99100108 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY O O
CITY ON CUPF,NTINO IIUO.DING-hF.C'l'I'RIC'AL I'IIRMI I'NO.
RUIIAINC DIVISION APPLICATION/PERMIT I'LUSfI{INC.-hIEC11ANIC-AI, SOOOI
BDII,DING PROJECTIDBNI'IFICADON
BUILUINGADDRESS, - SANITARY NO. APPI.ICAI'IONS(1BM1'I.1'Ai.DAI'H
0221 ( v sten Drlvz
GMT
E: I'IIONE: C NINAC'1')R'SN IJC NO
L�is -Q.r ,b u N NIC CON'1'RUI,q
• ARCIIII'LCI'l1iNGlNiiliR: hICNf): ADDRESS: wn,q �- ❑
• CONI'ACI` PHONE �i HUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUMB MIiCH
' ❑ El F-1
I.ICIINSED CONTRACTOR DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I ant licensed under provivons of chapter 9lconnenrmp JOB DESCRIPTION
00 with
hSction 7000)off Dlvixion a nrmc l)uxinms unit l'ml'swions Cock,undmy uecn,w;i.v RESIDENTIAL:
PL'RMI'I'ISSUANCE ,,,//
_ ❑SPUWI, yMkKl'1'CIIIiN RIiMOUEI.
TUU Licenvc Class Lie.M
6 U AI'I'LlANC1i5-RESIDENTIAL ❑ADDITION PLUMBIEVG RUCTURAI. IYIi
F+Z IA Dale Comatcl L
ARCHITECT'S DECLARATION PAYEfS ❑MUh1'I-0NII' ❑S MODIFICATION N y Z_ 1 understand m I %hall be used u.public c N. MOUII+ICAI'ION
OZ— my pu icren UP'10200 AMPSYry��{NfEk10R ❑CHIMNEY REPAIR
1-'!I f'I�i] Licensed Professional 201-10)0AME5 IMI'kOVEMIiNI' SWIMMING POOLS
OWNER-BUILDER DECI.ARATION OVER IM)AMPS XBATH REMODEUREPAIR DEMOLITION
M 6 I hereby amnn that[;in'cxr,mpl IToro me Commcmr'u Few fhe i,lrnmc or t
X O a U following reawn.(Section](Ill s,Bus rat,and I'rofewinns CWe:Any city or county SIGNS ELIiC'I'RICAI. ❑OTIIIiR
47 3 W which requires n permit to commuct,altor,improve,demolish.or repair any structure
�a70
it to issuance,alvorcquire.v moa,licantfnr.,nvh prmonto,Fle usignrdnmmment SPECIAL CIRCUII'IMISC.
Eloy that he is licensed pmmaat m the Provisions Of the Com icon"License Law(Chap le Y COMMERCIAL
III C4 (commencing with Section 71 lot Division l of the Business and Professions Code)or TEMP.Mi:IlIR OR POLE INsI'.
m m e C thin he to emupl heirloom and the heels for the dir,o l cacmption.Any violation of ❑NEW RI.DG/ADDITION ❑URMOLITION
Xaa
Section]031.5 by any applicant for a permitaubjccts me applicant n a civil Formally of POW17R DEVICES ❑T17NANT ❑FOOUSEItVIC1.
F. not more than rive hundred duties(S504 IMPROVEMENT
r�SO O I.nnowncradlhapntpr,my.ur, my cntployccx wlnh wages us their nnlr,compensation. SWIMMING POOL ELECTRIC
d will do the work,and thexlmc,.m isnot mended or offered fin sale(Sm.]IDx.Busincso DTIIIiR
zFo
W and Profcsslom e Core: Contractor's Licerse Law does not appy to an owner Of OIf11,ETS-SWITCIIRS-FIXTURES
pnparrly who build,or impasm themr+ and who Anes such work himself ur do 11
[drawn employees.Provided that mor improvements are nm n m akd or uttered lin NEW RESIDENTIAL.III.ECI'R SQ
sale.IL
however.the building or improvement is wdd within one year ofcompleuon.the SQ FI'.PL(H)R AREA SISV.FT.
rwn
c,limider will have the harden of proving What he did non build or improve for pur-
psu nl sale.). T($AL:
.ono
owner of the(Sm.7044,
am exclusively contracting with licenced emmeturs m
malruan hcpct netIScu.]Mx.amerof andly who Imoium,Code'J proves themor, rad
nu Lawdoes,fonor rSch pymon With
aofproPcny eccesedpds rsiant to the Contractor
QTY. PI,UMHIN6 PIiRMI'1' FEE
who contracts riot such protects with a nmuacu,rt,)licensed pursuit to the Cnnmctor's
Ejector,I,w. PRIVATEISSUANCE
1 am exempt ynder lm. .11&PC for this«aeon
O ALTER-DRAIN&VI; -WATER HILA) VALUADON
Owner [late
WORKEk:S COMPENSATION DECI,ARA'1'ION BACK FII)W PROF EC I'.DEVICE D l\
I hereby afire under Penalty of perjury one of the following declarations: F-/
❑ Ihuvcon"will mainmmnCenifcnlenrConsemmsclf-in.wre ben Workers Compri- DRAINS-FLOOR.ROOP.AREA.CONU. TIORIE TYI'IiCONti'I'RUCI'[ON
satin,as provided for by Section 3]1X1 of the I.abur Cute,for the performance of the
ark for which this permit is issued. FIX'rUR&S-PER TRAP
I hose and wid
ll :,,nlai.Worker's Coce
mpemair.Insuran ,as refilled by Sem i -EA.SYS'fC:M-I INC.JOUII,IiTS
nn
3,
,(to
the hales Ce.for mr,performance of the work for whiahnhi,Permit k v<tmd GASOCC.GROUT'
My Workers Compensation Emulative comfier and Policy number am: CAS-F.A.SYSTEMOVERJ(EA) -J
Currier. Policy No.:
CERI]FECAL 1:OF EXEMpfLON FROM WORKIIRS' GR EASUINDUSI'RI.WAS'1li IN 117 CEPTGR
COMPENSATION INSURANCE. BUILDING DIVISION I B
(Ilri,wouna,wed fail MxontpletdiRhe pair is foronl hundred dollars IS Halt GREASE TRAP
' nr less.) PLANCIIFAK PIiE
I cenify that in the perfornatme of the work for which this permit is issud.I shall SEWER-SANITARY-STORM EA.210 FE ENERGY FEE
am employ anY person in any intoner so a,to become Muhjell to the Workcrs'Compery
Z ,anion Laws of Cldfarmo.Date WAFER HEADER WIVEN'1'IELECI'R GRADING FELL
Z O Applicant t
NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you should WATER SYS'ITMIFREATING
ben:ntesubjr,rt m the Worker.,Compenxaliolo provision,of the 1-aha Code,you must 5011 ti ITE
UJr et
fanhwithmplywiboach pr..vrunmudd,permit shallbe churned revoked. WATER SERVICEi
Q
7 z CONS'FRUCI'IUN LENDING AGENCY NIiW RIiSIDIiNTIAh K1,113 SO FT. PAID D:nr, Rcaclpld
U 0 l hereby affirm that there is a construction lending agency for the performance of
6. nhr,work for which Thi,permit iv issued(Sm.3097.Co.C.) TOTAL:
Q V InmJer's Name 'DOOM.:
r W Lcndrr's Addma BUILDING FEE
0. 1 artily That 1 have read thin application add etre Thar the above infommtirm is
rFa V, ctractl i,ment mraply cont.11 tiny and county onlin:um,,and s,am lotwn«Hating to QTY. MECIIANICAL PERMIT FI?E SS Ii_-ISmC'pop
U Z budding comuumion.and hereby aumave«presentarvea ofthj,city to enter upon the I -
nMwo-mm
emioned ppeny far monm ion propose, PERMIT ISSUANCEI:LGC[�tFFE1:
(We)agree no once.Indenmil'y and keep harmless the City of Cupertino agolnu
I 0abilitie,judgmcros.rosBanlespouses whichmay assay way amnengeiml said City ALTER OR ADD'1D MECH. ' PLUMBING FEE
oroci uranc of the griming of this permit. 1�
AI'PLICAN'I UNDERSTANDS AND WILL COMPLY WI'1'11 ALL NON ROINT Allt HANDLING IINIT PIfI 1!1,0X1 CF11) Il MFCNANICAl.MET 199
SOURCE E 'L S.
r Z At R HANDLING UNIT(OVER I RM)O CFM) f� CONST RUCTION TAX
ills amid Ap,hemtiCnmracmr Dae EXHAUST FOOD(WMUCI') ffI IIOIISING ME I'IGAIION I'lili
IIALARDOUS MATERIALS DISCLOSURI:
Willlhen,fitanlor Into,,Fuddling oscupmwac a In dlc har.nrdou„niarial DEALING UNIFit O 100IMM)BTU) __-
a,debnd by rhe Cupcmino Municipal Code,Chapter 9,L2.and the Hirci h and Safety HEATING UNIT(OVER❑MhIXMI 111 IH
tale,Seen...255Secnl.a 2553200 � ,(
❑Yea pQ r�o VIiN'1'ILA'fION FAN f51N 11.E RT.51D) PAID
/4 Ilnlc Recciptp
Will the applicant or future building Occupant use equipment mr devices which BOILER-COMP(JHP OR I(Xti BTU)
mil h:o'nous air cnmuminunl,a.,JetineJ by the 11ay Arca Air Quality Management r/ TOTAI'. Q 0 a SI
District? B(B,ER-COMP(OVER ROOM 11 IT)
Yes <No
Alk CONDTI'ION17R ISSUANC17 DATE
m 1 have mind the hazardous rvlerials mquiremema under Chapter 6.95 nr the Call-
ford.Ibalm&Safety Cooke.Sections 25505,25533 and 25!e x.1 understand that if the NEW RESIDENTIAL MECH. SV.14. / 0 _ Z,0 . 9 j
It"Idngdoc, a tally], m Rnn:I denill„mym,prm,dalityu n...lfythe"ou"a I
of dw regal a cora eem0eaeaffx panty.
Ih me cot u Du¢ TOTAL: ISSUED BY:
,walOFFICE