S 2377 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPEKI'INO BUILDING-ELECTRIC L PERMIT NO,
BUILDING DIVISION APPLICKFION/PE.RMIT PL.UMnw;-MECBANICAL
BD1L11ING PROJECI'IUI?N'I'INICAI'ION S 2377
BUILDING ADDRESS: SANITARY NO APPLICAt ION SUBMI'MAL DAI'
7 74/ O OL' 1 7 .5 -q ? .
cIWNF NA li: - I'I{UN^C -�O CONI' , 90 :S ME ('I L�:Sf)./C,/^ N/C CONTROL
�•AltClll'1'EC'I/ENGINITI4X; LIC NO: AD 6s k�OX�{ro vX y '595Z,(,( ❑ .
CONTACT: PHONE: /`r✓h 6 BUILDING PERMIT INFO
❑ Co.sblumt Fees Paid by Applicant(Inlllal) BLDGCIJT f PLUMB MEl'JI
El 'W
❑
LICENSED CONIRACTOR;S DECLARATION QTY ELECI'RIC PERMIT FEE
I nermy alfa:n that 14111 r02-cal under previsions m Chapter 9 ten:nmeneina JOB DESCRIP'T'ION
FQa all
te Scainn]fXX)uO)ivision3nf 0:cMuni fJdv"n,A l'vnln.ionv Code.and my hccnnc ix RESIDENTIAL:
IAO I'I?RMIT ISSUANCIi
��� n full force and efre 2A �[� ` ❑SPUWI, ❑KITCHEN REMODEL.
FZW pcvnse[Ilt' Lic.p APPLIANCES-RESIDENUd. ❑ADDITION ❑PLUMBING RE&PIPH
>y ARCHITECTS DECLARATIONPANELS ❑MUI:I'1-UNIT ❑STRUCL
fUkA
mZ_ l understand my plans shall be used as public recoN MODIPICA'1'IUN
O-�Q Ulf F020IAMPS ❑INTERIOR E]CHIMNEY REPAIR
f"W 'weau'ui Profess:anal 201-1100IAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DITCLARRI']ON OVER❑X0AMPS ❑BATHRF, )DFL/ lil'AIR ❑ )FMOLITION
5 C Q 1 thereby if,.that I am csattpt from the Comrm9or's.License Law for the N -
fnlldwin6 rcaann.Iseainn]11115ItuProtestant,Axl
. niness and lhofesss e Any city or um^tY SIGNS ELECTRICAL ar
�a
W 3 LL.y which require.,a permit m construct,alte,improve,demolish,m repair any sbuch::n
priorwil,i.xnane,alsnre:,ma:l the applicant hush Permit,,file a'i'led date:no 1 SPECIAL CIRCUI'IIM TSC. 2 r J
}, that he is licensed pu,u:muo thepmvWonsofthc Connectors License Law(Chaplerl
�ry'CQ Qvn,meneing with Section'R00)of Division 3 ofthe Business and Professions Cdxle)nr TEMP MEItR OR POLE INST. COMMERCIAL;
Ohm he is cxcmpl third and the basis fur the alleged u,,uptinn.Any vinialion of ❑NEW BLDG/AUDITION (]DEMOLITION
Semon 7131.5 by any applicant for u permit wbjets the uppli,od lu a civil penally of POWCR UIIVICES
V' not ream than Five hundred delta,($500). ❑'IRNANT FOOD SIiRVICIi
SSG I.asownerofthc n SWIMMING POOL ELECIRI IMI'HOVI3MITN"f
property, my employees with wag..Ibcia se.compensation.' ❑O'I'HIiR
ad will it,)the andtheI hemurei,lkWl 1.nJedm La,due,
Business
IA 3 :mJ Pral'essionx Cudc'.'I be Cnnnudod Lim:ue Luw dnen nm apply to un owner of OU'ILEfS-SWI'fCllf:S-FI%'1'IIRBS
L progeny who M1uihl,or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are nut intended oroffered ll, NEW RESIDENT]AL ELECTN SQ 14.
sale.IL however.the buildi ng or Improvement is sold wall none year ofem nupirinthe SQ.FI'.FLOOR AREA SISQ.FT.
ar-builder,will have the burden of proving that he did nal build fir Inmmvc fur per- r
p:. .r: 1 rar I
T
❑I, rth p sa, I IY tract 8 tit to sed t t„ma fib p J t(A 71109 13 : .. d l I :C ri Ia C t t —t.
,eHo, t plly Ip ty n 'I l: p :fi ,ted QTV PLUMBING PERMIT FECh e t s f rsuchproj twthaumtui ns)Icensedpursuanti theC um.e J 9
Lae.e Ltw. PERMIT ISSUANCE /
I am esennu under Sec, .B&P C far this mason
ACIER-DRAIN&VENT-WA'I 17K(EAI VALUATION
Duper Dute B
WOR KER'S COMPENSATION DECLARATION BACK FLAW PROI LCI'.DEVICE
�❑ I hereby affirm under Penally of perjury one of the following declamtions: - �'-
Inavm:ntl will:mm�eunaCcnilirnlm+(Cona7nnnclhinserelor Workor',C( ,en- TRAINS-FLOOR,ROOF.AREA.COND. STORIES "1 YPH CONST RUCTLOt
nation,as prnvidcd for by Section 37(91,,f the labor Core.ha the peforn.alt nl the ,
a kforwhichthis penult,issued. FIXTURIiS-PER'I'RAP
� - have and will muradin WHkers Compensation Institute,as mnmic l by Semina GAS-13A.SYSTEM-]INC.Y OVI'LETS
"bonf tlm laMr Cade,l'nrthe Perlbnnnnwof the work fur which this permit is issued. GAS GROUP MIN
Aly Workers Cnmp alien ser ca p Policy�u,u:u�'r r'
Carrier: ay Na:GULdd4 '0/ GAS-ITA.SYSTI3MOVITRJ(IiA)
CERT119CAEUEI SMIONINFRANCH IiR$' GREASE/I NDUSTRI,WASTE INT ERCEPI OR
COMI'13NSA'I'ION INSURANCIi BUILDING UIVISIO_N_FCFS _
(this section Hell not bunny,tried it the permit is for one hundred dollars f$l fury GREASE I'RAI'
or lees.) PLANCIIf?CK THE
I coni fy mm in the peamarcloaHf the week for will his .it is i...id,lshall SEWER-SANITARY-STORM EA.2N)FT.
nal emploan ..
y .. ...Ham,manner su u,a+hunme suhjeet u+the Winkel"Com,.- ENERGY TEL
Z waxen lawxof California.Dae WAT ER HEATER W/VFNI/IJJiCI'R
z 2 Applicant ) GRADING FEE'z'.'h NOTICE*10 APPLICAN'P.If,ufmr ,making this Ccrtificmc of Exemption,you should WATER SYSI'EMrtREATING
baemcFide, ,,the WnrkeBx Cnn,arriatio i pro sin.of the Luba Code,you mus SOILS FEE
.
ballnvlth enn+ply with such provision,or this permit shall be decreed:evoked. WNYiR SERVICE
p' CONSTRUCTION LENDING AGENCY NEW RIiSIDENI'IAI.PLh1B. SQ.FL PAID D r Rccc11,
O
I heathy affirm that them is a aonvweti...+lending agency ler the perrommnceor
fire wale for widen this Inst mit is ,md(See.3097,Clv.Cd
O U lancers Name 'II)'1'A L:
lender',Address TOTAL:
I certify thin I have real this application and state that the above information is BUILDING FEE
IrN
lalres,.lagrn,a eonlply wiihall city and cn.ntyordinanccs and sone la--dating u, Q'I'Y. MECHANICAL PERM I FEE SHISMIC EL.IiCfRIC PEE
pleb
U Z building conomelion,and hereby authomm mpresenelivcsnl thineflym enterupto the ]
above-mentioned pmpeny for inspection puroses.pPERMIT'ISSUANCIi � O
(We)agree to save,indan lfy and keep harniless the City of Cupertino against of
Iiabilities,juJ6mcmx,cues and espenseswhi1lHH1y in any way amrneapxinasaid City ALTER Oil AUDI 0 MECH. PLUMBING FEE
re..sequence ill 8ranting oI this permit.
AI'PLIUNI ISTANDS WILL COMPLY WITH ALLN'1' AIR HANDLING UNIT(TO 10.000 CFM) MECHANICALIsEE 'V
SOURCHI r 61' ONS 7 9
AIR HANDLING UNIT(OVlil<IfI,I11X1 CFM) CONSIRUCHON TAX
Sigoawm.f ppfiema/Commaor dam EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE. q O
Will the applicant or future building o¢npaurtnmm or handle hur.urdmus material HEMINGUNIT('10100,X0ILtTU) 4
;is demand by the Cupertino Municipal Calc,Chapter 9.12,and the I lealth aid Safety -
Cede Soetion 25532HH? HEATING UNIT(OVER TIMI qXl BTU)
Cl Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Date Receipt)
Will the vppiisam or future building occupant use laInpmrm or chairs,which HOILI3R-COMP IJHP UH 100,00)B'rU)
mit M1avardnus air ei nwmi ands as defined by the Bay Area Air Quality Mza glarent TOTAL:
Dlema" BOILUR-COMP(OVER 101,100 BTU)
❑Yes No
jq6I 1 .2-
I have read the hvardnu.materials requirement under Chapter 6,95 of the Cali- AIR CONDI'HONER ISSUANCE )A
maria Ilcelth&Safety Costs,Sections 25505.2S533 reit 25530.1 uHde,..d that Ville NEW RESIDENI'IA[.MECH. SQ.Ell
huildtugdoe,notcurrcnfiy haveamnam.0m iI,,n,Y re,forobility uua+..fy the, nt [
ofineand +• deb muse met)dorm Lswan's of u Crialicaw nl:fu:a /�
Owncnv authy t>W- )am T 1 O� ISSUED BY
OFFICE