99100080 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
• CITY OF CUPERTINO 6UILDING-EL19LOUBE U PIiRMI'f NO. 59
APPLICATION/PERIMIT PLUMxmr.-no-:cunN. At, l0
BUILDING DIVISION BUILDING PROJISCr IDENTIFICATION 01
BUILDINGADDRISS: r SANITARY NO. APPLICATION SuBMI'rIAL DAR
/0 -/57--3p9
OWNERti NAME,: PHONE: CONTRACIOR:S NAME LIC NO.
- NIC CONTROL
1 ❑
•ARCBITHCI'/ENG] EER. LIC NO: ADD ]TSS 41 Y
CONTACE PHONIS: BUILDING PERMIT INFO
❑ Corumbanl Fmx Paid by Applicant(Initial) BLUUyG GLLEECIPLUMB - MECII
E ElS E L'J
LICENSED CONI'RACTORIS DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1:nn licensed ander provisions ofchaper 9 a,ommeaang JOB DESCRIPTION
Ot Z 'tit Sr,ian70KXdof Diaieion?oche Baxn¢ax and Pmfeaa.n Cnna,nndmyliccitwix RESIDENTIAL
wOO wl PERMIT ISSUANCE
b ,, t fullfnmumW cA'« p ❑SFUWL ❑KITCHEN REMODEL
aVU license Class iEhL!'�_Lic.p 44'1 'r' APPLIANCES-RESIDENTIAL ]ADDITION ❑PLUMBING RIs PIPIT
HZW Date Coonan().
mGn
F 5 y -3 MULTI
ANCiII'ECTS DECLARATION -UNITEI STRUCTURAL
mZ L understand my plans shall he used as public records MODIFICATION
OZ= UI'TO 1110 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
O
F L/LW Licensed Professional NII-IMAMPS IMPROVEMENT E]SWIMMING POOLS
C Y OWNER-BUILDER DECLARATION OVER IIIW AMPS ❑BATH REMODEDREPAIR DEMOLITION
tX Q 1 hereby axion that I am exempt from the Contractor's License Low for the El
OTHER
�•31 F following reason.(Section 7031.5 Busines and Professions Code:Any city or county SIGNS ELECTRICAL
filch Illi n 4.1
copmanyfntart n t c 1 'sLaw( nmcmenr RI'ECIAf.CIRCUIT/MISC.
she 'm ¢how lGM1nPtcr9
) fcsslllasCode).. 'll?MPMITER OR POLE INS'i'. COMMERCIAL:xempt there roe abases or a eJ cxa ran.Any vimlmion of El NEW BLDG/AUDII'IDN ❑DEMOLITION
Sec ] u rc un acivil penalty of 1'oWT;H DEVICES ❑TENANT El FOOD SERVICE
I„ rat he� f ) IhIPROVEMIaNT
cera ]n thcinole compenmtion. SWIMMING POOL ELECTRIC ❑OTHER
n lc(Sem.70tLBusiness
Ol t anw 1x not applyman owner of OUTLETS-SWITCHES-IIXTURPS
np n msdf or lM1mugh
.y vied h 1M nr.ffcreJ for NEWRESIDENTIALELECI'R SQ ET.
Jin ye,: nmlction,the SV.IT.IL(IOR AREA SISVIrI'.
u d n imps f P.,
Emil
a n'u 1 TOTAL:
1,as owner of the pm,vmy,an exclusively contracting with licensed connector,to _1K0 —15L
.nnuct the pngat(See.]IW,Busine,R and Professions Cdtract
e:)'On,Comoh Li-
nm law does nor apply to an owner ofpmperty who build.or improves thereon,and QTY. PLUMBING PERMIT FEE
whocomovers for such projects with a mntector(d licensed purmantto the Carna rs
L.iceme Law. PERMIT ISSUANCE
1 am exempt under Sec. .N&P C for this mos
ALTER-DRAIN&VENT-WAS IiR(EA) VALUATION
(trine. Dale 00
WORK17R'S COMPENSATION DECLARATION 13ACK FLOW PRITTEC71 INWICE
1 herebyattired under pcnnhyate of Conencof theinsurc for Workers
o V
t have and will maintain inection 3cml of be Labor
Code.l of erur Workers Glmpcn- DRAINS-I1.00R.ROOF,AREA.COND. STUNII?S TYPE CONSTRUCTION
ration,as PmviJW for by Stenion?]1x1 mf the Labor Cole,for the perlinmanec of the
ork ithwhichmixpermitisiswcd, FIXTURES-P[NTRAP
1 have and will mainein Worker's Compensation Insurance,as rcyvired by Section
3700()fine labor Cache.for the performance of She work for
whichthispermit isissued. GAS-F,A.SYSTEM-]INCA OUTLETS OCC.GROUT' AI'N
My Work o perlsti :nrsuiy¢ rur/re carie Pol cy No.Y..,r�^Shpt GAS-EA.SYSTEM-OVER J(EA)
Carl - h d -37-GYE
CERTIFICATE OF LiXEMP`r10N FROM WORKERSGREASFANDUSTRL WAS If:INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(rhl,,rainn nedoon She,cmn.re,difinepermit is for tine hundred J.Ilam(S 1 BE) GREASE'I'RAP
PLANCHECK hili
Loy any the in the any nrmm�cenfthework For subject
It is Pcnnitis Worker,
SHW RH-SANITARY-S'IUItM ITA.21q FT.
not employ any @'rson in any manneno as nl become wbj«n In the Workers'CnmPem ENERGY Piili
Z action law s.,Ca'
mmia.Uvm WATER HEATER W/VENT/ELECIR GRADING FEE
ZApplicant
= NOTiCE TO APPLICANT:If,utter making This Ccnixcvte of Eacmphun,you shmuM WATER SYSTEM/IREA'ING SOILS PEE
[-� become subject tu the Wnrki Compen.mion pmvisiyns of the La1en Cale,you muss
IZ forthwith comply with such provisions or this Permit%hallM deemed revoked. WATER SERVICE
v] O
7z
CONS"I'RUCI'ION LENDING AGENCY NEW RF:SIDENTIALPLMII. SQ.Ff. PAID
I M1creby affirm mut mem isxcon.gmmian lenoin lin the Hermance of Dom Hccaptb
LJ O .C.) Y Pre
LF. H the work for which this perndt is iremd(Scc.3B9],Civ.C.j
l ornl:
O I<ndcrs Name TOTAL:
L:AJJress _
1 I ecnify mot I have read This application and mate that the aloe information is BUILDING hili
nF. to coned.l agmem comply with all city and county ordinances and slate laws relating to QTY, MECHANICAL PERMIT FEE SEISMIC FEF.
U building cmahm,,miredfid lamehymnaml rx,resvirmavescfthis city,.enter.,.the
aMrve-memi.ned property for inspection purposes. PERMIT ISSUANCE ELECTRIC IEE
(We)agree to save,indemnify and keep harmless the City of Cupertino again,
liabilities,judgtnenta.lnmsnnd expense which may in any way«cme against said City ALTER OR ADD TO MECII. PLUMBING FEE
in
consequence of she gaming of this permit.
A'PI.ICA NT ONDCRS'SAN US AN I)WI LL COM PLY WI'IPI I n LL NON-POINT AIR HANDL.]NO UNIT'LTO I IkIXXI C17M) MUCHANICAIT17.
SOURCE REG ISLATI(N.S.
AIR HANUhINGUNI'I'(OVER III(NXICPM) CONSTRUC'I'ION'I'AX
Sib of APPliramUCenn.art Dane HXIIAUSTHOOD(W/DUCI'1 HOUSING MI'TIGAT'ION IIJi
11ALARD S M HUAI S DISCLOSURE
Will the applinnt or fuwre ding«cupantn«e nrhenJlehlmnal usmamrim HEATING UNIT(TO 100.000 BTU)
as dcxnd by the Cupertino Municipal Code.Chapter 9.12,end the Health and Safety IIIiATING UNIT(OVER 100,0013,BTU7
Code,Section 255321sT! �^'
E]Ye, Nn VENTILATION FAN(SINGLE RESID) PAID
y D1 Rctip
Wi11 the applicant or future hall lding occupant use equipment or deviceswhich BOILER-COMP QHP OR 100,000)BTU)
Ain hanndous air enmmninalns as defined by the Buy Arca Air Quality Management 'TOTAL;
iNrin] BOILER-COMP(OVER 100.0011141 U)
E]Yes lii No
1 AR CONDITIONER ISSUANCE DATE
1 have mad the hazardous tions 2l. 5,2i 533 an under Chapter understand
of the if She
Asmia Heath&t currently
tlym Satires 25505,is no, and 25534.1 undcnund that if the NEW RESIDEM'IAI.MI[CII. SQ.FT.
building does not curtcnc huvcumnant,the i",ximrtot.Cerryase,irr the«eep:lnt
ofmc rtgmmm tic m hC men to issmnce ofa Certificate,of Occupancy.
Owner()r authorize ugenr Date TOTAL: ISSUED BY:
OFFICE