S2878 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELECERIC\I, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PRO.1ELT[DEN'I'IFICATION'
BUILDING ADDRESS: SANI'1'ANY NO. APPLICATION SURbII'19'A.DATE
i o ge z Lt,►Das�6-y aJ�
OWNHi NA41E: PHONE: C(N'IRACI'OR'.'NAMB LIC NO.
f-LW&- ass---4493 l2 S/ ,,� 60sl y- N/C CONT ROLTO
ARCHITECT/ENG NF.I.R: LIC NO: ADDRESS El/150'*Sir &'AM /'( c
COMPACT PHONE: BUILDING PERMIT'INFO
❑ Consultant Fees Paid by Applicant(Initial) 131.Lx Fit.li PLUMB mI CCH
❑ ❑ CI
LICENSED CON I'kACTOR S DECLARA'T'ION QTY. ELECTRIC PERMIT NEE
I h,rehy of i I I ,Fed a d p os of Cm1W 9 c ,ane 1mg JOB DESCRIP'T'ION
nt th
OOZ with Swim.70001afD i, 3 fate Bus dPrf,,mr:Cal d ylicemlc 3 RESIDENTIAL:
l- in full force and effcu PERMIT ISSUANCE / ❑SFDWL ❑KITCHEN REMODEL
s'�F '" C1D V ,
QUU Licmtsc Clvss Lic.g D APPLIANCIiS-RtlSIUIiN'I'IAh ❑ADDI"LION El PLUMBING kIi-PIPE
y Z W Dole Co......nr
ARCHHECESDF-CLARATION ❑MUI.Tl-IJNIT ❑S'IRUCTURAI,
Z O y Z 1 undemand my plans shall be and
as uncorksPANEuncorksCH MIFICA'I1ON
OZ�s> UP'T0 EAMPSS ❑IMPROVE MODIFICATION
Fd ul Ucenael Pnsfersinnul 2111-HNNInMPS IMPROVEMENT SWIMMING('001.5
Wsl a OWNER-HUILDER DECLARATION OVER Him)AMPS ❑BAIII REMODFIAREPAIR ❑DEMOLITION
x Q I hereby a1Rnn that 1 vat exempt from the Contractor,License Law lin the
X31 U following reams.(Section 0031.5.Huainess and Professions C,afm Any city or county SIGNS ELECT RICAL ❑OTHI:R
WLLOywhich requires a pormat :Bun,after improve.demolkh.or repair any:t cture
F�NJ priturn,it, I: qmr,,lie a,pliwmitl h permit 11 KncJ:l content SPECIAL CIRCUIT/MISC. 2, f
� Y batt licensedp tt thep : n fu ( t t L (Clk,ptcr9
W50p nonnurag. with Semon 70BBnfU viz""3oOhe Burne,wand Prono,i"ne Code)or TEMP.ME'TE'R OR POLI:INST. COMMERCIAL:
nae x that he is exempt Ihercfmm and the bveis for the alleged exemption.A.,violation of -1 NEW BLDG/ADDITION ❑DEMOLITION
mt ' permit suhjmts the applicant loacivil lwnulty of POWER DEVICESKLl TENANT ❑FOODSERVICE
Section]031.5 by any applicant for v
arc lbnn five hundred dnllam 135 Wl. IMPROVEMENT)'
.F..Z+< D htev owner of the propenY,anny untployngv with wnyex ux their eolcmmly.7,xnlion, SWIMMING YOOLF.LLQIRIC
Fp OTIII:K
will Jo the work,mA thanwemm i.not imended proffered for rule(Sec.)Odd.I{usinesz
a3= and I'lnfessinnc Code:The Contractor's License laxdoes not apply to an ux'ner of OUTLETS-SWITCHES-FIXTURES
pmpaty who builds or improves Ihemon,and who does such work himself m through
his own empinyeu:,provided thin such improvements are not intended nr oflred for NEW REdDENTIAL 11LRCTR SQ EL
.vale.IL howevcq the hui lding nrim'm,,unrnt is sold within nuc year ,of mntplcdou,the tip.UT FLOOR AREA $ISR Ff.
owner-builder will hate We burden of pro ing that he did not build or III for par
pmt If c), v s
❑I.az owner of the prnpeny,ten exclusivelyom1.contracting with licensed cunoo, TOT O a
construct the project(Sec.v)dd Ba:iuc,,out Proln,don,Cnlc)The Come n s L.-
-
me Lawdor,not upplyt rot'p-Fla, 1 Ohmic—, rFaovn, fare .nod QTY PLUMBING PERMIT FEE
who contract'for such p aecu with a eotuaaon,)licensed pursuant to the Contmclorz
License law. PERMIT ISSUANCE
❑ 1 am exempt under Sec. ,It S I'C for this reason
ACrBR-DRAINS VI?N'1'-WATER[EA) V LUAT
Owner Uute
l� WORKER S COMPENSATION DFCLARAI ION BACK FLOW PROTECT.DEVICE
Ihereby affirrin timic,psrally fpc) ry of the rolliii,d 1 tons p
Ih d 'll I'- Cnf I fC uu If ins f W k Coml'en DRAINS FLOOR.HOOP.AREA.COND. ���llf� GONSIRUCTION
sats :provided' I by Section 3700 f theLabor >lot C dtheperformance It the
work For which flus pr'n't is issued, FIXTURES-PFiRTRA1
❑I have vad will umin e.IN kers Cumpenemion Imumnce,as o,wind by Scion
AWof the Extra,Code for the performmne of the work far which this pc.If.is issued. GAS-HA.SYSTEM-I INC.A OUTLETS (KC.GROUT' IL
oo
nl'N
My Work((R Co tion 1 nJ I4dicy numMr a
Cunice uMr. "'on yaec Barrie Policy No.: rTu�µ�4((';70F GAS-SA.SYSTEM-OVER 1(EA)
CEMVICATF.OI'FF:XEMFIION FROM WORKERS' OREASIJINUUSTRI.WAS'T'E INTIiItCIJr1 OR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(@ i n d the p1 I d fda, I,is fortune,hundred d 11 '($100) GREASEIAAP
or PLANCHECK FEE
le1
1 n"Iy hard' Ihe pert l the soakl hich Ih pn t Jlshrh SEWER SANITARY-STORM EA.2011 FT.
not coo,loy any ryxso ',myna us,rax ,I bee ,.s,bleat theWakers Conpcn- 1INFROY FEE
� Z .tion Law,of California.Date WATER THEATER W/VEMTMLFCfR
Z Applicant GRADING PEE
NGrR: 10 APPLICANT.It making This Ceraftcan,of Exemption.you should WATER SYSTCNRREATING SOILS I EE
(•-' belt bj 11 T W k C R t p f th L h L I you most
Iavhw'th coniply with such pr ski( fino,on t shall ht,&,nued n000,d. WATEk sLRVICE
aQ
= z CONS'fRUCI'ION LENDING AGENCY NEW REST DENTINAL PLV 9. SQ.II'. PAID
UO 1nocbY affimuhavLere is a conzwaion lending agency for the paformanceof Dam NettiptM
(•'t the work for which this pend m issued(Sec 31141,Civ.C,)'1's Lena,,Namo �t^t TOTAL:
O U Lender's Addon,, '1 IOTA], ..
} IL 1 comfy that L have read This application and state that the ubas'e information is BUILDING FCL
F %1 correct.l agree m comply with all city and county ordinances and state laws relating. QTY. MECHANICAL PERMIT FFE
U Z Thai lung consoumion,and hereby authorise represcunawe—rdo,city 1. mcr.,m the SEISM IC FEE
ah�..... ionnl prnpsay Tor no,non purposes' PERMIT'ISSUANCE' j7 f D ELCC'TIdIC Pill r �f' Q
(We)"gree to sae,indcomify and keep harulcss the City of Cupertino against
liabilities judgments.costs and expenses which may in my way attic against said City ALTER OR ADDTO MECH.
'IAMBING EEE
in consequence of the granting of this permit.
APPI.ICANT UNDI!RSTANDS AND WILL COMPLY WI'1'll ALL NON-POINT AIR HANDLING UNIT'?O 1TyW)CFMI O
SOUHCIi kFOULAfI NS - // M1IFLIIANICAL Ffa?
SC//r{A�///� y^la• AIR HANDLING UNI'TGVER I0,mm CFM) CONS]RUCTION hi
Sigmwrc ofAppli<aHVCo RDOL DatcT EXHAUST HOOD OVIDUCT) HOUSING MITIGATION PEE
fiAZARmu—b MATERIALS DISCLOSURE RC n O
Will the upplle'am ar fuwtc building oeeupum stow or handle hararJnux mwcrial HEATING UNIT(TO IINI,(KK)0"TII) L
m defined by the Culwrtino Ma a]Cade,Chirac,9.12.and the Health ad Safety
Cade.Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No PAID
V F.NIILATION FAN(SINGLE RES ID) Date Itinerant if
Will the applleam or future buildo,ocn,rin use eyuipnmm or devices which
zardousairs"niamel,as defined bythe Hay Area Alr Goan' Management ROIL(?k-COMP(]III'Uk 100,000 11'TU)
emit hafam 'IxYI'AL-
Districll BOILER-CO.NIP(OVER 100.000 BTU)
❑Yeo (�
nIR CONOII'IONIiR r
lh Ithc1 d - t riot y a Order CuTpur 695fah Gli- ISSUACE DATE
lianin IIculth S Sfvy Code.Sent ,25505,25533 and2553a l..Id,,,;r I that'f the NEW RESIDENTIAL MSCI L SQ.FI'.
building does n t Cu tly team,,th t to.jily—Neo M1 I'y a I',The accuourn 7 L -�
"fth-'ty{Fotremcia tch met Por to issuance of Cmil cu} Z cyyyy y.
Ownern,r uuthnrtn'A agent Y are l= a ISSUIIDHY:
OFFICE