S 0221 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPBRTINO BUILDING-ELEC'1'RICA I. PHRhtl'INO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL _ C O
BUILDING PROJECT IDEN'IIVICA'I HIN J
221
BUILT/GAD �S:5 ��� / r.�0�� 69 1 SANITARY NO. APPLICATIONI/ti�y1111M1'I'I'AI.DAPI
OWN pyNhffA/V/l_ /A�//h/S✓Y��N(rjlP/ C THA UH' G: 4 �r
(//Y'/CY V-L✓�L:/i �!' NIC CONTI'ROI,IT
•ARCHITECDeNGINEER: LICNO: yRl.$Y � �0 �J � n ❑
CONTACT.. // PHONE: ✓S5 CX/w— BUILDING PERMIT INFO
/ 1i��/� ❑ Consultant Fees Paid by Applicant(Initial) BLDG I3LIi PLUMB htF.1
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby aflirm that Into IicxnseJ under provieinn of Chapter 9lannnumcing
cgQ with Seefinn 7lNXq olDivisinnJof the Bmi.—tor Frufes ons .Ac'nJ myliamsc is RESIDENTIAL:
PERMIT ISSUANCE
F��F int llltnmcand 1' ❑SFOWL ❑KI'T'CHEN REMODEL
04Z liter,: Chs i.ic'b APPLIANCES-RF,SIDENTIAI. ADDITION ❑I'IAMIiING NIi-1'11'1:
y Q U Uwe Cnmreelnr
ARCHIIEC T'S DECL RA 1 N PANELS ❑MULTI-UNIT ❑S'fkUC'TURN.
F raZ Iink,isund soyplmsshull housed us public records MODIFICATION
Ozv�Q UP10200AMPS ❑INTERIOR ❑CIIIMNI?Y REPAIR
FBF 111 Licensed Prnfcxsinnal 201-10g)AMPSIMPROVEMENT C]SWIMMING 110015
ad J OWNHR-RUILDER DECLARATION OVER IINXIAMPS El BATT!REMODFUREPAIR ❑DEMOIJ PION
6 1 herchy.them that I am exempt from the Contractors License Law for the C]OTHER
K6 V following reason.(Section 703 LS,Business and professions Calc:Any city or county SIGNS ELECTRICAL
W 3 40 y which requires v permit it)constmct,.her,improve,demolish,or repair any stmctum
E� Q
poor o its issuance.also requires the applicant for such pennino file a signN.mmmcut SPECIAL CIRCUIT/MISC.
fey that he is licenmdpunuannothe prov1.mns0fde Conuactors License Law(Cbnpmr9 COMMERCIAL
(commencing with Section 7000)of Divkhm 3 ofthe Bminess and Professions Code)or TEMR METE POLE(NST.
a d cy that he is exempt therefrom and the basis fur the alleged exemption.Any violation of C1 NEW BLDG/ADDITION [I UI3h101.1'I'ION
CMNSection 7031.5 by any applicant for a perrulmbjeets the applicant to a civil penvlryof IIT R EV &S El TENANT ❑F(A)D SERVICE
nm inert than five hundred dollar,($NID). IMPROVEMENT
Sp ❑1.as owner of the property,or my employees with wages as their sole compensation, SWIMMI .ELECTRIC ❑OTHER
gyp., will do The wark.tradmemomme,is not imendedoroffered for sale(See 7044,Business GET, S-SWIT - URIS
L 3 and Prnfexsinn.s Calc The Comment's Licence law docs not apply to an owner of
propcny who builds or imprwc+thereon,and who does such work himself or Through
his own employees,provided tha such improvements are not'-'ended or oflcrtd lin NEW BESIDE L E SQ FT.
one.Ben
'.however.the building or improvement is sold within one yemolruentction,the SQ.Ff.FLOOR AREA SISO�PP.
ncrbuilder will have the huNcn of pmvi ng that he did nm build or improve fur Pur- P /Y A ' D
post III .it..) TOTAL:
E) 1, (it the P lelY exclusively contracting our Ts d uni . 'to
constimettl project Poe,]11,148 : and P1 :.' Com,JIno,C ector AUG1 J rapply t fp perry M1 h 'IJ p :th d QTY A CC
WPLUMBIN R Plili
who contract,fnr.such pr,)ecus with a contrdunrO)licensed pursuant to the Contouors D[I/u
License Law. PERMIT ISSUANCE T�
I am esmept under Sac. ,B&P C for this mason 1 1 Ur
ALTER-DRAIN&VENT-WATER(EA) AT ION
Owner Date
• WmunderSCOMPENSATION DECLARATION BACKFhOWPROTF.Cf.DEVICF. J �-
Ihertbyelfin-Under penalty of of Cortone ialffollowing declarations
Ihavc ami will mainmina Cenificam o(Consenuo sdf-insure for Workers Cnmpen- DRAINS-FLOOR.ROOF AREA.CONE). STORIES TYPE CONSTRUCT]Or
,lotion,vs provided for by Section 37M of the labor Code,for the pedormame of the
w for whichthis pe.it is issued. I'1%TURPS-PER TRAP
I have and will mainwin Waked Compensation I-mrance,as required by Section
JP08ofthe lmM,Cale,footle pedommnce nfilewo for whichthis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLET'S OCC.GROUT' MIN
My War is �m � .if sr,l+y�n$ a a GAS-EA.SYSTEM-OVER 4 EA)
Cath i 0 uhcy Ay
No
BIIFIC MPE COMPENSATION
NFROM WOBKERS'O GRGSPIINDUSTRL WASTB INTF,RCI3YI OR
COMPLNSATION INSURANCE BUILDING DIVISION FI435
(I Inksectinn need nor he unnplc¢J if ihepem;it is for one hunJM dollars l$HNEor less.) ORG513 TRAP
I'LANCHECK FEE
I lenity that in the perLrtmantt nl the work 4x which this permit is inamJ,lshnll SOWER-SANITARY-STORM EA.31X11'1'.
na cnployany person in unyonnncnnos to become x.hjecnn OC Workers'Com ,I- ENERGY FEE
Z wJon I.uws nt California.Data WATER THEATER W/VENT/ELI!CI'It GRADING FEE
ZO APNie;mt
% NOT ICE TO APPLICANT:IC after snaking this Ccnirl.m nl E lcroplion,you should WAIT 17R SYSTEMOREATING SOILS PEE
�^ beeomeauhjce,Io the Worker's Compensation provision of the Labor Code,you must
fL' forthwith comply with such no,vonnor this permLshal he deemed revoked. WATER SERVICE
V
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID
z Dom Receipt M
L)� Ihereby which muhunhit,issued( ee,10lending agency for perfonnancc of
W the work for which this lKtmit is issued(Sec.3lN7.Cir.CJ TOTAL.:
O lenders Name TOTAL:
} lUhl Lender's Address BUILDING FEE
P. I certify that I have read this application and state that he above animation is
F' h correct.l agree to comply with all city and county ordinances and.sore laws relining To QTY. MECHANICAL PERMIT FEE SEISMIC FEE
fJ z building ennstrvmlon.and hereby motorlm represenmdves ofthis city to enter upon the
move mentioned pmpvny for incpeainn furpnsec PERMIT ISSUANCE 1_'2 ELECTRIC EEE
(We)agree m as ,indemnify and keep hartnlesc the City of Cupertino against
liabilities.judgments,costs and expenses which may in any way aeeme against said City ALTF,RORADDTOMECH. PLUMBING FEE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10,000 Cl'M) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IILfNNI CFM) CONSTRUCTION TAX
Signature of Applleuat/Comrecor Dale li%HAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
WIIIIhcappllcum nr future handings;ccipamsinreor handle lnoallous material UHATING UNIT(TO 100JX()BTU))
us dein eil by the Cnlwnlno�Tfa�"u"fiding
l Code,Chapter 9.12,and the Herth and SeEfy IIPATING UNIT(OVER 100.000 BTU)
Colo,Section 2553'(.0 Yes VENTILATION FAN(SINGLE RESTD) (ALD
Dom Rsecipt pWIII the applicum n occupant use equipment or devices which tlOIL[R-COMP(JHP OR 100.000 PTU)
emit limited,air contmninanI v defined by the Bay Area Air Quality M....main 'TOTAL;
District! BOILER-COMP(OVER 100,000 BTU)
❑Yes
AIR CONDITIONER / ISSUANCE DATE
I have rcS the b ode.S[materials 5..533 an under Chapter rsta of The Cuh.
forma Hcah Safey Gde.Sstinns 25585,355JJ and 255J4.I undersmnJ the if the NEW RI!SIDEMIAL MECH. SQ.IT.
buildi a cunendy ea fenanl.Nmit is my mspnnsibiIty rennin the uccupam
t which be met prior m issuance of nn' cam n rte)'.
win, r agent
I as TOTAL: ISSUEDBY.
OFFICE