'IAX
Signature afnppftcarWContmmor Date EXHAUSTHOOD(W/DIIGT) SID HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE O
Will the applicant or fmure MtilJing toccupwtsmrc or Handle M1mardnrorearial HEATING UNIT(TO 1(X1.(001 Tq)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety t t ucV
Ctodc Scer if 25532(x)? �',✓/ I113A1'INC,USE I(OVER 100,000 BTU)
F-IY11 L9is^ V PN'I LAI'ION FANS I NGLFRES ID) PAID
Dntc Rcccipi a
. e mit haWill the acontaminantspplienni or Area
building median,use equipment or devices which BOILER-COMP 1311P OR 110.(00 BTU)
zablous air contaminants as defined by the Bay ea Air Quality Man igentxot TO
District? BOILER-COM('(OVER 110.000 BTU)
L]Yes
SIR CONDITION21t ISSUANCE DATE
Ib needda,Intend dol, n 1 ('1'pl ev) +1nd11'Car-
f. g'es notm )Cd S I' 55atitis y 12553; 1 notify
TOnII he NEW RESIDENTIAL MIiCIi. SQ. +I'. Joq ^ `70
building Does not wm.nily have n imam,that t s my.c curb s nil ty to not fy the leen p tut
of me ttem,wmen mnxt nes .tint to in.voce afx eertifieme roext a. ,y �
Oumer Drat Aired agent Doc TO I'. / D ISSUED B �f ^ d
OFFICE