S0981 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
,CITY OF CUPERTINO DUII,DINI:.ELECTRICAL P' UTNQ
BUILDING DIVISIO APPLICATION/PERMIT PLUMBING—MECHANICAL
�J 0981
BUILDING PRO D BCT IDENTIFICATION'
SANITARY NO, APPLICATION SUBMITTAL DATE
OUILDINC ADUNESS:
{5 5 0 1
O Q ME: O K C v I'HONyr�^�X �� )R_S NAME: ✓ LIC NO: N� �pHfR01
_ C L//S p-(Olio. o�.� lrU c
A ITL LIC NO'. ADD
S[
ONT BUILDING PERMIT I PO
I'IIONE:
HONE ❑ Ccnsulunt Fes Paid by Applicant(Initial) _ BLf E F PLUM" MF.CH
LICENSED CONTN CfOR'SDECLARATION QTyL
LECTRIC PERMIT7t FEE JOB DESCRIPTION
I herchy aThr,that,I am licca y oras pmvisians of ChelNcr 9(commuTcine
Qn Z with SaPoin fiX101 of Division?nfthc Rosiness std f`mfevvinnx Citic,and myliceetvc in NCE.
��si lull force old eRml. h ❑KI'ICl I EN REMODEL
a V�j License Claes Lk.0 -.RF_SIDFNlAL ADDITION El PLUMBING REPIPE
a 6'1 Dye Comt'xta
ARf:B ECPS DECLARATION PANELS ❑MULTI-UNIT ❑MOI)IFNRAL
F�Z I unkluaW my plans shall be event as public wurds - Af0U1FlCATION
_ PS ❑INTERIOR ❑CHIMNEY REPAIR
�Z OIAcrned Pmicssirenl S MPROVEMENT E]SWIMMING POOLS
XaQWNBH-❑UILDHR UECWHAI'ION P5 ❑HATH REMOUIJJREPAIR ❑UIiM01.1'TION
1 hereby affirm that I em exempt from the Contran„is License Law for the ❑OTHER
K 3 y V follming reason.ISecunni]0313,Busirc,ural Pmfeasiorn Code:Any city or county SIGNS ELECTRICAL
41 LL. which noires is pcmd,an rnlstruct.alter,intlam",demolish,in repair any strvewrt
H LL'04� prier to its kcwvec Ms.requites the appliam for st Jl permit,.fk..,w IIn.no SPECIAL CIRNRIAi15C.
yy the,be is news,N.,,.Re pmvisians of de Co.In's Lictai,Ur(Cl'apter9
-�O (rommrncing i+'ith Scctirm'100()ofDivision J ofthe Businxsand Professions Ctdc)n TIJi11'.METER OR I'VU:INST.
aqx e That he is exempt'ocrcfmm and the hairs fir the alleged exclarti.n.Any violation M ❑NEN'BLIXHAIJDITON L OLITION
Ramey Section 703 1.5 by any epplicvnt G.0 Instal wble's'he uppllcnnl weclvil lnnelry of 1'OWEH UhVICLS LTi a j� CUNt JSERVICii
F-
ZYnorn.se than five hundred dollars(5500). IMPROVLMIJ4'fV r I'I'I
Q ❑L as owner of the ptoperty,ta myemplays`es with nal us their sok Ko,al SWIMMING POOL ELECTRIC ❑OTHER
will do ft worl,and tai snunirre is tom ineedei m.Rertd for sale(See.7044.Rusin,,
W aM pmfcsslons Conic:The,ConlnenNs Laccase Lar dues rose all en vwtw of OUTLETS-SWITCIIFS-FT%NRFS
0.3 property who build n itrtpmve,Ihcscuq and who docs such wmk him,elf m through NHW RI!SEDt1.'TIAI,IBFCfR SV IeT.
his own employee,Pn lulted'hat such imprnvcrosarnl um nn iroralcd ar offurcd Gr SQ.FE FLOOR AREA 5)SQ.IT
sale,If.M1uwevcpll ba,
,dingmerat ru,ar,lthe,he ithins,build
ar arxnplctiun'M
cr-FuilJcr will have the hurdan of pmving That M Jid'xN lulld ar impmvc tlx par-
pore of sala.l. T
L as sera of the property,am nndrsivcly mneated,with IinnsN curmemn Io
cmetruct Ilse prejed(Sox.I014,Buttress and Profeasisms Code)The Co'amendi s se w does D- 4507, 74
rnLaoroopply,.w mcm
vnvof prmwywho Nilds or improves thn.rd QTY. PLUMBING PERMIT FEE
who malul fmarch n ecvwithaconlmcawO IiccnsN putvwnt mre Cmtmclurs
L'icenw War. PERsu r ISSUANCIi
] Iumcxmnpl mdrr See ,It&PC Perin,rcnwn
ALT!R-DRAIN&VENT'-N'Al" VALUATION
IYwrcr Dete
}�
WORKER'SC1SATION DfMluTrIOingNdeclarvims:
BACK FLOW
OPROTFCT.DEE � M
\X
I thereby alRm'utdec^try- ci)iry me office
❑ DRAINS-IlOR.ROOfli
N STORIES TIDE CONSfRUCfION
nation,as q vklud for by Section 390141he fah,Cmle,fur be pwoun,aacc of the
work fur which th6larmn is Lam d. lil%'IlIR1:S-PER THAI`
1 have std will maintain Wnkc/s Cumpensrion InwmmIt,as required by Section GAS-HA.SYSTEM- INC.J OUTLETS
37W of the Won Caere.far dueprfonwtex of Re work for w hich this writ is i—ed! OLC.GROUP APN
My Warkc('C tour' e - ard Policy mon are GAS-I EA.SYSTESTOVER R Bs)
Carrier. PoEicy Na.:_
CERT,lCATEOP "EMPTION FROM WORKERS' GR1:1S2fiNDYiTRL WAST:INTERCEPTOR
COMPENSATION INSURANCEDIVISION IRFS
IThisrcctiva ncedous hccvmplcud iftle,cnnil in 0,nnchmdrMdaflma($100) GHI?ASI!IRAP
I'IANCHEC P '
nl ss.)
],wily that warm in ff.,cm,, oOhewMfnwhichthbpe,mitiLers'C.lnl'.all SGWIiN-SANITARY-SI(JNM EA,2110 PT. 1, 'R PEE Q�a
tin employ vny pttwh in nay manr'cr w u to becarrc subject m the W.rl:tri Cunyen-
� z urian Laws of CMiOrmi..Dare WATER IIPAITR WNEbf`DVLECB GRADING Ft
z Q Applicant
NOTICE TO APPJCANT:If,after making this CcrtlEur.f Escmption,you should WATER SYSEF\MHATING SOILS FEE
E" asith anuhpet m t,,W.rkrr'n Cnmpen.vnirn ctnnl.na of the 1aahir C,sk,you muss
❑mhwhh nxnply wl'h such lxmixinnxorlhlxp'.sett,shall Rdrenwd rcvoAnl, WAII!H SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RI'_SIDEMIAI.PLh1H. 5V 19'. PAID
I hcrchy afhmt tlu,mere is a croamnisai i`nling aymry fn the perhxrtvatee of Rcaip,M
V C) thewM for whieb Nu permit is issued LSn.N)sO.Co,C.) TOTAL:
C)1-' 1< ,Name I.
W hetukr's Address BUILDI G19J? /
1y. 1 cenify'Nw I have read this upplicatim mill stn',tout the ah,ve infun'iWion it
i..o rn 10 11 agree'.comply with all city and county on inoses seta slate laws rclu'Ing to QTY. MECHANICAL PERMIT IAB SETS 7E
V z building cnM1'INCI'Iml,end hereby authorise rtpte enmJvc ufthis city m enecr upon that
above-mentionW ImaertY for aregw'tlom Paul es. PERMIT ISSUANCE IC H
(We)agree to us,,indemnify and keep harmless the City of Cupertino against
Iiablliae judgnrcms,coats and expetues which may in any wry acme agvmed said City ALTER OR ADD TO MECH. PLUMBING
in C os,,,crce M Ile granting of this pwail.
APPLICANT D 'ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 10,000 CI'MI MECHANI AL ItJi
SOUR4U4N &
1 NHIIANIJLING UNfCO)VPJi IU.0XICIM) CONSBL. ION'IAX
Sigtu, EXHAUST FOOD(W/DUC) HOUSIN MITOATION FEE
ATERIALS DISCLOSURE
Will no,applicw mfurm Witch,ncupam store m hand)lwar,FNu material HEATING UNIT GO 110.010 BTU))
as deftwl by the Cu natim Municipal Curie,Chayter 9.12,aN Re Hedth and Safety ISEATING UNIT(OVER 100,000 BTU)
Coda Section 25532(.)?
El Ye, ❑NnVENIJ"A%UON FAN(SINGLE RISID) PAID "
R¢dgM
Will the.pplieom a,true,hni d ng ran,lm't one n,ipment or devices which. BOILER-COMP PHPOR IIXL000 BTUI sed,haiallous air cmtamintants w def tlM M Rsc Boy Ates Air Quality Mwagetoer TOTAL
U,strx6 BOILER-COMP(OVER 110.o00B'IU)
❑Yea C]No
AIR CONDMONER ISSUANCE DATE
I have rend tai nJoos nwtcnuLs rcx,uiremcn'n arts,C Ia[eI It.95 d de Cul l-
men.Ilve,h&Safety Codc..Gw.ns 2SNYS.25533 and 255.d 1 me u aaad Pru If the NEW RESIDENTIAL MIiC II, SV.I'I�
building docs not cmremay hove a tarot,that it is my m siPur ihility to mtify dr iavvlvot
M Ile rogaitenwas which raw ha ern prim an iasuarta M•Cerahces,of ONOmatcy.
Owner mawhorirW-gem Date T \ ISSUED BY:
OFFICE