S 1553 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEg 1553
n'NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANIC\L
'111111.DIN(;•PRO,IECT,iDEmriFICATION..
BUILDING ADDRESS: SANITARY NO. APPLICA'T'ION SUBMITTAL DATI
at/ - X T & 23gg
OWN-R"NA .PEON@ CONI RAC'I OR'S NAM& LIC NO
6 '�� loin N/c -orv'rea.w
.� ARCO ITEC T/ENGINE.R'. I.ICNO, All l LISS'. I���� �� ❑
CONTACT: PHONE: ///+++ / ,'BUILDING PERMIT INFO S-7. 1707 ❑ Consultant Fees,Paid by Applicant(initial) rBIAIG P.1_PLT PLUMB MECH
❑ ❑ ❑ I\O-�C-f
LICENSED CONTRACTORS DECLARATION QTyY - + ELECTRICPERMITi (' FEE, pl
I n by H m t l r 1 l p r c1 1 t -9(' , Is l .: , ,TOB DESCRIPTION
=az wiba I Yowl fD 1,3ofinems -,d Pnd
fess'9se(A,,I, nyloe,.en RESIDENTIAL:
O O PERMIT ISSI]ANCF
1y m011 c G1t„ru.rnd Jlun
Lieens( ❑ ❑
SFDWL KITCHEN Bny L
ri
X90 tetany/
Fz[il Dam $4,�'-cL Cmvnnpr APPLIANCES-IEESIIJENTIAL ❑AUDI T]ON [_1 PLUMBING RE-PIPE
an mTom..
,=byb ARCIII 111 EC PS DCCLARA V PANELS ❑MULTI-UNIT ❑S'I'RUC'I'IIRAL
ZOyq Iundervmndn"PLos call l be used as entire em..1, MODI FICA'I'ION
OZ�p UP GO 200 AMPS ❑INLERIOR El CHIMNEY REPAIR
W LicaloccalPmI .usual201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNERBUILDERIIECLARAI'ION OVER 10(t)AMPS ❑BATH REMODEIJREPNR ❑DEMOLITION
0.'a I hmy uf0rm Ilml I ou
n, cmpl ILicenseo the Connector,License Law fur me
O eh
y U foll,wing Is...se (Swtinn 90315,Beau—.and Pmfessipm Colc'.Any city on county SIGNS ELECTRICAL ❑OTHER
0.E' 'leen reyuiess a permit m c(mmmL aft,impwve,decal er repair any slnmane
pr's to,(, al...ecotone,fiecal,plecoutIor suchjacciait)file a agred sethernient SPECIAL CIRCUIT/MISC
0.k" La h I : Ifl : 11 d l In Contractor L L (Chapter9
a'C (c( ,nLog Vih Su.ro,7000)o1 D\'sl I tlhe hls usn lllel.seu COJc)ur 'IYMP ME I IR OR POLE.INS'I', �Q)'ME-SIAL.
feat he is usnnpt dura tion'apd She basis for[he alleged exemption.Any Violation of ❑NEW BLDG/ADDITION ❑DEMOIA LION
q0
m 0.
Section 7031 5 leyany applicant t I p bl d o ppl .' I n n hr,f POWER DIAICGS
mn than f hundred l ll :X5001 TEN T ❑FOOD SERVICE
Dh p p ry - ) IIY II ag. 0 : 1 p r SWIMMING POOL II YC I'RIC IMP VEMENT
FA valld tit k dA B n f t I J ff dI (S .9044 Business s ❑( ER
L m and P IcKmU Coda:The C,mmcn,rl d,v Law does
iwoikhapply tn atown'nf OUTLETS
property who eyed,plaw,drnva..t...[I t and who Aocs such work deed I,l onhnmgb
Msownow...eIn,pildia, chat suchiny,ws sold sumhot:mar offnroffered for NEW I1 F.SIDIiNPIAL13LECTR SQ FT
,.I,.fl;bnweveq the M1uilJing nrimpmvemem is sold w'ifhlnunc year ofwmplofiun,the SQ.FI'.FLOOR AREA S/SQ.PI'.
Issue,-Hadar,will have the hursenof pro ingthat[I,did sell beed(ry,a
inrve for per- P A I D
pse pL'ale).
❑ L m owner al the IT perry,am exdasively comrncring with licensed contractors m TOTAL:
attestual the project(S 90H4 Businessd Pracessicir,Co.,)Th _e,i I I. -.. ..
' f rts)I'u sW' pt rstt sup Bun Cut nmrnr.. r1 rMBINPERMIT . FEE''. I d t-wtyt rp pry h builds Dr0 'smer' J QTY Is PI. APR 2Q
ANST
who,coulastor...hp jwsIvma,tn
License Law. 1'F:ItMI'I'ISSUANCE❑ Itcs n,ptunderSee. .B&PCfortensreas�n CITY Uf UUrChIINU
Owner' Dem ALTER-DRAIN&VENT-WATER(EA) VALUATION
-• WORKER'S COMPENSATION DECLARATION HACK FLOW I'RCO ICT.DEVICE
1 trashy WTvm under penalty of p,cr,one(f rite folkesmg decla,I on,
I have and will maintain a Ccdillent(olCememo self insure for Workers Conoco- DRAINS-FLOOR,ROOF,AREA,CONIlSTORIES 'rYYHCONSTRUCOON
,alliance,pmvlded for by Swtinn 37M olne,LuborCode,for the perfomm�nce or the
work In which nhis'conn A issued. FIXTURES-PER TRAP
❑ 1 have and won actual Workers Compen.salion Insurance,as rcymrad by Section
3700(It the Labor Code,In the perfnnriessafthe lark l or which this pcnau,,iswwE GAS-EA.SYS'I List-I INC.4 OUTLETS OCC.GROUP APN
My Wicker',Centpersale n lnsnrt carrier and Poli,,F ,b
Gorier: ER--- No
��TIONIFROM WORKERS' .GAS-EA.SVS I'1LM-OVER YfEA)
COMPENSATION INSURANCE GRFASI%INDUSTRL WASTE IN'I'BRCEFFOR
B_ DING DI V I ION FEES
(ThisccclionncrJnmtlwwtnDloardil me,audit,funnm[I dead dollars is 103) - - -- ->+N
nr less.) GRBASB TRAP
PLANCHFAK FNl3
Ioyany fihm(,me perfommncrol'thcw(rk[a wubj,v,ch ls In,Wikel, dlahe0 SEWER-SANITARY-STORM EA.203 P1'.
nal employ any person in any mtmner xa us to hwonm snbjwf m the Workers'Compam ENERGY PEE
Z soften Laws(If CIryW.Def
O O Applicant t�FA / WATER HEATER WIVENT/BLF.CI'R GRADING 17EE
NOTICE TO APPLICANT IL after making This Cel ificale of Exemption,you shodd WATER SYSTEMRREATING
F hewme subject to She Worker's C(ngrensefirn provisions(ffhe Labor Code,you nmsf SOILS FEE
Qavowal,comply with such paper..nirvo,this permit shall he devoted revoked WATER SERVICE
z CONSTRUCI ION LENDING AGENCY NEW RES I DEN I(At,PLM B ' SQFE, PAID
UO I her ehyenirm fhsh here is it contraction needing egency for the performance rt Dam Receipt#
kLt r.. food art or wbreh this pemat isiswcd(Sao 3097,C'rv,C.)
O U Lenders Nam, T(YfAL:
r fT.7 Lenders Address TOTAL:
1 I vedif,that Ihave read not, ,finfial suit arce her the proveInkanal - c BUILDING FEE
rn correct.leglegra,to ply withaII sity' 1 county 1 red spare laws Ff gf QTY MP.CHANICAf.PERMIT - , PPA(
Utz
building'n.wq nn and hereby vnhr-z repeenn w(fm sitymwmrupnn me SEISMIC IT
above mentioned properly f impwu al I u0msrv' PERMIT ISSUANCE
(We)agree m save,indemnify end keep harmless the City of Cupertino against ELECTRIC FEB
liabilities,jdg pts,costsand expenses which easymtmy way revenueagainst ordCity ALTER OR ADD TO MECH. PLUMBING FEE
in n ey e fThe g I' g flh''pem I
APPLI N UNDERCIANDS D 111 CO 'INWITHAIL NON-POINT AIR HANDLING UNI'I'('10 EOhu CFM)
SOU .F UI 4TI0 � - �l MECHANICAL THE
% Y.2 ` AIR HANDLING DNI'T(OVER I0,I1IXICPM) CONSTRUCTION'PAX
Signaunp of ApplicensLbnmecmr Dum EXHAUST HOOD(W/DUCT) HOUSING MITICACION FEE.
HAZARDOUS MATERIALS DISCLOSURE
Will We applicant retinues hoilding(rcepare doreorhandle hamrdous motcria1 HEATING UNIT(TO 1001030 BTU)
as definwl by me Cnpe0lna Municipal Code,Chapter 9.12,and he Print
and SufeD
Code,Se,tion 25532(a)? � _ HEA'T'ING UNIT(OVER 100,0(1(1 BTU)
El Ye, VENTILATION FAN(SINGLE RESID) PAID
Derr R„SNI a
Will meappliwntor furore building occupant use equipment nrdevicca which BOILER-COMP(iHP OR 100,000 N'I'll)
emir ha/nNamm'mu
nue ir connfs es dcfnaJ by the Nay Area Air Quality Mi ugeme°t TOTAL:
Dial D
Yes Nn HOIITR-COM P(f)VER 100,000 13 TO) -
I have reed the ha/ardoes nearralsrequirements under Chapter s,95 of Bun Cali- A IR CON IJ 11'IONFR ISSUANCE DATE
f0mia Icahn n l ty Code,S r 55115 25511 125534 J J tM1u'I the NLW RESIDENHAL MECH. SQ.FT.
none s I A n e ttyn t t un-n t y :p -nityt rrrnerta„pod
of`� rg`en h1. /hc ct prof cs J'a Ccaf i I/,H,yyy��kpppYYY���ey
Own' o noamniti'adoop nt (E'fDuo 'rOTA1.: I$y(IF.0 BY
OFFICE