S 1227 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO nun.DING-F.LKC2
7
TRICAL rr rr Na. 12
BUILDING DIVISION APPLICATION/PERMIT ILONnnNG-MKCHANICAL 1 L r
BUILDING PROdRCT IDKNTIPICATIIIN
BUILDING ADURHSS: SANITARY NO. APPLICATION SUBMITTAL OAIP.
(oy I ),J6m
o v E �Ge--D2 �3 ` 1
OWNER'S NAMF. '7 CPHONE: CONTRACTOR SS N/A•MC:/� L�IC/NO'.
Sipa FL-I L G.,�52-OG C.F-L� l- T. L// 7-17
SIC �RICONT9NOI,Q
ARCHI'I ECI'MisGINpER: LICNO: ADORLSS^'y+L CF/kJ 2�w_A:UWh9
CONTACT: PHONE: Sl, BUILDING PERMIT INFO
CH� _�� ❑ CDnsullanlPcesPaid nyApplicant(Initial) BLljl ELECT' _PWMB _ h1ECH /
LICHNSED CON'TRACTOR;S DECLARATION' QTY ELECTRIC PERMIT FEE rL-S/Jj�� IIr..��A/ L-�/ rxL/
I hereby antrot that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Od'Z with Section 7aNpnf DivisionJollhu xusinesn and PmfessionaCWe,and my llmnsc i. �/� RESIDENTIAL
(L O I'1?RMI'T ISSUANCE' N
F<_-� in full hncl:rod cf SbL/l.�^Lq ONE . ❑KITCHEN REMODEL.
U Liccn.vl CP.x hick i,-PI.IANCIiS-RESIDENTIAL IbIXO1)I'I'ION ❑PLUMBING RF.-PIPE
IQ-ZW Datw Cnnlrna /f.AYS'.
vaQy ❑h1llhl'bUNI'I' GSTRUCI'URAL
m ARCIII'I'I:CI"$DECLARATION I•ANBLS
pZF y Z I nndertund illy plum Shall be abild a.public mccub. MOD NCC Ith 1A
1 UI"IU 200 AMT'S ❑IN'I FIRIOR ❑CHIMNEY 121:PAIN
1-�4twmil Licensed Proossional 20MON)AMPS IM I'ROVI?MEN'T E]SWIMMING POOLS
�.W�; OWNER-BUILDER DCCLARA'IION UVI[R IIXxIAMI'S ❑BA'PII RI:MODEUkBPA1R GDEMOIAUON
C z Q 1 hereby mflirnl Ilial 1 and exempt from the Comracmr'..Licalse I.aw rill dm
i lil DOIl11:R
X
mow<
U whfilich
requires a Sectio17031.5.compact.al was and lve.dearth h.-re ai city nr amure SIGNS IiLIiCfRICA1, /l
1x13 LL sc which requires v perm re ,'healcor.impr
ove.h Nerabsh.-repair n signed statement
/ •�^___ —�
F�OJ pdonniucensed pursu reit)the Revisions o the CrM1pelanil Inoccowfile aaw(Chapter l SPECIAL CIRCUITIMISC.
(home islicensed pursuantit) of Di.iom of the Cammnss nd Prodlaw(Chapter COMMERCIAL:
m00
(commencing with Section 7lNXp of UivisinnB of the Business and Pmfelsiuns Code)... TI:MI'.MISfE LE .T.
iLE o y (hal he is exemia inaction,and the ba...fee the alleged esemptiou.Any violminn of ❑NGW BLUGL\DDITION ❑DEMOLITION
XMa Section 703.5 by any applicant lit a permit subjects the applicant o a civil penalty of IVWER DEV ICL DTIWANT ❑FOOD SERVICE
nonareln five hundred dollars(S500). ..• IMPROVEMENT
E=C D I,us owner of the property or my employees with wages as their sole comgialvaion, SWIMMING POOL ELL 1
la:p. will Jo the work.and the structure is not ntended or nRemd follicle(See.7051,Business BOTHER
L 3 mand Pmfcoiona Ctxle:The Common&Licenw law rices not apply m an owner of O OUI1.ITS-SWI" -!B 'TUR Z D
property who builds or improves mermen,and who does such work himwlf to Ihnmgh
his own employees,provided that such impmvemelns um not intended or offered for NEW RISIUI:NTIAL EL
vale.lf.however.the building or improvement is sold within one year ofmisidedur.the
SQ.FT FLOOR AREA SISQ.FT.
own
e,hadder will bare the burden of proving that he did not build or improve for pur-
pi of wird. AI.:
D 1,as owner of ole progeny,am exclusively contracting with licensed contractors to /
,room""Nw Prolm(sus 7(Ha.Hostile,and 11fe..tons CWa)The Convector,Li- Q
_w:Law mks onapply to an owner if pro,my who buildsor improves thereon.and QTY. PLUMBING PERMIT FF,E
whit ummncls litsuch projects with a contractors)licensed pursuant,,the Contractors
License Law. MGAS-I:A.SYSM-M-0VER4(HA)
UANCE!
D.l nut exempt coda Sec, ,B&P C for do,mu.on
ItAIN&VI:N'I'-WAIT
(EA) VALUATION
Owner Dam
WOR KE R'S COM PBNSATION DECLARATION W PROfBCT.DpV ICEO O !.Openuryoeof the followingJeclaraion, (0E]I huvemtl will mnin1.inu Ccnixaum of Cnnncm In roll-insure for Worker'.Cmnpco- FLOOR.ROOF.AREA.COND. S1ORIE; TYPE CONS'TRUC'ION
sntiom:w provided for by S,Ocm J70bof the Labor Code,for the perfnnnmceof 0eworknrwhich Nixpermiti.issue, -PER TRAPD(I huce:md will maimuin Worker's Compenseleal Insurance.as required by SectionI7an oflhe l,No Code.for the arfmnnewcof the work for which this permit ix iswcd. ' SYSTEM-I INC.4 OUTLETS OCC.GROUP AI'N
MyWor esConn irmuponIvumnce antsier and Policy number rots wpPolicy No.: 117ATZ'73�/T SYS'IL'M-OVER4(EA) /1r
CERI'll'ICATT:OP I:X:MPTION FROM WORKERS' GRBASI%INDUSTRL WASTE:INTERCEPTOR
4^
COMPENSATION INSURANCE BUILDING DIVISION—
or
IVISION FEE
("is.ection need not hemmplaed tram pem(ilis follow hundred dollars($100) GREASGTRAP PhANC ' E —
nrlusJ -_
c
I cenify thin intM Pwdommeeofmc.,,,it far which this permit is i...ed.Diboll SEWER-SANITARY-STORM EA.200 FT.
not employ any berm n in uny man p t subJec(to Ne Workers Combat- I:N'R.Y Eli
O z nation Law 'nmia.[)am 7-/QTS e I N'AIER((EATER WNEN XLECfR G GRADING IT rt/7T N
Applicant `Q-
tz. h NOTICE TO A PLICANT:If,afmr making(his Cettilica of Exemption,you shoull WATER SVS'1'lihflfREATING SOI IS PEE
F Income sublem to tire Worker'%Cnmpenenion plaskinm of the Labor Code,you nrusl
I imhwith comply with such provisions or this permit shall be.deemed m'uked. WATER SERVICE
0
CON5rNl1C'TION LENDING AGENCY NEW RISIDI:N'IIAI.PLMB, SQ.FT ('AID occi
U '01 herehyallirin that lhcm %a conswmion lending agency for the perfrnane of ]),allp
W. tine ot,Ibrwhich this permit lx isened(Sec.1097,Civ.C.) TOPAL
nder
U Le 's Nmtn IM,
Lund ,Add...,
>. a I certify that 1 have mind this application and state That the ahnvm intiancloon i. BUILDING ILEI?
� ZE ( 'el.l a"m to cotllply wi0 all city and county onllnvnem and 11.11 Www"Goal m QTY. MECHANICAL PERMI'P Il3E SpISMIC hili
C.72 huillingamxmmdnn,and hereby uuthoriac representatives of this city to enter upon the
aMrvonumtlmred prnlnrty for im,mlion Imposes. PHRMI'IISSUANCB 1:I.ECIRIC FHT:
(we)agree m wve.indemnify bull keep harmless the City of Cupertino agaiml
Iiubllhies.judgmmne.co.0 and espel.ws which may many way mane ugaimnnid City AUBR OR ADD TO MECH. PI.GMBING FEE
in consequence 1f the granting of this permit.
APPLICANT'UN Up R S'IA N OS AND WII.1,COMPLY WITH ALL NON-POINT AIR IIANDLING UNIT LTO I0.0f ll CF.M) MRCHAN[CAI,FSH O
SOURCE:RFMILAI IONS. 1
9/I„I�� AIR HANDLING UNIT(OVER Iq(NID CPh) CONS'INUCI'ION TA%
Signature of ApplicantlContreclnr L (Dale EXE MUST HUOD(W/DUCD HOUSING M1'I'[CATION FL:
IIALAROOUS hiding ocTERI cupant
SCLO handlURE -f
Will the applicant or future huilJing«cupantnmre or handle haaaNnus mamrial ' HEATING UNI'1'(TO I(X).(Xq BTU) Z
to define)by the Cupertino Municipal Cade.Chapter 9.12,and the Ileal(h it Safety
Cole,Seaton 25532(a)'2 HEATING UNIT(OVER I00.00)BTU)
❑Yc> 'n Z VEST ILAHON PAN(SINGLE RESIDE 15\ID
r IMe Recviptp
Wrdour,ll the air coantorfumrc building oe the nt Bay
wea Air equipment or Management
whet BOIIHR-COMPQHPOR 10th(: TU)
mit M1marJnLLs rots eunmminanr m lclinnl by the Bny Area Air Quality Mvnvgemenl p Q
District? BOILER-COMP UVHR 100.000 BTU)
E]Yon yo
TA_
11' read tile 1 I t :I y I: d Chap fi6,95 of th ('INRCONIAGONBR ISSUANCE DA
'� �•l/J
Ic HeAt &4ftyCd SI :254152551& d255141 ds IEnditllt NHW IIBSIDBN'I AL MACH SQ FT /
h bit I' I)I' ' I IIIt,,I y":1 �Ghlyl Ilythm pan 2_ / -3
o gt'acra"ItJt�.�e�rntprtnt ut. I'uCof " /r� n
owolr tmnlnri,wngum 1 IO 'I'f)" Is
suBnHY: C�6 �- A
OFFICE