29101 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
'I CITY OF CUPERTINO BUILDING-ELECTRICAL - PERNBTNO,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. /j O.�
BUILDING PROJIicr IDENTIFICATION G
BUILDING ADDRESS ,' SANITARY NO. APPLICATION SUBMITTAL DATE
227 6 , .PHONE
PHONC: 1, CONTRA 'AIR'S , TIC NO SIC
IN CON'1 ROhp
1•�ARCHIfECT/HNIGEEI TIC NO ADDRESS_ r
CONTACT - PHONE: - BUILDING PERMIT INFO '
/ 1 hereby affi lint Natll pnrvrsmnx f Chaper 9(nnnmenctn Y PP (Initial) BL ELECT PLUMB M[CH
❑ Consultant FeeS Paid 6 Applicant Initial
DCONTRACTOR'SDECI.ARAI'ION O , ❑
am LiwmeJ under - QTY ELECTRIC PERMIT FEE
spp�yy g JOB DESCRIPTION
F E Z e with Section and effect
Division 3 of ilia BU.ire—ord Net.rant.Cn le,add my hcenw is
I'ERAIH ISSUANCE
�UzUFU Ltceme Cl... Ler p OMT)Wl. HIEN REMODEL
ti6y Data —=— Comracor (APPLIANCES-RESIDENTIAL' ❑ADDITION UMBING RE-PIPE
ARCHITECTS DECLARATION OMULTbUNIT OSTR CTURAL
PANELS
z o n z I undasmnJ niy plun(.hull be mad m puMlc rcund. , e MODIFICATION'
OZ..o UPTO;WAMPS ❑INTERIOR OCHIMNEY REPAIR
F.�{,`°" Licensed Prafe....md .1.• "IMPROVEMENT
Y 201-11,10 AMPS
Oat I am exempt from the Contractors License lax for the OVER I001AMP5 ❑EATH RCMOUIEVRIEPAIN [I DEMOLITION
>(�a U following reason (Section 70115.Bmulr.s and F'ntle..ior.Code Any cry or rouinY SIGNS ELECTRICAL [I OTHER
F C N which regmrc,a pcnet to ma"aret.alter.Improve,deuohsh,or repair any Gmciure
face 1pn.wmie.avarequires lheaPpllcdnt for wch period to Man named smtelnent SPECIAL CIRCIJI'I'IMISC I ,•
ao that he is licensed pursuant)the provisions ofthe Couturier's License Law(Chapter 9
�0a (cammencmg wrh Section 700(onf Orvlunn 3of Ne BUmixi, id Probe..tam Crce)or TEM R MET ER OR POLE INST, - COMMERCIAL:
6 o LL Nat here exempt Nercfmm and the thesis Inr the alleged exeinpuen,Any violation of _ 0 NBW BLDGIADDITION `EI DEMOLITION
�w
Section 11U1,5 by any applicant for a period subjects the applicant at a civil Penalty of POWER DEVICES I OTIENANT ❑FOOD SERVICE
�'��. rtmnm Nan lice LUnJreJ dallm.65U111
¢ I,as ownerof Ne norm to acs wnh win.....ftcosolecom Lion, SWIMMING POOL.ELECTRIC s IMPROVEMENT
SF the structure ct Yot in Y B pcnsa
will Jo the work,and the stiunurc is not intended or offered for (Sec. Business /� � ❑Ol'HF.R
6 3 m and Pmfesaon.Cade:The Couracmr's License Law Jun not apply in an owner of I OUTLETS-SWITCHES-FIX'l/F$'_ � l
prnpeny who halide......rves thereon,end who d«.such work himself anhmugh
his own employees,provided NJI wch improvements arc trot intended m offered for NEW RESIDIENTIAL ELHCTR
sule.lL however.the budding orimPmuemrm iz,vddwnhtn one yearofeampItheor the ( SQ.17 FLOOR AREA $ISQ FT
er th
n budder will h.nec burden ofprovmgth.0 barbell no(butWar l lnpoorforpir- \ ,
O I,w ut air of the limped,am exclu.rvcly counsel,with hcemed utmocutrs m TO
nesnan the project(Sec 7(94,Busmen and Profession,Core,I The Contractor,hip ••
extra law does not apply o an owner of property who buldsonmpurve.Nrieon,and (QTY. PLUMBING PERMIT FEE `
who nimracts f nr such pn9ests wnh a convemon.l brrnsed purs.anno the Cuntmetors
LI<ense La ` PERMIT ISSUANCE
Olun under. r. ,B&I'Chatho,mawn �� "•I ;'
De•• ALTER'DRAIN&VENT-WATER(EA) VALUATION
WORK S OMPENSATION DECLARATION c BACK FLOW PROTECT.DEVICE
I herehy affirm an pectily of pepury one of the follow,.,electrocutions r
❑l hale and will maintain a Cent icae of Con.entto ml binfore l ar Workeh Contpra- O RAINS-FLOOR.ROOK AR EA,COND .I S'IY)RIIE$ 'I'1'PG GGNSTItIJLTIGN
ration,as provided for by Section 37W of the IaMr Care,for oM1epeRnrmanre of the
n, work for xhich thin permit is ixweA ,1. FIXI URES-PER TRAP
❑L have end wdl maintain Worker's Compensation Insurance.me eyorcd by Section
37M of the labor Code,for the performance of the work for which this permit is issued GAS-Lin SYSTMI-I INC.4 OUTLETS I [>CC.GROUP APN
My Worker's Compensation Insurance cutrice and Policy another are:
Cartier. Policy No (GAS-EA.SYSTEM-OVER 4IRA)
" CERTIFICATE 01'[KFEMPFION FROM WORKERS', st
_
COMPENSATION INSURANCE OREEdNDUSI RI,WASTE IN'fERCEPfOR' BUILDING DIVISION PEES
- Tmn.ection arednat he cmepleteJlfthe Perms is frrona hundrec dollars(SIM) ro
nrir m l ees'm a p l I Imo'y m anlyy tpheat r sIon n i lim a apnery fi mnmanmnnecr e s oo f u o:h eoo w Gorek n fovora wsuhhsjehm dh m tv pee WorAcrJ Cnntpen- GREnSG'I tAP, PLAN
hm SEWER-SANITARY-STORM EA.210 IT, CHECK
N 0 �n'yNy-T I
iNEtGSPii
O O nhpinLaws of Caltfomta Dade ,;I WATER HEATER WNENTIELF.CfR GRADING s
OZ �Y ut• GLIYvH III If,
y became TO APPLICANT.me Aorker s f¢rmaking
..tom p Ceram,of of Exemption.Code,yen amid WA71'.R SYSTE•MGIR PING
F' focn,.r subject o the Workers Cmor,or fit, provtsums t Ibe LaMn Coke,you must SOILS FEE.
forthwith complywnh such provisinm or Ntspermnshall he AcemcJ revoked l WATERSERVICE '
q
L' Z CONSTRUCTION LENDINGACENCV NEW RESIDENTIAL PLMB, SQ FT PAID '
U� work which hik ha0hcre ts ecol(See.0alending agency fnr the perfomtnncc of -- _ Date Receipt In
F the work far which lhi.Period nisnued f,rc.3(w7,CIV.CI -
O U Lender.Nam- ' ^ TOTAL
W lender's Address I tI'nl. , I
1.. C I caddy Nat I have read(his oppllcauou and state that the above mfmmatom I. I BUILDING TUE.
F. rn correct.I agree to comply with all city and county ordinances and some laws relum . (QTY, MECHANICAL PERMIT FEE I -.
U Z budding canxtrumion.and hereby auNonre teprewnwlrveset tbtscoy mrnterupnn the SEISMIC FEE
above-mentioned property(or mspecan"purposes PERMIT ISSUANCE
(Wa)agree o save,In lconafy and keep harmho%Ne Cny of CoNninu against - ELECTRIC FEE ,
Inconsequence.f Nc grannng al this pmnin zx'oy accrue against sstd Ory ALTER OR ADD TO MECH (PLUMBING FEE d
Imbdine,judgments,costs end expenses which inn)m any
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT I AIR IIANDLING UNIT(•fO IIAWU CFM) MECHANICAL FEE
SOURCE REGULATIONS.
L AIR HANDLING(IN[](OVER 10,000 CFM) ` CONSTRUCI'ION'1'AX
, .' Inure of ApphnotlComarrom Date EXHAUST HOOD(WIDUCTj HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WJI Nc.,,I,cntor fuorc boiling occupant.ore or handle haxaNnus mxmnal HEATING UNIT(10 10.009 BTU) -
as defined by the Cupertino Municipal Code,Chapter 9.12;'atd the Ihma ddt and Sulm,
Code,Section 25532myi HEATING UNIT(OVER 100,004)BTU(
❑Yes No I VF.N'I'LLA'IION PAN(SINGLE RFSIDI (PAID
Date Receipt p
/ Bill Neapphcammfourc budding wnipant.,a eyropacut or devma which BOILER-COMPOHPOR i(AfoUGHIU r
eon haaatdn I,so counterman,as defined by he Bay Area Air Quality Management 1 s
District?
❑Yn' F1 No ' BOILER-COMP(OVER IOLNX)BTU( ,g i•) !I
AIR CONDITIONER V 'I
I have rc.'td tha ho.odo. nmteenle reyuircment'mdcr Cheplcrb95 nT the Cali.
ISSUANCE DATE
fomia Health&Safety Code.Sections 25505.25533 and 3534.L understand Nat If Ne NEW RESIDENTIAL MECH, SQ FT.
bulldingdoearcre.oarly have a¢wtPoorn lv..acofa blhtyonoufy
ofld nywrcmem.wM1n'h man Ganum.mrtins my retda,h,l eof Occupancy. '
Owner or toment,ad agent Data " 'TOTAL: ISSUED BY
OFFICE ,t '