S 2964 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO II1111,HUNG-KLEC'TRIC'AL PHIL MIT NO.
BUILD NC DIVISION APPLICATION/IaERMIT PLUMBING—MECHANICALS 2964
BUILDING PROJECT IDENI]F'ICA[ION'
BUILDING AIIIIRESs: SANT IARV NO. API'LICAI'[(IN SU13MI ITAL DAT[
2&� _P_f,�TATEp _ K z 9
'Ni?k'S NAM': PHON"2 COST�� ft S NAM" EJC NO:
IBV\ A IRr t�l14_ NIC CON'I'kOLp
ARCHI ffd77UENGINEER: LIC NO: ✓✓S� ❑
CONTACT': PHONE'' �•/�i✓,7 BUILDING PERMIT INFO
^✓ J Y I WAv ❑ Consultant Fccs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LD/ D— JMB17/
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby mffimn mol 1 in nceeed^oder p.,,I..om of Chapter v(commencing JOB DESCRIPTION
WOOF
I.full force an ,I IvieionJoflnc Buxincscund l'n,rec.iomcodc.and lnyliccnxc it PERMIT ISSUANCE
RESIDENTIAL:
CO nnh Se,lion7f)(toolD 5
❑SFDWL ❑KIT CHEN REMODEL
CI: s a
Q U I APPLIANCES-RISIDENIIAL ❑ADDITION PLUMBING❑ RIiPII'li
F+ZIy I Cnmmmor
FDy ARCHI'IECI"S DECLAIt ;'ION PANELS
❑S'IRUCI'URAL.
Z°-Z 1 unJemwJ Iny plain nM1ull be usnl ua public records MODIFICATION
OZ-0 UP TO XXI AMPS ❑INTERIOR ❑CHIMNEYRHPAIR
24!r LLI Licensed Pn le"iunal 201-IsHIAMPS IMPROVEMEN"r EISWIMMINGPOOLS
ATION
all 1 hereby aflirm thin Ilam a el:npt'fromE he Conmomr's Liccme Law for the OVER TRY)AMPS ❑BATH REMODHURHPAIR ❑DEN101.11']ON
°'°a U fellowin Section 7031.5.B.,iness and Pmfes,mm,Code:Any cit t ❑OTHER 1==it'yKj 31y F g nuwn ( y ar coon y SIGNS ELECTRICAL
m which ospnres a porno[to mmc.uc[,idler.improve,demolish,or rep:ur any amelme Y.J
priorn.is iecaance,almlequlrestbc applicant forsuen permit .the u rigned ctatemam SPECIAL CIRCUIT/MISC.
feythat he is licensed Pursuant to the pmvixinas ufine Contractor's Licenu Law(Chapter 9
��°° (coinmm�cing wi[M1 lection 7lXND of llivivinnlnfthe l{usinws and Prabssionx Crvle)or 'TAMP.METER OR POLE INS'C COMMERCIAL
a a e
W nit he La axelnpt thacftom and the basin for Ihu alleged exemption.Any vlolmion ,If El NEW HI.DGIA)DI'TUN EJI)FMOLI1'ION
Section 7031.5 by any applicant for a Permit subjcthe e applicant to a civil Penalty of POWER IIEVICIS
nl_w ❑TENANT ❑FOOD SERVICE
nn[mom Ill..rise hundred dollars(5500 L
F Z Y IMPROVEMENT
5EMQ ❑ Lo neworo[ma pntstmenm is not imendeawith eradO tside(See. 044.13wtinn, SWIMMING 1'001.1?LEC'I'k IC
W ea will dothewnr%and the Me Co lis not%License La R thiev of apply t44.owner
❑01(11?k
aim and
enywho b Code C.estheeo License Law Jcec work
han imself
of 33 OUTLETS-$WITCHES-PIXTUkfS
progeny who builds nr improves merlon,and who dncs such work himself or hmugM1
sal awn mnpinyma,pnrvided mot such int is
are on iyearof or offered The NEW It IiSi DENTIAI.ELECT If SQ PI,.
s�le,i,butdovec the builThe bur improvmneng T aih did a.
buil year arnpro le[far Tthe SQ,EL FLOOR AREA $ISQ.UT.
o. cr-buiWcr will have the burden of proving[bin be JiJ not buil)or improve for pur-
1 q'sc of sole.).
I,as ower of It
ct pa,TALI oro Business
mnfessi ns with Biomed naot Commerce
i- I f
amuseconstL[the project apply
.1a n.Business and u,who bei Cedd,,),i pr ve,thereon,L.i-
eselawdocanotahplymaswithaofpropcnywhesedpuaimr to doahommw and QTY. PLUMBING PERMIT FEE
�hn contains orsuch projects with a mnwcmr(s)licensed purnw[m t.[hc Cmm�mmr'a
Liccnsc Law. PERMITISSUANCE
1 1 um exempt under Sec. .H&P C for this reason
t
.no, Blum ALTER-DRAINA,VENT-WATER(EA) 00 r3 0 VALUATION
/�
WOR K ERN COMPENSATION DEiCLA RAI ION BACK FLOW PRO[EC.DEVICE 3
I hereby affirm under penalty of perjury one of the fol tie ing declarations: r v �J.
I haveand will nminmina Cenificatcof Consent m self-insure Lia Worker's C.mpen" DRAINS-FLOOR.R(IOP.ANBA,COND' STORIIiS '1'V Ii CONS'I'RUMIOD
en[ion,ue provWCJ fur by Seek...37000 me Labor Code,.a the perfonnunce of the
work Lia which this peondo issued t FIXTURES-PER'rRAP
EI 1 haveand will maintain Worker's Comperoa[inn Ino[.....as"govt by Section l/
9700 of its,Lehr Coca,fon hefon ancron me work for which his tis issued. CAS-IEA.SYS'ILM-I INC,4 OU .1I
M1 pc^'^ T1 ; S OCC CROUP gAPN
MyWnrkc6 Gmgnnsadnn lnrnnutec carnal and Policy number are n Y rj
Cnmcc Policy Nn.: GAS-FA.SYS'I'EM1I-O\'Ek 418A) /
CERTIFICATE COMPENNIIONEXEMPTION FROM WORKERS' CRFASIJINDUS'Dtl"N'AS'I'I:IWT.RC[71'[OR
GO c P mpleteTON INSURANCE f3UiLD1NG DIVISION hr':.5
(IM1ium[inn need not he completed lfthcpttmi[is(Drone hundred dollars($In)) GRHA51i TkAP
nr less.) FLANGE BECK PEI;
certify that in the performance oflhu work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.21(1 FT
nm antpToy auy"'s,in any mm�ncr sn u,m become xtih O,I ,,the Work—Cour
pcn. ENERGY FEE
z .anion Lawsol California.Dana
WATER HEATER WNE,YI/G:LECTR
2 O Applicant GRADING FEB;
Ex UjNOTICE TO APPLICANT:IL user making this Cenifte:ne of Exemption,you should WATER SYSTEMR HEATING
; Income subject m[he Worker's Compensmian provisions of he I,ahm Code,you mm[ SOILS FEE
D] F
forthwith comply with such provisions orthic permit shall he deemed revoked. WATER SERVICE;
a.
CONSTRUCTION I.ENDINC AGENCY NEW RESIDENIJAI.PLMH. SQ,Fir PAID
U O l hereby uBion that there isaconeWni^n lenJingagency orthe perfonnunce of D' Receipt#
I. F• he work for which this perm;[is issued(let.3097.Cie C.)
0 U I<edHe,Name TOTAL:
Lcadvea AJJr sa AI'
1r" 1 «ally hw 1 hm't rood his applicminn end qac Nat he above infonw...is HUI ING FEE 3 7
Jr 7
U7) correct,I agree to comply with all city and county ordinance,and cute laws relating it) QTY. A1ECHANICAL PERMIT NO"
U Z building mms.uaion.and hereby authonr representatives ofthis ci[ymenrer uponhe SMIC PEE S
;,I vcmcminnedpr.p:nyf rinyu[inn pmpo'e, PERMIT ISSUANCE 2
(We)agree m,ne,i^dcm^ify and koep horndces he City of Cupeninn against �/ C "il
I'abiliticijudgments.costs and expenses which may in any way accrue againa said City 1 AITERORADU TOMECH. I CPEI;
APPLICANT'UNDERSTANDS AND WILL COMPLY WI'I'IT ALL NON POINT AIR HANDLING UNIT(TO IB(gHCFM)
SOI'._ tl UI A'IIONS ] MECHAMCAIJ'EE
' /1-,�I�7-q9 AIR HANDLING UNIT LOVER IILIXkI CFM) CONS"HRUC'HON'TAXIF
Signmurcof pplicmNContranar "T L6 Um/e (— t EXHAUSTHOOD(WIDUC[) ( I IOUSINGNIRIGATION p.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant infinite buddingoccupan[more of handle bamNOns manorial BEAT ING UNIT BTO I00,000If'TO)
Jclined by the Cupcnino Municipal Ctxlu,Chapter 9.12,and[he Hwlh and Safety
vlc.Section 25532m) 111!ATING UN'T'O"ER IO don BTU)
V Yes PAID
VENTILATION I-AN,SINGLE RESIDE Dom kn'ciptp
Will the applicant or future building occupant useequipmentordevices which I301LF.R-COMP(3HPOR IW.OBO BE BE emha
it zardous air contaminants as defined by he Buy Area Air Qualify Management (I)TA l.:
DiaricC
0YW 149.1 BOILER-COMP(OW;R 100.1000 B'D))
1 have read the h—w,,O,ma¢rid,re .under Chapter 6.95 of the Cali. AIR CONDITIONER
yu5513a p / I ISSUANCE DATE
otil Ilcul[hI Ono,Cocc.Sc Sc inna255f15.2553)unJ 25534.1 undcrx[anA tion if[Le NEW RIiSID1;NTIA1,MECH, SQ.IT.
buil ' ,[ tncurrI TO H I,,iemYoc .ibllitymn of he neeupvm
nl 1'h sc PH I,,icwvnec y(aC iyytc ofitanyancy.
I 4 x! G�
Owner orunhonzcdugunt D"'. TO L:
r ISSUED BY. /
OFFICE C
AFiPPOVEUIU-6"
------------------- --------- .... .....
IN ACCORDANCE WITH THE CITY 00
CUPERTINO CODES AND'W91
ffANCFZ
SATE
SIGNED
This set of pans -iu -P.-. cations MUZT
be kept on tha jo'r a air times and it is un MASTER EH BL LK[❑I JOM
lawful to mal e an,, , -.r j,s or alterations I5'X 15' 1
on same with.,uk i,,ari pe mission from
,he building Dar),.. G:zy of (;up2,tino.
Fhe stamping of this li,an -.nd specification_
WI-L. NO'l be he d G permit or to be an
ipproval of the violation of a,.qy provision,
,f any City Ordinance or State Law.
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BEDROOM
10'X10' CLD
FAM, RM, LIVING ROOM
12'X25' 13'6"X17'
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LUC KITCHEN
12'6"X18' OFFICE
13'X7'6"
EEDROOM
12'X12'
GARAGE
20'X20'
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