31507 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'RIGI. PERMIT NO, O
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MEcuANICAL
BUILDING PROJECT IDENTIFICATION
BUI NGA ) FS - /r SANITARY NO. APPLICATION SUBMITTAL DAUB
O `//'•�I' N'' CO dCIOR'S AF1 LIQ N
A //lI NIC CONTROL♦
AdINI� IvaARC O'
ADDRESS 70 !.sido'.,
Se CN. ❑
NTA : HONE: BUILDING PERMIT INFO
FI'G5 Paid by Applicant(InlNap � F PLUMB MOH
LICENSSEE,COMRACIORR S DEECIARATION ELECTRIC PERMIT FEE.
I herenyeRtm Ihnt I tun licen.cd.aler Ptoviu.nsor Chwar 9 b,.mmcaing JOB DESCRIPTION
Zwith Saiian 7a00)of Divisiao 3af the Buri.ad Pnarlssionns Care.and my license is RESIDENTIALo MSSUANCr:
full ChicesJeDcm. ❑SFUWL ❑KITCHEN REMODEL
�F.WuE License Clan Lic.N APPLIANCES-RPSIDFIJfIAL ❑ADDDION ❑PLUMBING RE•PIPE
N<L Dare Comose or
ARCHITECI'SDECIARATION ❑MULTI-UNIT El STRUCTURAL
F. y I undcmumE my plana,lull ed u.ad as puhl.latents PANELS MODIFICATION
OZ-appp UPTO 200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
r:F-11-knosed Pmfea.iaml' 201-1000 AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVER IaIX1AMP5 El BATH RFMODFLRFPAIR ❑DCMOLIfION
y�y C I M by aR1r Jut 1 am exempt from me Contractors License law for the
>(oLU following ri (Saelim 7031-1.BusirrA.mW Proo cions Code:Any city or county SIGNS ELECTRICAL []OTHER
LLLLII a 4 which oce,im a Permit to cmwt eller.improve,hmoh b.or refers.'wuctula
Prior m its issaarce,nor regaues the applicant for neh 11,16,to file.signed hare. SPECIALCIRCIRTINIISC.
} mm he is licensed pursuant m Jac laovaaoas of the Conlmclere Lice.Law(Chepler9
<� (cmimcxing with Section 70001.1'Mike.3 of the Beeircss inns,Pmfa ions Cade)or TEMP.METER OR PULE INST. COMMERCIAL
Ia. o Nu he is,sinno mmcrrom ad the basis fee the dlcgd escmptier,An,violation of ❑NEW BLDG/ADDMON ❑DEMOLITION
qlarim170315 by any applicant foraper-oh object,11he.1heral to a civil Perch,of POWER DEVICES Ll TENANT ❑FOOD SERVICE
ZNinto more flurn five herdml"I.(S5I r IMPROVEMENT—< 1]1.0 w m of the property,«my employca with wages as their sole compensation, SWIMMING POOL ELECTRIC
will clo theworli,ad the structure is as iminded or oRerd fir m1c(See,W1YL Bauircss ❑OTHER
ami Profcasimu Code:The Comtmctars Lianse Law does vai appty to an owner of OUTLETS-SWITCHES-FIXTURES
,,aty she builds or iwptosas Ihcteon,and who ileo inch worts himself or thrwgh
hire awn amlleyas.Pri vidul,hal such inlpmvcmrnu me not imcand n1'.Karol fa NEW RESIDENTIAL ELF.CDt SQ Fr. -
aalelf.hvwevm,the former,aimptovmmcnr uwd within owe ycerofrnn,barm.thepoQ.FT.FLOO�RwARREAA I/SQ.FT.
ncr.luildc will have their ve the bust of roving eir rte dd mimps
mo,hold or impvc fon NOV
Pat- O25 IyyA s of silt). V IVIJVV
(]1,m owner of rhe property,can exclusively c.ovang wins li
cucamod cwuactas to TOTAL"
cennrua tic pmFct(Sec.70W,Busims ad Profc.siwu Code:)The Contowt 1i.
awe law donil napply to Brown of pmpcny who heilci m impmvc Recon.and QW.. PLUMBING PERMIT FEEPermit—
17Y Ur GUNtHfINO
who emuams far....h pojeeu with a mmrsta(x)Eamaed pnsa•..r m Jc Contnacurs ,
Liranx law. pPg
❑,I tun exempt until Sea. .B&1'C for the,rerc m
ALTER-DRAIN&VENT-WATER(EM VALUATION
Ow7er Usti, pp
WORKER'S COMEINSATDN DECLARATION BAC I, oEpan check COMPle ' n
I feby aff anent pe.],yet arjury core or the,ralowlog thermometers:
p Ihavlendwinmein,ainaeanirataercr,,.antlo�eu.irornarorw«ter.cemlen.
11AQWjKtou.a WN P-FI Mp Icft'ps TYPBCONSTRUcrION
action,as provie ed fee by Section 3700 of me Labor Cak,fon mrc
the o forae of the
FI , or eorre m a ns,
work(tor whicM1 this pmmit is iawcd
❑1 have oar will common Wmkm'x Canpetembon Insurnnte,a,on,i d by Section
3701.1'theLmorCode.fon the petformertttof the soot fire wh�ich�mhix Permit it issad. GAS RdJreViSi0nSon (iCC GROUP APN
MyW sCnrnpeeewioo id.ficYPo4eY �JefJ3e / GAS ♦
CERTIFICATE OF EXEM ION FROM WORKERS'
COMPENSATION INSURANCE GRF ly dffl BUILDING DIVISION FEES
(Thisewmmocedm be complcled if the porno,is for one hurcred dolWn(S HMI) GRFASETRAP
or gin.) lx1.ANCHECK FEE
I certify mot in the pofanmrceof me soh fm which this permit u issved.l shall
nelploy any Pawm
Parer.in any . avc
nner m asm bmsubjarin the Warkems Crimper-
SEWENERGYFEE
oti
Z .don laws of Cdlfonnia.Date WATER HEATER W/VENT
O Applicant I FPE
T^jJ NOTICE.TO APPLICANT:If,.Her making thio Cemf a of Exlmprion,you shwM. WA -
F-' become subject to the Workers Comperuelion posi ems of Jae iaGr Code,yon V
Wforthwith notably with ouch pmvisiam or mu permit shill be decent]revoked. WA S1' VICE.
Q
5 z r CONSTRUCTION LENDING AGENCY Dau Radpt0i
Ihwhich that acavooucu YM,
agency far the pertutttuottM
the week Incm which thin pemdr is issued(Sec.AM,Ci,C.) TOTAL
t" I<dce.Name
W I.codK1Addrta - TOTAL
1 certify that i have rod this appliari.n oar tem that the ab.ve infnmmritm is BUILDING f'f?I?
vii cowi l cares to comply with all city ad county dsdimeni and sure laws rebbirs to QTY, MECHANICAL PERMIT FEE
U 'Z building comm
tc,imh W hmin cby auth reiaerenutivcs ofthis city to calm upon me SEISMIC FEE
.hove-menti V1 ptopcny for in.apaction pmpoxcm. PERMIT ISSUANCE
(We)agree to save,indemnify mrd learn rm ha ,"the City of Cupertino against FJ.ECfRIC HE
Bali ities.judgmeou,coros oar e.1.1 which may in any way.cense agaiw said CityALTER OR ADD TO MECH. PLUMBING IYE
in rnryu
nsena of the graming of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POEM' AIR HANDLING UNIT LTO 10.010 CFM) MECHANICAL FFE
SOURCE REGULATIONS44* -
AIR HANDLING UNIT(OVSR10.0WCFM) CONSTRUCTION TAX
'ignatureof AppliraNK7..rr D e EXHAU.STHOODIW/DUCT) HOUSING MITIGATION FEE
,HAZARDOUS MATERIALS DISCLOSURE
Will me'Ouna ce future building oa7rpam1 stone a hadN
le haraoumm
s erid HEATING UNIT(TO 100.000 BTU)
es defined by the Cuprnino Mwicibd Carte,Chapter 9.12,and the Hlalrh wed Sorely
Cda Section 255321x1' HLA'rING UNIT(OVER 1001 BTU)
❑Yrs F1 No PAID
VENTILATION PAN(SINGLE MID) PAID
Raeiga
Will the applicant or feiera building oaup.ni uva quipment or ikvicec which
excut le audws r u sannmivou in defineJ by th1 Bay Ana Ain Quality Manugertra BOILER-COMP UHP OR 100,000 BTU)
TOTAL'
Disvicl7
[]Yea -1 No BOILER-GOMP(IVER 100.000 HIV)
I have rend the hvmslasm.uriWx rryuinanenis carer Clarm,6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
fawn Iledth&Witty Code,Saticns 25505,25533 all 25534.1 undueund too if the NEW RESIDENTIAL MECH. SQ.Er.
bwlduitdoo rot.1y hne a tool.thin it it my respmlbiEty to natif,the.eiuri
of Je on,creocmx which ansa be anal prior Io i.saumas of o Cottifimle of Occulwtey.
OwmaauUlotia,agar One TOTAL ISSUED BY:�
OFFICE