S 1510 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CIIPER'I'INO - BUILDING.IU.EC'rRICAI• PEIy11'r NO. 1510
BUILDING DIVISION APPLICATION/PERMIT vl,ununrvr..nucunNlc\L \V
BUILDING 1`ROJIiL7 IDY141'IFICA'1'ION 1 BUILDING ADUIIESS: SANITARY NO. APPLICATION SUIIMITTAI.HATE
)OIZ16 0496)h C77
M� YIIDNI CONTRACTOR'S NAME: LIC NO:
- NIC . CON w'I'It01,rr
ARCHITECI1pNGINRFR, LIC NO: ADDRESS'. ❑
CON'I'AC, PHONE BUILDING PERb1IT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG P,LF.(2 PLUME MFAH
LICENSEE)CON UZACI ORS DICLARA I ION 'Qty,r ,ELECT RICICRMIT t FEE ' L]`J
I hereby dl m,11 I I r J J n f Clm 9( s' - (': - 1' JOB DESCRIPTION
F%OZ full Section?(XX))
elTecDv£on3 nfthcam rte sandlr fc.ionsCWe oWnrylicense is RESIDENTIAL:
O w` I'LRNI'l ISlUANCI.
y'u2 OSFIIWL O KITCHEN RBMOIIEL
QUU License Class Lic.p AI'PLIANCIiS-HPiSIDEN'I'IAL ❑ADIII'I'ION ❑PLUMBING RF-PIPE
y Z L Date Contractor
> ARCHITECTS DECLARATION OMULTI-UNIT ❑STRUMURAL
Z O h p 1 undrrxu nd lar plans shall he.wd un,mbde rem
eds - IANF.LS MODIFICATION
OZ`3� UPPONat AMPS ❑INTERIOR ❑CHIMNEY REPAIR
l.icetccd Pone,innal 1111-1000AMPS IMPROVEMp NIMMING POOLS
C6 pd� OWNEH-11111LDHIt Di;CLNtA'DON OVIIR list) O MTI I REMODIi1JRl?)'Alk 'MOLT"PION
C I hereby affirm that 1 no exempt In m the Ccneuch is Liceow Law far lha
O M U following reason.(Section]031.5,Business and Prnfessions Code:Any cit t OOTHHR
�( any
Onua^Y SIGNS IiI.IiCI'RICAI.
W 3 W h which requires a pennin e.connnml,oleq improve.Jcmnlish,or repair any awnure
0� print t '. •,ma y d ppM1 tr hpum' n Emaainen SPECIAL CIRCUIVMISC.
v)4 )hat he is live -dpmaund to he prividumufffic o t on License Law(Chapter 9
p0 (co r g itISec( 9000)of o isi l ofth B .'nesand r.fors Code)nr TI:MR ME ILR OR POLE I NSI. COMMERCIAL:
a 0.e a' that h,,,exempt Ihcrefrn;u and the basis liar 0,c ullcycd esourron.Any violnuon of O NHW BLDG/ADDITION O DEMOLITION
LL•ly�
Sachem 7031.5 by any applicant or a permotmbaOslheapplicant ton civil poLSnallrnf POWER DIiVICy El TENANT El FOOD SIiRVICC
.H, ynor mnm than live hunoreA Joll:m(5500). IMPROVEMENT
< 0 Ens ownerk.andpngwucture is of intendidero orad fox B,eirnAc rnmpensatiom, SWIMMING POOL IR.EC'I'RIC
ce will An thewom ande *Me om is tees Linda(,Law dos not apply n an owner of O GTHI?It
3wand Professions Code *Me Committees....Liccnw law Jrea not apply a,m owner of UUTl.G1:S-SWITCIILS-Irl%TURES
his o ny who builds or impmw4 t such and who docs e into h;ed ,or 11ed or
his awn however,
the pmlding )hal such ment is%old within nm ern inendfJ or Offered rar NIIW RIiSIOI?NTIAh ELGC'IR SU Irl'.
ownshudder qll hale(the brn en of prmcnt ith alli ion old r llnowetfor the SQ.f(C•Il.f)OH ANI?A SISQ.Pf.
er-hnllder will hnnvc the harden nr proving that Le Aid ma buil)or improve for par- Y A ' A
solene 6/
of the P .7 I_ IYcontracting ov sed t emto TOTAL ol?
cool Rh e .. ]fW li pprofessionsCel )ThC f tuxar " f)D
e t pPlm fl 1x.ly h d p e ,rout QfY "') PLUMBING PERMIT PEI? i Fj V � }y
xehn embraces f such pmleds w th a con nurh)licensed pursuant n,IM1e Commemr s •gk�'pf,
Da Lan Loom,pl under$cc .B&PCfrn this ncnenn PERMIT ISSUANCe �n OF��rC V -10�U/o
ALTER-BRAIN&Vpi EPA)Date : /�. O
ER'S COMPFNSATION UL LARAI'ION �� 7 BACK FLOW PR(YI'I?CT.` CI, • !i �d
Ihereby.11i.under penalty of perjury onenf the following Aeciwaumns: `IV-\ VVV
O 1Isocand will maintain uCenificaeofConsem toself-inwre fna-Worker's Compen- DRAINS-FLOOR.ROOF.Alt - ND.
,elan..,na provided rar by Soot na 3700 of the Labor Code,far the onformance of the STORIES '1 [?.CfINSI'RI1CI'ION
work tin which this permit is I%utial Il%TUHlis-Ylilt'I'ItAP
❑1 have and will maintain Worker's Compensation Insurance,as require)by Section
3700 old,Lahor Code,for the pvdnnnnncauf the work for which th is Penn,(o issued. GAS-EA.SYSTEM-I INC.4 COTEz OCC GROUT' APN
My Workers Compensation Insummce carrier and Policy number mc:
Carrier: Policy Na: GAS-iiA.SYSTEM.OVFR q IM ,
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMI'IiNBAT10N INSIIRANCii GREASWINDUS9'RL WAVE 1:IN'I PRCEPTUIR
BUILDING DIVISION PUBS
(rhis wain^need nm be unnpleaA iphe permit is fonmeM1undreJ dollars(511X1) GRBASE'I'RAI'
or leas) PLANCIMCK FUU
certify that o the any.....n n r o to t work I'ne object to permit is Workers
C,I shall 51100FJt-SANI'IAItY-S'Ik BERM HA 2110 FI'.
not e,nplay am arson In any manner so a.m neamoa snnjem m that wooer:cotnpen- F :u 101E
Z ,Z cation Luwsof Calif,mia.Dare WATER HEATER WNENT/ELELTR
O APPlicem ) ORA i FF.E
N NOTICE TO APPLICANIf.atat amking )its Ccnifim
cc of B oa,a.nn,yoI F,
u should WATER SYS' M/IREA'I'INC,
a T:
; Iscao a subject m the Worker.,Compensation provisions of the Lather Carl you must SOUS FIDE
{TJ Embalm comply withanch mooinnsor 11.14 perms(ehall bedeomred ravakal. WATER SERVICE?
Q
CONSTRUCTION LENDING AGENCY NI?W RP_SIDENTIAL PLMR. SQ.Ff. PAN
UO Iherehy affirm that her,is a constmcann lending agency future perfomameemf Data X
the work for which this permit is issued(Sec.3(191.Civ.C.)
w h Lender's Name TOTAL'
O L) Lcude,s Addrax TfITAL:
1 canny Lha(I hove rwd 1111,application and store(hal the above iafnmveE nn isBUILDING PER 4r,01
VE correct.I agree to comply with all city and county ordinances and sae laws reWling to QTY. MECIIANICALFERMIT 'FEI?
Ua building conn¢tion,and hereby amhnriu representatives of this city'In enter upon the SEISMIC ITE
7
abavu unit Al pre,eny for nspcetion, mns v.
(We)agree to save indemnify and keep har,uless(lie City of Cupertino against I'HRMI'IISPUANCIi
' I?LFCTItIC FEE
fiabilitics.juignnenlx,costs and expenses which may in anyway accrue against said City AI.TFR OR ADDTO MLCI I.
in emucyucnee of the granting of thio panni(. PLUMBING FP.II
APPLICAN"r UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Alit HANDLING UNIT(1010,000 OWE
SOURCE HLGUL`A /
w�I(1V^C,Vn� MECHANICAL II31?
Ott AIR HANDLING UNIT(OVER 10,(NX)CFM) CONSIRUCTION'fAX
Sfgnaumo . UContmctrn !! aim/O IiXHAUS'1'HWD(WNUC'1}
IIOUSINC,MITIGATION ITE
HAZARDOUS MAI'IBUALS DISCLOSURE
Will the applicant or inane building nccupunl atom of l the ha armir,Tmcrial HIPAIING UNIT('IO 1011.11110 BTU)
us defter by IM1e Cupertino Municipal Code.Chapter 9.12,and the Ilcalth ,to Safety
Code,Section 25532(x)I HEATING UNIT(OVER f 110,000 B'Un
0Yea 0 N PAID
VI?NTILAfGhIi ION PAN fSINRESEED Dee Receiplp
Will the applicant or future building occupant use equipment lar devices which
em it bvanlons air a( tminunl4as dafned by the Bay Area Alr Quality Manage an, BOH.PR-COMP(311POR 100,01i
Ld�S
'I OTAL:
s ON.
I1011.F.12-COF11'(OVER IINLBINt 111 U)
tced the hornrdmobalerial.s rcyuireuncus under Chapterfi95 of lbs Cali- AIR CONDO[ONLR ISSUANCE DATE
&Safety Code,Sections 25505,25533 told 25534.1 undersand than if NEW RESIDENTIAL M1f icil. SQ.]if,
I nut currently have it court,that It is my rasponeihility to nnry the occupantn%onts wine[%nes[be Inst prior to Issuance ofa Cedifirom of Occupancyonacd agent Dam 'I(3TAL: I'SUHD BY:
OFFICE