S 1870 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Yli'a�\a4d1TN �1 O
sIDLDWO DIVISION. APPLICATIONMERMIT PLUMB IING-MECHANICAL. Cl V 1870
BUILDING PROJECT IDENTIFICAT'IUN D
BUILDING ADDRESS'. - SANRA VNO. APPLICATION SUIiMi'PPAL DATE
1 o Asr�rL I.,Al S LoPi&T,l./o^ CA g,Soi g � 3 °c8
/ r ~ OWNF,R'S NAME: PH NE: CONTRACTORS NAME. LIC NO
I � n S N/C QCON'[ROL#
/mRCHIT.EC.�fIF:NOINEER: ,ICC NO: ADIJItESS: ❑ /
C�IN,GC L PHONE;I� BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
(glas) 7581 LZ Z� ar�
LICENSED CONTRACTOR S DECLARATION, QTY. -,' ELECTRIC PERMIT
i neany sono n t l d ti p f cbapmr JOB DESCRIPTION
QWa2 with Section 9cnn)ofDiv's'rn 3 of the Bu,ftexsatd fr l. ' ,Codamdmyfice.a RESIDENTIAL:
W O in PERMIT ISSUANCE,
N y full force and e¢mt � _ ❑SPDWL El KITCHEN REMODEL
�VU License class Li,# APPLIANCES-RESIDENTIAL [{].TION ❑PLUMBING RE-PIPE
F z ly Onto
Center,....m<6 os, ARCIIITF,CPS DECLARATION [IMULTI-UNIT [ISTRUCfURAL
Fy z I anderswnd my plans-.hull be usul vx public aanrds PANELS MODIFICATION
yZ 14_Q Oil DO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Pmfm,lonal - 201-1000AMPS IMPROVEMHN'P SWIMMING POOLS
OWNERBUILDERDECLARATION
eL Q I herehy affirm that 1 um exempt from the C-mean,,License Law for the OVER 1000 AMPS [I BATH REMODEIJRI?PA DEMOLITION
yV following reason.(Section 9111.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
E.E' which requires a perminI t t alter,improve.docadoli,or repairany structure
1'"r+yd pr'n t t I: q re IM1 ppl' If P ilt 11 g d t temenl SPFAIALCIRCUIT/MISC. '
d�O math l la thep of the e to L L (Chapter O1; RIA
0.' (a0 m
tiing wilh Section 7(M)ul Dvis� 3 o the Busness .dPh fvlsCade)o- TEM P.METER OR POLE INS'C �
Y y A{ that he Is exempt herefr m and the basis for the alleged exemption.Any violation of [-IN?W 6LDOIADDITION [I DEMOLITION
CYC] W Section 7031S by Imant freta pendo suhjecP the applicant to a civil Ely of POWER DEVICES
not marethno five hundred dollars($500). - ❑TENANT ❑FOODSERVICE
E.'b Y IMPROVEMENT
d D 1,os owner of the property,or my employee,with wager a"heir compen.wtlinn, SWIMMING POOL ELECTRIC
�Q will do me wmk.Imd lhesuucmre is not intended or offered for sale(So,. Box nes, ❑OTHERg. -
3�
and Profassians_Code Th.Comfort.,License Isw dory not apply m an code
011l'LETS-SWITCHES-PIX'rUI1HS
property who builds in im,mvcs thcrcon,and isno does such work himself or Ihrnugh
his own employees,provided that such improvement,arc not intended or offerall for NEW RESIDIIN'ILA L EI,FCTR SQFI'.
s.1,.ll;bowcver,the builma,uimpmvemeni,old withinone year of coa,urnmathe SQ.FI'.FLOOR AREA 5/SQ.Er
r-binds will have the huNut of proving that he did not mild or improve far or-
'ce,of,al'.).
-&I l life properly. exclusively I I' g with licensedcontractorsm - h
construct 0 project .I(S 9044 Ba,ressand Professions C d p PeCommuctor'sLi-
acres,Lw dols not apply lem owner tip -pray who holds or improves theren and QTY, PLUMBING PERMIT - -FEE.
who-onnacts faraucb protects with a contractors)lieeosed pursuant to the Contmcmfr
Ljecow La, PERMIT ISSUANCE � +
El nm excmpl under Sec. ,B&P C lar this to.san
Owner Data ALTER-DRAIN&VENT-WATER(CA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE fN T
1hercb affirm under It f of follawin declaration t) L
ya Penalty perjury once g u
A Q Ihavc and will maintains Cenificateef Cancrnl In self-insure l'.r Workcdx Compen- DRAINS-FLOOR,RODE,AREA,COND.
smior,a,provided for by Swtion 37W of mo Labor Code,name pi'mangnca of the STORIE TYPE CONSfItUCPION
work for which Inv permit is issued FIXTURES-PER TRAP -
El I have and will mainlaid Workers Compensation Insurance,Its required by Section
3900 aflhe Labor Code^for the ofthe work for which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS DEC.Go UP - APN
My W list,Compaosa me Insurance ruminated Policy number are
Carrier Policy No.:. GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMFI ION PROM WORKERS'
COMPENSATION INSURANCE GREASE/IND i '1101
¢F .DINOtIlM51(1N III
(Ih-ea...dredmtbuaomplmedTthepenil's fororcharaddolme,($100) 4
ori ") GRt1ASE TIUPLANCHE K
ICCtIify Otat In me parformmueaof the work far which this permit is lssucd,Ishall SEWER-SAN -STORM EA,2011 f?P.
no employ any person in nay manna,-so m.to become subject to the Walker.,'Gmpen- ENERG 13
'j. ,mienkevs.rCefl'nmle,Dam WAI ER HEAT NP 'T
O IN Applicant ` GRA ,P.
199
i-�I NOTICE TO APPLICANT:If,ager Inking lht,Certificate of Examp.ian,you,maid WA'fI.R SYSTE CREATING
become subject to the Worked,Compensation Prov suns of the"her Code,yon must SOILS PE. -
fSa mahwlm comply whh oeoh provision-,!hie .,air shall be dccmedrcvok d, WATER SERVE E. $
Q _ _
Ceamem UC conarreenc LENDING AGENCY NEW RESIUEN - _ SQ.FT. PAID
z (herehy uffinn mal mere ixaconstmmlon lending agenYfnrthe perfonnonec of Dam Receipt#
U the work far wnlch this pemtd is iss.ed(So,.3097,Cr,C.) t z2
Lendera Name( - T
L) Lender' NameAddircss TAE:
1 certify dal I have read this application and into that the above information is BUILDING FEE
�ian coreetIage,to comply with all city and aunty omloancesand state laws relmingm QTY. MECIIANICAL-PERMIT .FEE
U Z. buildingcontmaaan,and hereby authorim reprexwmlives of this city memo upon the SEISMIC FEE
ahove-mentioned property for inspection purpoes. PERM['P ISSUANCE
( e)agree o save.Indamndy and keep harmless C'ny of Cupertino against ^ ELECTRIC FE e ��
IinM1i""a' a n east,and rape swhitlt they inn ayacemeagainmsald Cily ALTER OR ADD'10 MP.CH. _ I,/ A LA 3 .
onseq of a ranting of lIt out. PLUMBINGP
m C. A I eZI L COMPI ITH ALL NON-POINT AIR HANDLING UNIT(TO 11,1X10 CPM)-
MECHANICK h
AIR HANDLING UNIT(OVER 10,000CPM) CONSTR 'TI TAX
Sit
rcolA c II Dam LXI{BUST HOOD(W/IIUC'I) HOUSE I (CATION PEC
ALARD SMATERIALS DIS SURE,
If
the applicant.,forum building acta"al,lem or handle lecommusmmenal H EATING ON I'P(TO 10,000 BTU)
is debar by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cods,Se lion 25532(a), HEATING UNIT(OVER 110,1X1!1 BTU)
Yee ❑Na - PAID
VEN'HLATION FAN(SINGLE RESID) Date Receipt
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR Ifq,01X1 BTU) s
nut ha vrdoux air conmminams as defined by the Bay Area Air Quality Management TO
District' BOILER-COME(OVER 100,000 BTU)
0 Ye. ❑No
I have and the hmnrdon mamrinlsyuiau
tndar Chapter 6.95 afmo Call- AIR CONDITIONER ISSUANCE DATE
romfa Hwhh&Safely Cele Srebro 25505,is Fay and 25534.1 rude catity di but ifct° NEW RESIDENTIAL MECH. SQ.FC
buildingdoe,nal svren0y naves tenan4 thntft is my responsibility m n.Ufy diametrical
ofthooqufamem,which must ba metpdor lois a of.Ceruficam ar Occupancy.
✓. _
Owner or vuthansul agent" Data TO'fA I ISSUED BY: A7T9
/ OFFICE