S 1966 'APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
BEII.DING-KLEC'PRICA I. Pli�41T
CNO
ITY OF CUPERTINO ,q.,MBIN,:-MEcuaNlcnl, J 1966
BUILDING DIVISION APPIACATION/PI6RN1IT
BUILDING PROJECTIDKNGFICATI(1N
art�� vi-e' SANITARY NO. AYI'LICAI'IUN SWiMITI'AL DATEDATEIt1111,Do S.��R� ��� C/ t Y
O N ISNAME / P I>NL'.11-1160
CON'I'RACI'OR'S NAME: LIC NO: NIC CONTROL it
ARCHITECPIENCLUSHER: 7 LLCdN`O ADDRESS: ❑
COSTAL PHONE: - ,BUILDING PERMIT INFO
D � ,, _/��� Consultant Pces Paid by Applicant(Initial) BLDG ELECT PLUMB MGCH
LICENSED CONTRACT R'S DECLARATION QTY. '•ECIjCTRIC PERMIT ., FEB
I hereby affirm drat I am licemed under provn.aona of Chapter 91�om ting JOB DBSCI2II'"PION
aOz with Sort
ion pn(IUptr Dlvieion3ol'pia Busine..and Pral'ca.inne celle,unhay license is RESIDENTIAL:
PERMIT ISSUANCE
FWr infull force. Jeaccl ❑SPDWi, ❑KI'IGI[EN RIiMODIiI.
XVzV Lion" LIaK APPLIANCE S-BESIDEN'FIAI, ❑ADDIT[ON E]PLUMBING RE PIPE
P Q C Date Canimdn .�
ffn� ARCHI'M=SDECI RA ON ❑MUCI'I-0X1'1' ❑SI'RUCTIJkAI.
) I and...lmimy plmtseball d peo
se-rd ua ublicrnN. PANELS MODIIICA'I'1(1N
ZOwyZ� UP TO'III)AMPS ❑INTERIOR ❑CHIMNEY REPAIR
oz-q
F�•�,F]W Licutecd PI....iunnl 201-100OAMPS IMPROVEMENT` SWIMMING POOLS
Qpm; OWNER-BUILDER DECLARATION OVER 111W AMPS ❑RATIi REMOUELIREPAIR ❑UEMOLITIGN
.a+f4 yayh�G, i herchy alGrm'he'I ant exempt from the Contractor's Lirense LOW for the E)O'LEPR
X L O following reason,(Section 91131.5,Rmincss and Prnl'Aomov,Code:Any city or cotmly SIGNS ELECTRICAL
W 3 y.N Which ,jo,i permit to conarmm,aIle,.improve,Jemohill.or repair any su11dme
.F'.^CQpr t.'. ,al :II p,l' II 11 nnit fill, d
'y ente nOn, SPECIAL CIRCIADMISC.
qQFthe h .I licensedl ,h p :n flh C t t" L Law'(CLapnm9 COMMERCIAL:
W� O (m g it Sad FID1Xl Division tar'hIt .n cl .
f w... c7 m TEMP MITER OR POLE INST.
,a ax C C Lha,he is exempt immoraland the basis for the allege)exempuor.Any vinlawm of El BLDG/ADDITION ❑DEMOLITION
C
Section 2031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES �,, ((.,rygry9' ❑FOOD SERVICE
IL c then fio,luuk nil J011am18500), IMPROVEMENT V W/
FS< as owneroflhe postj onny empbyces with wagesastbeirnokOnto....alilm SWIMMING POOL ELECTRIC V
F• wdidmhe wmk,L Ilheenumnre is not immbJcdorn0hred Ensule(See.TN4,Briskness ❑OTHER
3 m and 1'ndessians GNB:Tlnc Commcmrs Licelrse Law does not apply to an owner a1' 0U'I'LF.'I S-SWI'I'CHIiS-I'IX'fUIt IiS yL)� ,LOt //���
- property who builds or improve..,hemon.and who dao such work himself or,hmugh
his own employees,provided that such improvements arc not intended or offered for
NEW RCSIDEN'DAI.IiLCC'fR SQ FT.
svle.IC,hosvcver,the builAing or innpmvamem
sold within one year ofdtmpletion,the SQ.Fr.Al A iA SISQ.FI'.
M1 ld llha 11 burden fI ,t tl redid! Ih 'll ' p - -
AUG 0 6 AN5'D
ED I f0 p ty' I tly 1 i 6 With l' contractors it TOT L:
m l nil P 1 t(S 2f141 N d pr f '.' :C d )Ch C I I .L'- ,,ll
c 1 1 t apply I fp p ny 1 builds improves til d QTY: PLUMBING PERMIT'• ` F I' CI Y UI' VUI'Ctil IKV
wh Imcmfo.... lcnsw lheumv tn(s)lanulltr.uu llthe Cnnmemrs •t r
License Law. PHRMIT ISSUANCE
❑ Ilan oxen ode .N&P
ALTER-DRAIN&VIPST-WATER TA) VALUATION
Dwaer —Date /aj 000
WORK17R'S COMPF A110N DECLARATIO RACK h1UW I'ROI'f:C'I'.OEVICIi
1 hereby u1Rrm under penult,of perjury one of IM1e following dednm^on
nIbuveunOwillmmnluinu CerliOramnf Cnluennn Xdl-Invurc lar Wol kers Cumpcn- DRAINS_FLOOR,ROOF,AREA,COND. STORIES 'TYPE CONSTRUCI'IGN
anion,as Provided for by Section 37(X1 of the Labor Code,for the prefnnnaric,of the
work lin which This pen 1111 is issued. FIXTURES-PER MAP
❑I have and will maintain Warkels Compensation Insurance,m required by Seddon
3]1X18(the Lana Code,for One inefooname a(the work for whlehais permits issued, GAS-EA.SYS TEM-I INC.J DOTLETS OCC.GROUP 4PN
My Worker's Cnmpematiun Insurance carrier and POKY number are: -
Carzicr. Policy Nn.: GAS-EA.SYSTEM OVER J(EA)
CEKFIFICATE OF EX It MP'1'I ON FROM WORK 11I(S' C.RHASILINDUS'URL WAS I i INT I!RCHPI'OR
COMPENSATION INSURANCE BUILDING DIVISION FRES
(Thlxs yimuneednm be dmygmcd i ram ernni,is furore hundred dullan(S 100) GI(EASH TRAP
or Icss,) I'hANCI IECK FEE `
I send,that in betleforcume lefhework for which thispermit is i...ed,[shall SEWER_SAN] ARY-STORM EA.20X1 IT
not employ any pemt in any manners as to become subject' o jecthe Wmkes Caupen
n - ENERGY FEE
Eco
ant
onion Law. f Califomia.Dale WATER HEATER WNEN'PHLECI'R GRADING FEE
Z Applicant
NOTICE TO APPLICANT.If,after making this Cenllicate of Fsemplion,you should WATER SYS]EMOTRIHAl'ING
1"1 Leconte subject nt the W..on,Cam tion m of the labor Code,you melt SOILS PER
1 ptnea ecandn
DX+ � fonhwilh comply with wcM1 pmvisinns nr Otis permit ehall be deenneJ revoked. WAI'Fit SERVICE
i 0
P.1
CNS'IRUC]'ION LENDING AGENCY NEW ItIiSIIAiN'fIN,I'LMIf. SQ ET. PAID
7 'Z (1Ihcreby af0mvhm there isamm�mainn lending woragency far the perfmm�ancc of Oara Itcceiptb
Wthe k for such ih'n Permit Ix i...ed(See 909],Civ.C.) TOTAL:
QLdcis Name
W Iu 1 .A d �TO'fAL
Uen : f
0. 1 n'Iyd tlh a dun ppl , dmid ductile nib f nations i, BUILDING FEE
:.l V1 correct.lag ply With all ',y I my rd' ilce. t, I Imngm QTY 'MECHANICAL: SEISMIC FEE SEISMIC FEf
U Z I I l ng dm const on and hereby aulb rt u vprcse not vox delis city l ton',po t ll c
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC PIS
(We)agree to vnvq'mdcomily and keep han..ft,Ih,City of Coperlinu again
lishiliticc,judg^nents,co.sts and eapenes which may in any way uceme agaimisad City ALTER OR ADD TO MECIL PLUMBING FEE
in -eincnce or IM1e granting or Div Fermis,
APPLICANT UNDERSTANDS AND WILL COMPLY WI'I'II ALL NON-POIN"I' AIR HANDLING UNITED)I Luft)CpM) MECHANICAL FET!
SOURCE REGULATIONS,
AIR II ANDLING ON['F(OVER 10,000 CFM) CONST RUC'rION TAX
SlEnwurc rf Appl iuml/Com melon Date EXHAUST FOOD(W/DUCT) I]DOSING MI'I GAJ I(1N FEE.
HAZARDOUS MATERIALS DISCLOSURE
Will the uppluend or Gnrirc huilding uccup',nl once or handle limardo111 unded-I MEATI NG ONE'1'(TO 108.100 B9 U)
N.defined by the Cupertino Municipal Code,.Chapter 9.12,and the Iculm and Safe, IIIiA'1'ING UNIT(OVER 100,000 BLUECde,Seddon 25532(a)'!
❑YesVEN'I'I I.A'I'ION FANS I NGLE RES I D) PAID
—Ude
IteeeiplN
WIII lila applieunoInion,huiidnlg uo,upnnl meµuipm,m nr device,which IfOILEIt-COMP(911P OR 100,000 BTI) ,(—
"Di it harallous Bir amWmimm�m is a,JefncJ by the Ituy Arca Air Quality Managelnvm TOl'N.: / O —
01q_ricl'! / I1011.Ek-C(1MP(OVER IIp.fNXl BTl1)
El Yes
I bele read the haun doi s ntmeHal.mgnifumems under Chapmr(.95 of the Cull- AIR CONDITIONER ISSUANCE DATE
Cnmia Iicahh&Safety Code,Section.255 _5533 aM 25534.1 undcnnnd dins it the NEW RESIDENTIAL MECH. SQ.IT.
InliIf tats nal cvne"lly M1nvc alcntm'!LI r'meip mnbilitym ihexntpnm
c uiremcm Lich uxt be r la is:unnc of u Cvr11 c o 0'
caner nr Ori,horized a gen D e TOTAL: ISSUED BY.
OFFICE