S 1369 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.EURcrRICAL PE ITNO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 1369
BUILDING PRO]F,C'r IDId TIFicxr o.N
BUILDINGADDRIi55: SANITARY NO. APPLICATION SUBMITTAL DAT.
RCHIT'ECI'IENGINEERC: � PHONECO LICNO:OWNERS NAME.
NlC CONTROL
p
IqlT
LIC�NO_ ADDRESS: 3
J ❑
7
CONTACT: PHONE: BUILDING PIHCAIFINFO
� 'ksP"'� �8 —,a2 ❑
Consultant Pces Paid by Applicant(Initial) RLDc� IiLGL'J� Pl.Uht MO I
LICENSED CON'FRACFORS DECLARATION Q'Py ELECTRIC PCRMIT PEE IrJM df
hs eby afnrm mot Inn licenced under prnvixinns of Chuptcr 9(commencing .TOB PT
DESCRIION
�C
�O with Section]I11N)of Divininn?nfthc Business nnJ l'mtessions Code,nnA my
license is PERMIT ISSUANCE 3 RESIDHNTIAL:
1-•W in full force and.1l ✓ ❑SEDWL ❑KII'CHEN REMODEL
WP
U License Class Lic.#
IQ..,ZW Dae Comrac r API'LIANCIS-RCSIUF.NT1nL ❑ADDITION ❑1'LIJMBING RE PIPE
VaQL1. ❑MULH-UNIT ❑STRUMORM
ARCIIITF. S .CLARA N
Z FO y m cs nit y plan h use uhlle PANELS MODIFICATION
CZ— e UP TO 200 AMPS NTERIOIt ❑CHIMNEYRFIcUlt
[-,SFW IcOsed Not...ound 101-100AMPS IMPROVEMHNT []SWIMMINGPOOLS
�yf - OWNER-BUILDER DECLARATION OVER IOf0AMP5 El BATH RF.MOIJEI/REPAIk ❑DISMOLITION
C Q I hereby affirm mot 1 nm exempt tram the Comracwr's License Law for the
a0aU following mmun.(Section]0J1.5,Businessand Podesnimns Code:Any cityor county SIGNS ELECTRICAL ❑OTHER
0. y which requites a permit us.....Lama,alley,improve,demolish,m repair any suudure
prmrwits insuuncc..aLso requlrnahc aPPlicam for>achpermomBleas'ignedsmtement SPECIALCIRCUFUMISC.
that hchllccc,d Eat,ammanlbcprnvim oaftha Conitnclnr'u tanner,l,uw lChapter9 ,�;e COMMERCIAL
Q (commencing with 5eninn 911llfpnf OlvisianJnf the Bunincs and Prttlinsinn,Code)ar TEMP.MIMERORPOLEINST.r4
d e that be is exempt therefrom and the basis for the a11cgW exemption.Any violation of ❑NEW BLUGIADDITION ❑DIiM(1LITION
�N
Section 7031.5 by any applicant born permit subjects the applicant m a civil penaltyof POWER DEVICES 'I ❑TENANT ❑FOOD SERVICE:
^Z} not mom than fisc huneree doll urs($500). IMPROVEMENT
0 01,as ownerof the property,or my employees with wages as their sole compensation, SWIMMING PGOI"ELECTRIC
C o willdnthewark,and Restructure is not immridedoroff d forsul,(See 9DYL Foxiness 014 []OTHER
W eo
at Professions Coen.Tim Conuvemr's Licenso Luw dues nal apply loan owner of OUTI.HTS-SWITCHIis-FIX'I'111t17S
�- .. prnpeny who indiction improves Ibercon,and eche Jots such work hinssclf or through
his awn employees,provided that such improvements me nut intended nt offered far NEW RIiSIDEN'I'IAL F"LEC'PR SQ FT.
sale,If,however,the building or Improvement is%old within one year of completion.the SQ.Irl'.IaLOOWAREA $/SQ.PI'.
nwner-hni lder will have the harden of proving that he did not build or improve for put- //''��rye O
pose f.'I ) TOTAL: #A
❑ I fab p pe 044 i . ly tnt g tilicensed contractorsu' ` R,$
rat w es n a apply t)an u : perry wh c J )r1 1 t t 1't- �T
cert e L J tloo a fp p ny builds 'ml :theocratic A Q'1'y, 1'I,IJMBING PERMIT PEE
who contracts past proJens w''In acanwemr(0l ancc0 Panama 11)thcC w t Is
License law. s PERMIT ISSUANCE
❑lam eacntpt ander Sec. ,B.F PChnthis reason y'
ALTP"R-DRAIN bt VENT WATHR(PLA) VALUA
Owner Date �—� o
WORmIerp Ct1M PENSA'1y on UIiCLARATION #ACK PL(1W Plt(YFEC'I'.DEVICE D
se and will
a penalty to of Con enet)the
lf-ins rc following rkersmts.
mase and willmaintainIby ection 37M of Consent Laino elf-in sure for WmcarmiCompett- DRAINS-1'LODR,ROOF,AItIiA,COND. STORE.q TYPE CONSTRUCTION
scion,as provided ray mi Section J](NI of the talar Cade,forme perinnwnce of the
n I for which this permit is orker' FIXTURES-1'ER'IRAP
I have and will od,(maintainlot ,
Compensation Insurance,m o,cro by Section
17100 the Luhur Code.lonhc lwrfnrnavnaa ol'tha work for which this pennh is issueA. GAS-IiA.SYS'I'1?M-I INC.4011'F ,T$ OCC GROUP APN
My W akcfr Cotnpvnsation Insnntnce .,ier and Policy rman ntrc:
Carne, policy No.: GAS-P.A.SYSTEM-OVER 4(EA)
CERTIFICATE OF FXEMPFION FROM WORKERS' GREASBIT NDUS'IRI"WASTE INItiR'E
COMPENSATION INSURANCE BUIL DING DIVISION
Cl hissectlon need not bccntnpleted ifthe pcmtit is Enron,h rao•.d dollars F$1001) GREASE'I'RAI'nr less] I'LANCHECK PCE
I certify that In me per(urnnmen of the work fur which This permit is ionnd.I shall SHWER-SANI'T'ARY-STGEd,13A.2110
nal employ any person in any numner w ns to Itecanm subject to the Wurkerd Csnnpen- IiNliliGY FEL'
CZ sabmt lawn of California.Date WATER HEATER WNENT/ELEMR CJEERG FEE
Z Q Applicant
NOTICE 10 APPLICANT:If,after making this Certificate of Exemption,you should WATER SYS'ITMnREATING SOILS FEE
become subject to the Worker's Compensation provisinro of the Labor Gale,you must
LaFa
forthwith comply wimsten provisions an this pnnnitshall be deemed revoked. WATER SERVICE
Q
� Z CONSfRUC'TION LENDING AGENCY NEW RESIUEN'1'IAI.PLMB, SQ.PI', PAID Doc Receipt#
UQ which
this
i i...ed ed.30lenJing agency fonhe pertinmamcenl
L•' the work fm which this perosit is icsuM(Sec.309].Civ.C.)
0 Lender's Name TO'T'AL
U :
Lender's Addmss D
r y 1..airy that 1 have o ad thin application and'Ode that the ahove information is BUILDING FEE D
sF-t h oarrcn.1 ugrco to comply with all city ane county unlinnnws and awn law.rchning m
QTY MECI IANICAL PHRMIT FEB
Ula. nnileittsemt,wanehan.amheresyanthat;retepmnemadine.nrmincitymcnlerupnntne SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCIi is 0
(We)agree to save,indemnify and keep harmless me City of CuKr ino against I7l.ECfRIC 1LE
lialinfiies,judgments,rosts and expenses which may in any way accnm against said City ALTER OR ADD*TO MECI.
in cnseyuence of the gmntingof this permit I'LUh1RING PEE f
APP DERSTANDS AND W A COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(To 10.000 CIM)
AWTIRC rld..ATIONS. MECHANICAL Hit
3 AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TAX
7;,nature afnpplicanUCommmor Date EXHAUST HOOD(W/DUCr) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant to Enure building acupant.marcor handle hamrdous material HFATING ON['I'(TO 100,000 IITU)
as dufced M1y the Coianno Munloipel Lot Chnptvr 9.12,and the Ilculth unit Safcry
Cale,Section 25532(.0'1 �/ RELATING UNIT(OVER I Illl,lltlll If 1'U)
❑Yu No VENTILATION FAN(SINGLE ItI51O) PATO Date Recaipt#
Will the applicant or future building areupm uuse equipment nr dn'ices which
nit knound us air contaminants as defined by the Tiny Area Air Quality Management BOILER-CONTI'(3HP OR II0,0H0 BTU)
D14meR BOILER-COMP(OVER 100,IN)OBTU) N f
❑Yes
'I
1 nave read m �nl
e nann.tnmeriaH regnlmntams sneer,.napier 6.95 nr me carAIR CONDIIONI?H
. ISSUANCE DATE
(unit He:d Safety Code,Sections 25505.255ll and 255W.1 undenlanit that if the NEW RESIDENTIAL MECH. SQ.PR
ng 'unentb'have a ten.m rat it ist 1 msibilirymn�tify the acupant ( / Illlll
6f th qui wants their mus,M+ rnmi Icor,da Ccnincmc of(k'cupanry.
98 _ OTAL: �o r a
rite]agent Dutc ISSUED BY:
� OFFICE
1
r
Je.