S 1247 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO^� BUILDING..ELEC'TRICAI. Pr: rr No
BUILDING DIVISION / aP1'LICATIONIPERMIT PLUMBING-MECHANICAL J 1247
BUILDING PROJECT IDEN'I'IFICA'I'[ON
BUILDING ADDRESS: SAN]FARY NO. APPLICA'1'IONSUHMITTAL DATE
T �Q 4eF _ 2��1
OW 'S NAME �� Y)NP ,I CO, rR LTOR'S NAMii: fv fY LICK 1 N/C CON'IRo l#
CHITECDENGINFER; Li,NO AUDRE'S:Z 2, D ^i S A� ❑
CONTACD PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG F,LEC'r PLUMB MECII
,B, ❑ ❑ ❑
ACENSED CONIRACDIR'S IN.CLAkAI']ON rY ELECT RIC PL'RMPI' FEE
❑ce7 I nemby drmr mm I ant ticen[eilanile. inskinn.of Chapter 9 kmmonmcin, Q JOB DESCRIPTION
Wpm with Senrrw900fBol Divihion3poffhc BusinessanJ Prot..ions Codc,undery license a PERMIT ISSUANCE RESIDENTIAL:
F Il Ercc:mit coca Zl L1eg S4e]�3`CJ ❑SFDWL ❑KITCHEN REMODEL
QUU Liamc l lJ AI'I'IJANCIiS-REtilufiM]A[. ❑ADDITION ❑PLUMBING RE-PIPE
yC G Dmc Cnnbuamr
NCI{I'1'IiC'I"S UISCLARAI ION PANELS ❑MUCI'1-UNIT ❑S'1'kUCTUNAL
7 p y 7 I undcrmaal Iny plans shall be used as public records MODIFICATION
UPT020OAMPS
Qz'—OI OIN'1'ROVE OKI WMNEY MING PCO
PAIR
u] LianmJ Yrnlce[innal 2UI-IUW AhfI'S IMI'ROVFb11ipT 0SWIM)1ING POOLS
�-
OWNER-HUILDC;R DECLARATION
C C C 6 1 hereby vffiml Ihnl I stn oamnpt from the Cines,,......Limos L sew till'to' OVER His)AMPS ❑BA'L'I{REMODEIIREPAIN DEMOLITION afollowing erroaSiIimr 9031.5.Baein c,s and Profession[Crile:AnY cI county SIGNS ELECTRICAL
E-1 MIER
which qui [a prarIn ct,selleritpvc,denlisn,or pair ant'oturcy w
soto prinrlu lir ixamncgldso refines lhcupttbcunt fur Nisch permit to flea signed Mimeme( SPECIAL CIRCUIT/MISC.
XY� thin he is lseenxd punaint ,,the provisions of the Conancn''s License Law(Chapter9
SEGO (commencing with Section 9001Bof Division 3 ofthe Business and Pndcsions Crdynr TEMP METER OR POLE INST. CO NEW BLDG
❑DEMOLI'TION
Ah
It.d e n Ihal he is cmo npt lin,mlmnl and the basis Pr the alleged Omo,lnn.Any vinlulinn of ❑NELDG
OU Sectio 9(131.5 by any applicant for it entrit subjects the applicant as a civil penaltyot POWER DEVICES ❑TENANI" ❑FOOD SERVICE
not Diem than five hi n bed doll.._.IA00).
F Z i- IMPROVEMENT
S601dothe wrofthupmpracturmymmpinydodorowagesrsaic(role(RW.Bning,o SWIMMING POOL ELECTRIC
12
will Jo the work.anA themmcmmisern imcnJW ondTered fnrxule(Scc.9(ILI.Ousincss HER
L3 and ProfPlsit Code:'Ric Conttuao',pian¢low deo Dat apply I,an uwnar of ()(it LETS-SW I'rCHI S-I'INJURES
propny who builds or Iropmvm thereon,and who cows such work himself or IhfnugM1
his ox'n cmployccs.provided that such irepnn'cmcnts am not intended or offered for NEW RISIDIiNTIAI.F,LECFR SQ FT.
sale.It.hrnveveolhe Lu Jdingontnpmvetnctll is hold wnhin one ycnrdamlplction tlm Is SQ.Fr.FLOOR AREA F/SQ_F'I'.
iswroo-bornIde,will k ve the hedco of pmoon,that he did on,huild nr Improve for or. w
Else of s(11 re 'IfrTA 1,: A NA
❑ I,asowncr(It jlou SIIIPII ee 70s,.menero,and
cumntuting wllh.,11.1cd umtmaors.'
clew La the project Iso.9841,...inn.and Professions CUJ,Jobe es,he'con.Li. /
c mlrla",I not�It or man own a If i:onroplt(,wint lf-eddursinlpmves morcnn.o,I and Q7y, PLUMBING PERMIT FEE /fit O
whocmnos.4a.ucn PNj«IewithnenntrocmK.)lianscd par areaethe Cmnraetm'x � d�
License Lrw. ` PERMIT ISSUANCE:
❑1 i wcmOR under Sec. ,B k P C Intuit,mason L
Owner Dale
ALTER-DRAIN R VEN"1'-WAT 17R(EA) AI'ION'
CjT
WORKER'S COMPENSATION IIECLARATION HACK FLAW PROTECT.DEVICE �/�,
1 hereby affirm under penalty of perjury one if he I'olhesing dedaralion[: U
El Ihavennd will roainuina Ceni(calcof Comsenuu.d6imxum for Wokcr's Compete DRAINS-FLOOR.ROUP.AREA.COND' STORIES TYPI?CONSTRUCTION
nation,as provided lot by Sco no 391X1 of the Irho.Cuda for the pcdbmwncc of the -
work lin which this permit is mted. FIXTURES-PER TRAP
❑ 1 b se and will maintain Workers Co n,crea dun Inxumnce.as me i irtd by See ion
3700 of the Lalva Coda for the perlbmmnce of the work fur which this pemlil IN Issued, GAS-EA.SYS]I!M-1 INC,4 OUT LETS OCC.GROUP MIN
�rYal's�.fpiyy.'yJpm� y.�4anieand Policy nj�' r
Carrie ����,.LL(�7/LLl1�� 11kk�.,1 Edict'Nn:.j'j GAS-EA.SYSTEM OVER 4(EA)
CER'I'1FICNI']I OF BXEMII IION PItO. W) KEI31'
COMPENSATION INSURANCE: GREiASEANDUSTRI.WASTE IN]ERCEPIOR
BUILDING DIVISION FEES
(Ihin.[cainn nudnallw annpincJ iOncpcnnil In for one hundred lotion(511X)1 -
Thor keel GREASE'IRAP PLANCIIIiCK IIIH
Icenifythrt in the perfumenotofthe torkfofxhichthiz permit:,issuOIL[shall SEWER-SANITARY-STORMEA,201 FE
Dat Deploy tory person In any Inannerso us a!beconm subject us the Workers Conlpen- ENERGY ITE
O Z cion Law.of Californ'la.Dat° WATER HEATER W/VENTAO.ECI'If
Applicant GRADING FEE
Z O
q
NOTICE 9)APPLICANT:11L afe naking doh Certifrele of EXonI1tma,yulnh0ald WAI'OR SYS'I'EmfTREATING
a > bcaonic subject to the Walker'[Cmnfwnwtion provisions of[he Latin Calc,you must SOILS FEE
forthwith comply withhuch provision[.,,his pemril,hallM deeced revoked. WATER SERVICE
1Q CONSTRUCI ION LIiNDINGAGENCY NEW RESIDENT'LM.PLMIL SQ,ET. PAID
UO Therebyanion tem thele isvamstmcfionlending agency turns Perfnmmna of Date Receipt#
L
the work Infwbleh Ihie punnn 11.1-ed S,,,.3097,Clv.C.)
Q UIcnder's Nome TOTAL:
U I<ndar'I Address 'TOTAL
'� W sort:. that Lava mrd Wix u J sttnc thin Inc uhavu In4rnnwon In BUILDING PBC
F, a r pis lea inn an
rn building construction,
carriply with all aNrtyrnarvnm.and clam Dwcru,on.'he Ql'Y. MECHANICAL PERMIT' FEF:
U z building nlnxfmcfiun,and hcrchY authnrim NPrevcnntivo nfthi.city¢r t[[Ilcr uqw the SEISMIC Id?E
move-nwnlloned prepay for inspection purposes.
(We)agree to sone,indemnify and kevp humdc.h Inc City of Cupertino agaimt PERMIT ISSUANCE[ ELECTRIC FEE
Iiabi111ies,Judr cohfsnul e,rnscs whluhereyin any wacmy:a ;,amI,;iid City Ah1'IIR OR ADD III MECH. PLUMBING FF.E
me' nn 9ucJ co cgnnting of this crmil.
n
APPhIC [dT 'ERSTAy S It,.0 Is YWITH ALI.NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOIJNC I! .iDLAGGN/ MECHANICAL I Ii
q AIR HANDLING UNIT(OVER 10.0)0 CPAP) CONSTRUCTION TAX
Sig .Ilum ofAppliatuWCnn nonan' U c EiXIIAUSI'I IOOD(W/DUCT) HOUSING MITIGATION FEE.
HAZOM DOUS NINI'C:li SCI.OSIJRE
Will the applicant or future building occupant store or handle h'nardnus material f{Hn'IINC,UNIT('10I gif BTI))
o dulined by the Cottonton Municipal Calc,Chapter 9.12 and the Heart and Stfmc,
Crile.Section 25532(.)". HEATING UNIT(OVER 101,100 SITU)
0Ym 0 N PAID
. VBN'I'ILA'I'ION PAN(SINGI.Ii HESIU)
Will Ino applicwt nr Imam M1aiiding rccupam axe equipment or devisees which
c Date Receipt,
mit haraNnnv I,vo..lcoo in,es du0ned by the JOy Arca Air Quality MILm"en ma BOILER-COMP I311P OR 100,N)O BTIT
District". DOTAL
Oyes ON. BOILER-COMP(OVER 100,000 BTU)
I have read the havvJuun material.%requirements under Chapter 6.95 of the Cali- A IR CON DI I ION ER ISSUANCE,DATE
!ismer Health A Semy Code,Stefan,25505,25533 and 25534.1 onderstand that if the NEW RESIUENTAL MECII. SQ.F'r
hoilding docs not...needy Lava a inn; 1,Out it la ny m,s,00hi ley m nut:is the oecvpant
of the reyaireomeeh whim mint be met prior In 6wana of r Cenificatc of(Xeuryacy.
Ownerorttaf riaed ager( Dam TOTAL: ISSUED HY:
OFFICE