S2171 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 11
CITY OF CUPERTINO BUILDING-ELP:CIRICAL PE III'NO
BUILDING DIVISION APPLICATION/PERMIT PLUa1BING—MEHANICL 2171 1
-BUILDING PBO,IECI'IDI:N'CIPICATI(IN
BUILDING AIIDI{yR�/O 1 n - SANI'DINY NO, AI'I'LICATIONSUIiDA'fli
OWNER'S NA `/ 3 CO >:
N/C CONTROL#
�I ARCH](FCUENGI.NEER. LICNO: ADDR2SS' ❑
CONTACT: �� PHONE BUILDING I'ERb11T INFO
r
(54 W�/o ❑ Consultant Fees Paid by Applicant(Initial) HLDCC EC PL)M A �.0
LICENSED CON MACI OR'S DECLARATION QTl' CLECTRIC PERMIT FEE
1 hereby of0rn that 1 am licensed tower pmeisFoms of chapter 9(commencing JOB DESCRIPTION
Can with Seaion](X0) Dtvisian3ofthcBmincssand Pn 's ro ialgandmylioemmis RESIDENTIAL'
n in fullfea"and t PIiHMIT ISSUANCii ❑SPDWI, ❑KITCHEN REMODEL
a,UU Licetuc CP es Lic.X APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMIfING kF:-PIPIT
P F Z m Dam Contmcmr
Nim AR f ECTSDLCLARATI(1' PANELS ❑MULTI-UNIT [I STRUCTURAL
F-mZ I understand my plans shall 6e used as public records MODIFICATION
OZ�O OPTO200AMPS Ll INTERIOR El CHIMNEY REPAIR
ktl Licensml],n+lessimal 201-1070AMPti IMPROVEMENT Ej SWIMMING I'OOLS
OWNER-BUILDER OF LARA'ITON
aow< to, OVER IOOOAMI'S ❑BATH RIiM DEER Alk DEMOLITION
C O Q ng by ft on 70 n,, theContractor,L I ,unm,
IK 3 a V fnhic g (Section t ](HI S B J I (..demolish.O A y ) 'war, SIGNS ELECTRICAL ❑(/a1IiR. A�I pp
==yOQ prior
y - µrmu requiresapplicantl such,,due,improve. 'u rte�s Ja statement SPLCIAI.CIHCIIIT/MIS[ 5f, �ir�/L�YI K
Y� Thoth dp It th P Irl C I License Law Uh+plar9 JVV
W�O�O (em g 'IhS I ]INlll) iD 110 Built: II (uin)ar 'I'I:MP.ML'flllt OR 1'[115 IN Sr, COMMERCIAL:
L d c a that he is sxampt thenflon a td the E vss Tim thi.11,M c.ocipli nt.-Any violation of ❑NEW BLDG/ADDITION ]DEMOLH IDN
Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
~ggnot more than Five hundred dollars CIS00). IMPROVEMENT
I] flu owner of the propcnyt or my employees with sages as their sole compensation. SWIMMING POOL ELECTRIC
xt: wllldothe work.and the strucinrc is not intended crottcrul Inside(Sec,7GT,Bt,ImoYv []OTHER
a��
3 and I t C J 1'I C t t n I I d+ec t apple t ow ser of 01191[7$ SWI TCHGI FIX
property who h Td,., on,awo,th,nem,mal who d :such stick hicrelfor through
his own unplmyee:,Provided that such improvement,arc ma md d +Bared for NEW REMDENI IAL ELECT R SQ
safe.If.however.the building or imprm'ement is sold within one yearof complctionJhc 17.FLOOR AREA WSQ.ET
owner-builder will have the burden of proving that he did not build or improve for pur-
pocIII ale). TOTAL
C1 L m'owner Of the progeny,son cxClaSkely conlructing wilt,IiccnseA mmmantx m
onsni cl Ibc p,,,,,(Sec.70,W.Businenx and Prufevsinns Code:)Fm Cmcranmr'x i.i-
sr.Lowdresnotapplymanewmer of property who b.diNorlmpowv,thereat, it QTY. PLUMBING PERMIT .FEE
who contracts for such projects with a contractor(s)licensed pursuant e the Contmam's
License Law. PERMIT ISSUANCE
❑ I ant exempt under See .B&P C for this reason
ALI17R-DRAIN&VENT-WINE "R(EA) 1d_/VAI Al ION
Owner Date //J
WORKER'S COM,,f [ON man
BACK FI-OW'PkOTECT.DEVICE
I hereby tfbnn under pcnahy of perjury enc of the E+Ihmrng dcclamIvan
s: ./O
� Ihave pro idefith,maintain 370 of Conentmasole,It"
aue W'nrkers Cnmpcn- DRAINS-FLOOR,ROOF,ARE: .CONU. ^J' tifORIF_S TYPE C(1NSTRUCTION
radon,:w lliO cd fur by Scnimt 3]IXI of the Lulwo Calc for the performantt of IM1e
lel'which This Pennil is Issued FIN'1'11RE5-I'IiR'I RAP
o I have act]will am min Workers Coin mtimn Insurance,vs required by Section -
3 nl the Wlcn Cade,lira the Forman -r fleworkfarwhichtbispermili.si swed. GAS-EA.SYS'IEM-I INGdOU+1LErS OCC GROUP APN
C r war a oe +n m t and Pot,cy nyrybgrr�t„��7,y
Cameo' 'obey No.: K✓J— GAS-FA SYSTIi560\' AA�
CERTIFICA'I'I.OF EXEMPTION FROM WORKERS' Gk F.ASEINDU WASE Nlh 'F.PTOR
COMPEN'SATTON INSURANCH ItU1LDING DIVi510_NPP,NS
(Ihissuti.a neod not beu+mplcicJ Ide permit is forune handed doll ars(SIM) GK17ASETRAII
no less.) PLANCTUICK IEE
Icenifythm imhepsoomunceo(theworkrarwhich this pc,.i,isissend.[shall SEWER-SANT -S A.® .1
not employ any person in any manner so as to become subject to the Workers Compen' ENERGY FEEOZ \aion law,of California.Dam WATER HFATF /VEN'i'IELECI'It GRADING FIT
Z Q APPllcunl
NOTICE 10 APPLICANT.It,zinc,making Ills Cendleem of Exemplum,you xt,uald WA'I FIR SYS]'1!A IRHATING SOILS FEB
becemc wbjem m the Worker,Comm
pcmin I Pat of the labor Gxie,you must
iX ? with forthwith comply h such provisionm
s or this peritsholl be deemed revoked WATER SERVICE
0. 0
CONSI RUCTION LENDING AGENCY N12W RESIDENTIAL!LMB. SQ.IT. PAID
u IM1creby affirm[hut tberc iso cmuvuction lending uBency lnnbepn4nnun¢c mf -------
=) c.ptb
� F Ibe work lint which this pcnnil is issued(Sec.309],Civ.C) TOTAL:
0,U Lenders Name
Lendds Address TOTAL:
} 1 vertity that 1 have read this application and smte that the above information n BUILDING EE
F' (ail c now'.Iague to comply with at]city and county ardinanees:md state law,rchang to QTY. MECHANICAL PERMIT FEE
'1 V Z-+ bmIdingatnstmctien,and hereby mahoive reprcenmtivmof this okyn,omen.....the ELECTRCF
It above-nantiuned pmpery fat inspamlon pumosce. PI3RMIT ISSUANCE ELECTRIC
(We)agree m sloe,indemnify and keep hmmlas IM1e City of Cupertino vgvitm ELECTRIC IT i
liabiliries.judgmenrs.costs nnJ capenses whicM1 may in any way accmeaguimt 4,10n, ALTER OR ADD TO MECR PLUMBING tiE 4-4-11
nICANT Nthe granting StA NPermit.
APPLICANT ULAI]ONIANOS AND WILL COMPLY WI"I'H ALL NON-POI NT AIR HANDLING UNIT(TO IO.INp[FA) MECHANIC\L 'LE
t SOURCI?REGl1LATIONS. N
70
NN HANDLING 11Nl'f 7GVLR 10.000CFM) CONSTHUC'TIO TAX
Sigmturcof APPlicmslCuntmctm Dae EXHAUST HOOD M'/DUCT) HOUSING MITIGATION FIT.
IIA]ARDOUS MATERIALS DISCLOSURE �^
Will the applicant or fumrebuildingtccupvnt,ton or handle hazardous material BEATING UNII'(TO HXLM1 ifIU) V
as deBnal by the Cupunlnu Munni Cn In,Chapter 9.12,and the Health and Safety
Code,Seen 25532(1)! Ii1: HNOIINH(OVER IfX1,I1fX1 it]U)
❑Ycs Yu V ENTILATION IAN(SINGLE RESIDE PAID Dam keceiPlM --
..�
Will the applicant or home building wcupam use equipment or devices whicM1 Nf11LER-COME(311P UH 100.000 BTU)
emit houmn
loards air mmini as J by the Bay Area Air Quality Management TOTAL:
OismcT!
' ❑Ycz No BOILIiIE-GMMP(OVER IINI,INNI BTU)
I have read the hmurdaux material requirements nnJcr ChaPler 695 of the C'vli- AIR CONDITIONER ISSUANCE DATE
fnmia Heahh&Safety Cudc.Sections 25505.25533 and 25511.1 understand that if the NEW RESIDENTIAL MECH. SQ,IT. / / �j
building Joos mly huvcacnanh that his my resPtmxihility mnmify he acupam (/ /
ont,e ret mtn na>I rte root pdmm'txwmee aFa cMmate of r.nP:m.. �`/y'�
Ow cora tvcl agent 101'AI.: 1 ISSUEDBY: f//' 13
OFFICE