99100059 APPLICANT TO FILL IN INFORMATION WITHIN REO LINES-USE BALL POINT PEN ONLY "l'C' O
CITY OF C11PERTINO PLUMBING-F.ECHA ICA PERMIT NO.
�
APPI.ICATION/PERMIT PLUMBING-n1ECENTIFIC.
1}un,DlscDlYlsury xuu,roncvxoleLT'n)EnTIFMc\noN $0001
BUILDING ADDRESS: SANITARY NO. APPLICAI'IT IN SUhMl'MAL DATE
tl 32 0E R 13Y SNinE pRlvt
IiR'S NAME:: PHONE?: CON'I'RAC HALL S NAME LIC No,
LAN IJQ ND CL/+ USE A/ ILF(701of T) YOsJ NIC CONTROLM
• ARCHITECTIENGINEEiR: LIC NO: ADDRF,SX. ❑
204lit-0i HA/r/� - nD SANt
CONTACT: PHONE, BUILDING PERMIT INFO
❑ Consullonl Ft'Us Pail by Applicant(Initial) LBIDGEhgCfPIDMB MECII❑ ❑ ❑LICENSED CONI RACTOR:S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby+rantmot I ant licensed coder provisi ms of charm,9(comment, B DESCRIPTION
D=ZmScaion 7lMMry of DiKxionJofine❑usincs:axlPmfeuions Csde.and myli<enrc is L
won �I PERMIT ISSUANCE
1-(y,— full some and eRW.-i0 5i(�OS/ ❑SFDWL ❑KITCHEN RIihIODEL
at—i :accost Class C• hicM APPLIANCES-RESIDENTIAL [I ADDITION [I PLUMBING RE-PIPE
yZW Dae Ma J-Z —Corneae �,(/IUSf/✓ bLEU K
ARCHITECTS DECIARAI'ION UFIULTI-UNIT C)STRUCTURAL
p.,D w PANELS MODIFICATION
ZONZ Ian deremnJ my plan .,hall hausedacpnblic records
OZ=C Jam. UP T02fU AA11'S ❑INTERIOR ❑CHIMNEYREPAIR
1=¢•�FW Licensed Potfessional 201-INX)AMPS IMPROVEME ❑NT' E]SWIMMINGPOOCS
I CYC; UI
OWNER-HLUER DECLARA'T'ION IBA'TII HEMU'DE REPAIR ChmoLITIGN
C 6 I hereby utlirm that I am esempl Iiom the Contractor's License Low fertile
OVER fMMMAMI'9 U
L follvxin S«ion]11715.Busincsa and Profesaium Cedc An t chum ❑01 HER
,0"J 3 g neon.(,e Y ci Y^r Y SIGNS ELECTRICAL
a ¢h which requires'a p,nnir ort construct,a1mr,improve,demolish,or repair any stmemre
F.I'-.OQ prlorlo its insause.also requires theapplicanl orvuch permit ort lilt a signed statement SPECIAL CIRCUITIMISC.
that he is licensed p......11.The noes ion,ofthe Con occon.License Law(Chigoe,9
�LL�O (commencingwlth Section 10(f)0)^(Divi:ion 3 afthe Buainessand Profess:ions Cadelor TEMtt METER OR POLE INST. COMMERCIAL;
Co.L C that he Ix esempt Ihetetrmn and the had,for dm alleged csenmtion,Any 6,11uun of [INEW BLDWADDITION []UF 01.1'1'ION
0
ux.=y Section 7031.5 by any applicantfor a person ahje«s lbe applicant to a civil pcoalry nl POWER DEVICES UTENANT UFOOD Sit VICE
I more,him Eve hundred dollars(55001. IMPROVEMENT
01.us owner oflM proany.nr my cntpl^ytus wiW wngcs as orcinol,en.... m,uli^n, SWIMMING POOL ELECTRIC
E�2 will Jo the work,and the.structure is not intended or mitre]forsele(Sec.7044,Business OTHEk
a,3 m and Pmfo tinns Coda:The Centeno',License Law Jas col apply to an ow'rer;of OUTLETS-SWITCHES-FIXTURES
fompeny who build.or impmvm Them vnd who does such work himself.oftough
his own enpluyccs',provided that such improst, enls ore on'intended to,offered Ins NEW RL'SIDE?NII AL ELLC'IR SU FT.
ale,If.however.the building or improvement is sold within one Year or completion.the qIi.Ff.FLOOR AREA LSO.FT.
eo-heiWcr will have the burden of proving that he did not builder improve Import,
I,as owner of the proany,um exclusively contracting wird iu
vulicensed emmemn to '1(YTAL:
III
common the prejecl(Sec.7044,Bovine,sed PR
mssions M0 TTe Contractor's Li-
seLawJun^tapplyan owner of pmpcny who builds or improves thereon,aid QTY. PLUMBING PERMIT FEE
whnm o cotna<Is for such pmjeea with u e^ntmemHs)licensed pursuanuo the Comruaor's
License Low, PERMIT ISSUANCE
I um exempt under Sec. B k P C for this reason
ALTER-DRAIN A V17N'1'-WAI ER(PA) VALUATION
ar nam 2 yO O
WORKERSnoreCOMPENSATION DECLARATION HACK PLOW PHOTECI'.DEVICE
hand
moth,e01nn under Certify rte of Co encol'Thefollowing dcelamtions:
❑Ihvve undwie for bynection3meof,hc Lnuo Code.
for Wmkerace ofar- DRAINS-Fl.00H,BOOP.AREA.COND. STORIES T1 PE CONSTRUCTION
scion,a provided ford $norm 7]ItU of The IaMr cute.ror he artomtmc<of the
work for which this permit in issued. LIST UNES-PER THAI'
i. 37 1 has,the L will m le.for Wndch Compensation rkftur echi h required by Scalnn
7700 trf the Inbar CiNefor the pertnrmaea ofmc work Ter which this permit is issued. GAS-IiA.SYSTEM-1 INC 4OUT'LETS OCC.GROUP AIN
MY Worker's Compe^�yyti InWp V rand Policy no S, .-y
Cuma:GHL /N DL/)D✓evme Policy No.:�l'7?LOA GAS-IIA.SYS'TE'M-OV17R4(EA)
CERTIFICA'T'E OF E XCMPHON FROM WORKERS'
COMPENSATION INSURANCE GREASPILNDUSTRL WASTE INT ERCEPTOR (' iUILDI,N Itvisi ,E'S
(I missesgionneulaur he cu mplemdirihc,nail ix for one hundred 101un 151)(1) GREASETRAP
or less.) ' ANC PRL
Icmify that in no-perfrmmanee of the weed fawhicM1 this permit is kc,,' om,c - SEWEN-SANITARY-STORM EA.20U I1'.
employ any pcoen in any mvnnersommhcmme vuhja'I4t the W^hard Cempcn- rGRAWk
,L
O Z nein^laws ul CulJbrmo.Date WATER HEATER WNENT/P,LF,CI'R + I JZQ ApplicantNIT LICE TO APPLICANT.If,after making this Cenilieae of E?aominm,you choulJ WATEiR SYSTIiM,TREATINGbecome wmlcct le Mho Workers Coalenuenon provisionsof the Iahm Gala,yourustforthwith comply with such provisimse,Has permitshull Ist eemedres.ked. WATER SERVICE7z CONSTRUCTION LENDING AGENCY NEW RESIDELCIAL PLMIL SQ.FCDom RccciplM
V tz I hereby elfin that is.,an,to ion lending slier,fur the pertamrma el'
the work Tet which this permit is issued(Sas 7(19],Civ.C.)
Urmler'a NameU. TOTAL:
O {U Lenders AJdmss 'IYITAL: BUILDING FEE
1 codify That I have mad this application and nate that the isdi i menet ion ix
.F. 0.
t,r) coned.I ugree at atmplywW.11 citynnd mumy ordinances and state laws retain,nt QTY. MECHANICAL PERMIT FEE
U Z huddmilson,annl^n,and hemby,m1orierepd,crionoteol do,city menmrupoo the SEISMIC FEE
uMve-mentioned pmpeny for inspection purposes. PERM]T ISSUANCE
(Wet agree m ave,indemnify and kap harmless The City of Cupertino against ELECTRIC FEE
Lnbiliticv,judgtncmv,.slxund esperot,whichmuy in any wayvccmeagainvLaid City ALTER OR ADDTO MECII.
PLUMBING MEin consequence of the granting of this format.
APPLICANT ON DERSTA NDS ANT)WELL COM PLY W 11 IT ALL NON-POS NT AIR HANDLING UNIT(101 0,0(M CFM) MECHANICAL FEE
o
souacns /n
/� B �/'Y
� AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRLCTION'1'A%
Signaorm of ApplicanVComrecon W ETnc EXHAUST HOOD(W/DUC) I IOUSING MITIGATION ITHE
IIA%ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hassNous material HEATING UNIT(TO 100.0UO BT U)
an defined by the Cupertino Municipal Crile.Chapter 9.12,trod The Health and Safety
Iu.Section 25512(.)' ./, HEATING ONI1(OVER 1(10.(00 B'I'D)
�Ym fol No PAID
VENTILATION FAN(SINGLE RESIDE Durc Rcc
Will the applicant nr fawn buildin6 iecupam ora r,mpmeno or devices which p
coir Incrandous air cnntamin.nts as defined by the Hay Amit Air Quality Management HOU.Els-COMM'(3HP Olt 1(101X)11 BTUI
AL:100 1 4t)
Dadra«) BOILER-COMP(OVER 100.0371 BTU)
Yes XNo
I have real the hioani rretemils requirement,an&,Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DA
Esmia HnInt R Safety Cmk,Secriona 25505,25577 and 25574.1 understand that if me NEW RESIDENTIAL MECII. SO.FT
huirdin,tion'nm coneml,bust amount,mat it o my moponxiblliry m notify the oc vptml
efth immen whichin W�r 1pmemisstuvlttnfa Ccnilia 10cc
/south( //t,G2'rc /O %1 4y.
Owner to ammoldaed.gem 1 uule 'rfrrAl: Issuer xv:
OFFICE