S3257 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F11.RCI'RICAL PERy1TNO. 3257'LJ^ 7
^
BUILDING DIVISION APPLICATION/PERMIAPPLICATION/PERMITPLUMBING-MECHANICAL l`J 1V� /
BUILDING PROJECT IDLNTIF'ICAT10N
BUILDINGADDRESS: SANITARY NR APPLICATION SUBMI I'1'AL DA'IF
14 9 1V w /-7-1
OWpI{}Y¢NI ME: �x ��LPI�NIE CON'RACf(1H'S NAME - LIC NO.
J Ili N I9. �T� i Iak Dui�„ � NIC CorvTROL N
RCHITECDENGWEER: LICNO: ADDRESS: G- ❑
1
C0N1'ACC PHONE: BUILDING PERMIT INFO
..J(�h sUuetu,z -� _ I I'
E, CoFces Paid by Applicant(Initial) P l HEEl hLII❑l ntECl l
J ICINSED CONTRACTORS DICIARAI 10N QTY ELFCI'RIC PERMIT FEE
Ihrod,,nntthat1 I e d p fch'll -9( ear, _ - .TOE DESCRIPTION
/OW
with Scu'un 9lMNpnfD .iun3oftbeeus Il,dos:nn:Uxle atdn Ttt tsds RESIDENTIAL,
Ivo `.� PERMIT ISSUANCE.
' F n License
Classdencu. � � J ❑SlT)WL El KITCHEN REAIODEI.
Liceme Clan Licp
U APPLIANCES-HESIUENTIAI. El ADDITION ❑PLD)1BING RC-PIPE
w a 1 Dmc Comrannr
F4�=iJy RCIIITIiCI'S DECLARATION 1'AN[LS ❑MULTI-UNIT El STRUCTURAL
OZ�•^ �PtYI �n xM1all 6e unN ex public rccnnly CHIMNEY
HIMN Y
Hart U NETTS AMPS ❑INTERIOR ❑MODIRi S1IONREPAIR
Q__ I ltcrebY ulBnn OW 1 am UILDl tram the RATIOor 2(11-11100 AMPS IMI'ROVEMIF:NT SWIMAIMG PODLS
k O y U followlI nvwn.(Smarm 903 L5,BuxnteO aI, 1'e C anus an Licmtse Law for the. (WER RWAMPS ❑BATH REMODFIIREPAIR ❑DEMOLITION
e led Pro essmnul
OWNERBUILDERDECLARATION
a r
We:Any city nr nnmYSIGNS F.LECI'RICAh El OUT LER
LL:LL LL y which require,a permit to on,wn ,,ahe impmvc,demolish.in mpm,aaY rlmlame
[- �a pnor tit its issuance.also requires the applicant for such Permit n file a signed statement SPECIAL CIRCUIT/MISC.
thim he is licensed ptt the provisions of the C I t r License la (Chapter 9
W.a-p0
(commencing 'ithS 1 900(y fD e I thef11 .` :. II f ':' 'Cvlc)or 1'EM RMETERORPOLEINST. COMMERCIAL:
d Y e C
that he s exempt the el and,he basis f il Ileged ere I union,A ty\ulafut o f ❑NI3W BLDG/ADDITION F1 IIEMOI,I'1'I(IN
W^m Section 713L5 by any applicant fora pernn
tit subjects the rMlicano a civil penalty al POWER DEVICES ❑TIiNANT [I FOOD SERVICE
not mom than five hundred dollar,(S50I). IMPROVEMENT
❑1,as owner of the propcny.or myempinyees with wages as thcinnlc rompensminn, SWIMMINGP001-ELECTRIC
CCCLLL F' will) the k and the : t intended ff df .e.1 (S 70i B :' as El OTHER
at and 11 I 'Calc'. IM1 Contractors License I.lo,does no,applyI dOUTLETS-SWI TCHES-FIX'I'CHEN
propcny who bmid-r returned,theresm,trod who does such wad hinselforlhroosM1
his own employees,provided that such impmvcmcnts am not intended or offered far NEW RESIDENTIAL ELECTR SV IT.
sale.If.however,the building or improvement is sold within one year ofeompletion,the SQ.FC FLOOR AREA 9SV.IT.
owner-Wilder will have the burden of proving that he did not build or improve for pur-
Iase of vale.).
I] 1,are owner of the pr,",am eselaoild,coolunding with licensed contractors to 'IYYI'AL:
maventhe pmjcaIS—1044.Business and Profession,Cache:)The Cnnvrfullsv],i-
w Clew J,.,ma.pply to an ownerofpropeny who builds or improves thereon.and QTY. PLUMBING PERMIT PEE
who contracts for such projects with a commetor(o licensed pursuant o the Contractor's
License Law. PERMIT ISSUANCE
I all cxmpl under See. ,11 h 1'C for thlnrwnnn
ALTER-DRAIN ft VENT'-WAFER(EA) VALUATION
owner wO U
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE, Z
I hereby notion unJw penalty of permit,oneof tire following Waken, ..:
❑Ilno,and willl forbi Section roll,of be Latin Code,fortlfiorroardoff- DRAINS-FUllllt.HOOF.AREA,COPD. STO IES 'TYPECONS'I'kGCTION
sari p -d dfnl)S I 111X1 of be Lab CN f thepet voce folic
work .,which this pernri,i J FIXTURES 1'[HTRAP
l
/ s�g
rdlt
of theIMtCxde l thepef Cunre ecrth 'Tkfar wb hlhs term,,Ye mrd. GAS EA.SYSTEM I I NC.4 OUTLET
OCC GROUP AI'N
My Worker,C pm I :m Icy,yy
C,r' P I' y ) GAS LA SYSTEM(
3(9ao 5-cal
CERTIFICATEIINN FROMWORKERS' GREAS%INDUSTRL WASTE INTERCEPICR
COMPENSATION INSURANCE
BUILDING DIVISION FEES _
Of section need not bensmplemd ifthe permit is fo one hundred Jnllon(Slgq CREASE'IRAP
or less.) I'LANCHECK PIAT
,riifythminthaVcrfommncmdda,workforwhich thl,pannitinlnm.J,I,hall SEWER-SANITARY-STORM EA.2011 FI'.
act anploy any persin any manner.,as m become subject In file Warkeri Conllien- ENERGY FEEon
C) Z cation laws of Cali6mia.Date WATER HEATIiR WNENT/ELECIR GRADING FEE
Z O Applicant t
V] NOTICE TO APPLICANT:If,ofmr nwking this Certificate of Exemption,you should WAI ER SYS'EMIT REATING
H Sbean..,eobject In the Wurkcr's Contpcnnatmn Vnwl.ion,of he Labor Cade,yon nnl.I SOILS PEE
fanhwitM1 Ontply with such provlsion,or this permit shall be decnmlrcvoked W'AI'ER SERVICHi
1 CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PC PAID
V CI hereby affirm that wformance
here isa consction lending agency for the perof Dare mcipra
IM1e work for which ffi s permit ix issued(Sce.3092,Co,.CJ
Q U 'I OPAL
Lender's Name :
r LeudcrL:
x Addrtns TOTA
d 1 eenify the.l have mad this application and state that the rhoW informaian rs BUILDING FIA:
F' IA rorrct.l ormidairdy with all coy and county nrdiamwe,ead,dielaw ollanngto QTY VIECHANICALI'ERMIT FEE
T,J Zi building, mction.and hereby ambnri,,repro native,uf Il,,,citym cant......Ithe SEISMIC FEE
,oveanctnivned property for inspection pugmse+ PERMIT ISSUANCE ��
(We)agree m save,indemnify and keep bannless the Cily of Cupenino against ELECTRIC FEE
liabiliriesJudgmen¢.costs and enpenses which may in any way accrue against said City ALTER OR ADD'DO MECH. PLUMBING FEf
in consequence of the granting of this permit.
APPLICAN UNDERSTANDS LC M LY WITH ALL NON-POINT AIRIIANDLINGUNI'I'CIO 10,00ICFM) ^ t+
S( l:.R ULA'1ION . /✓/f 'I MECIIANICA1.Ii B
T?_-J� S% f�I/ AIRIIANDLINGUNII'(OVER I).W(1CFM) y-•�J ( S'TRllCI'I( r
Sig�urvalf/spplicamiCnn nor /\--^ Date EXHAUST HOOD DVMUC) FIOUSIM1G MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE _
Will tare ppler I tr laulding .......avc ort 11 hav dousn'nrtl IIIA'TINC,UNI'I('1'0100tIHN111'1'GO ��I off"I-:III olu
a,defined by the Culprit I M Code.Ch pt 1),12. d d Health and Sultry
Caere.Section 25532
HEATING UNI 7(OVER 100.000 BTU)
❑Y. PAI7�.
VIN'FILATION PAN(SINGLE REifin .p1
u
Date Rcttipra /9�CIO
W111 thallconditioners
o i ft molding red p' t scea '1 .)trials veli ch 1{OIL LR-COMI'(JfIP OR IIN),I1g1I1T11)
ut 1 N mr e t w ti worn nn Jyl ted by II [say Area A' (sunlit,Mnnogm inn 'f(YfAL'.
District? t / BOILER-COMI'(OVER 100.000 BTU)
[-I YO,
/ AIR CONDITIONER
I h J II 1 N ,25 Ch'pl 595 1 th C li- ISSUANCE DATE
tont II Ith&SltyCtl S I' :25511525511 J25S141 I a' dIl'r'f lc Nil RESIIJIiNI'IAL MIiCIT SV,I'I'.
bull
of J. I h I �iFear ihat y�ofasCenl to'o'ff Occup cyttl i.,��,/ p
/' 9 : "ICI-_I'O ISSUED BY:
wQnr vul•bent Dnte 'T(YI'AL
OFFICE