S 3916 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRIGAI. PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-NIRCHANICAL, S 3 916
BUILDING PROJECT IDENTIFICATION
❑111LD�IN�IJI>RGSS Ld � �� SANITARY NO, AI �CA'f NSUB AL DATE
OWNERS A6-7 IWA(AfMH P NE: CO TRAt:'rOR:SN B LIC NO:
- 0 vfo �_0 0 NEC (''� ��C//ON'IROLp
eCH TFC'l8'OIN- `[V 'LTC NO A)D ESS: ❑ ? ��
v z z t u.362 u1 E /
CONT'ACT'.` PHONE: BUILDING PERMIT INFO
04 L u&l � (_4(np_\(�q n /010( ❑ Cid aultaot Pees Paid by Applicant(Initial) BLDG 15Er 2 PLUMB MGC_
LICE .F.D CON'FRAC TORS DF.CLAKXHON QTY. ELECTRIC PERMIT PEE
I e, ernes I1. licensedu 1 1 .ofChapte 9(raneene ag .DOE DP.SCRIPTION
WOX vi lhS t ]000)o[Di 3 flu Heeie It-f sines code.vndnyleense's
H 'n fru r 1 ff eL PLRMII ISSUANCE RE NTiA
�Ul' I1ren CI 1'cp 'FDWL ❑KITCHEN REMODEL
F Jule Contractor APPLIANCES RESIDENTIAL El ADDITION ❑PLUMBING RB-PIPE
4i
ARCHITECTS DECLARATION ANRLS ElMULTI-UNIT ElS'IRUCTURA[.
yQr/cZ Infired my plvne shall be used as public oecuNc MODIFICATION
OZoO Too 200AMPS El INTERIOR ❑CHIMNEYRI?PAIR
IJce'sed Professional] 201-IOIXIAMPS IMPROVEMENT
Oat III
I II,rhi front
nt To CoATION OVER 1000 AMPS ❑BATH RENTODELIRITAIR ❑DEMOLITIONING OOL.9
C I M1ernhy n(Sect Inat I nm exempt Irom Ilio Connns Co Cleanse Law for the
W 3 T. following roes I That
Ion]IDES, , I....s and Professions Coda Any city ar county SIGNS GLGC'IRICAL C1 OTHER
l4 wtia q ' p n c I P demolish, v ):I erre
r'� J
prior to itsis y The pli hoR lI lle a,offoaddaloyarric,an SPECIAL CIRCUTIMISC.
n
�+
that with
i II Ib p ifTheContract,,,,License I (Ctrpler9
(mnI%engwuh SCc1on900dthebaf�n3lehecied Business,and Prolesone Code)m fY.MC MG'II3R()It POLIi INS'I'. COMPTBLDGAL
faid y o C Sec he nis exempt IanyTherap li and the pair for the ap,th d exempnna Any viulmion of ❑NEW BLDG/ADDITION ❑DIiM01,IT1(1N
Wim nor h�n 9031.5 hundred
licant Rru pennn cuhjedc lM1e applicant to n civil penally of POWER DEVICES ❑I'ENAN'T ❑FOOD SERVICE
FZY 1 morelhan in,,fthpatosodollursydrid IMPROVEMENT
CO ❑I,mux'net of lM1e pfopdty,or nay empinyeeswlth wages as their role VULlincinen, $WIMNIIN P .ELECTRIC
iG•' wjEdofir,on Coo thealrvnure isnolimended or otlaretl fur sole lSnn.9M4,Nosiness ❑0'fHPat
{y w wW Pmfccsineis Code:'rife Conwmare Llenme Lnw dnev nal vpply In ears owner of OUTLET Cf186-FIXTI1kH5
d 3� pmpeny who builds nr provided
tth Iharlif u and who dnev such wnrk deed on clinical
thmugh
his own empinyeex,provided Ihm such ienpmvcmeats vre not intended or offer W for NEW RESIDE 1FCTR SQ I'I:
Yale.IL however.the building onnepmvemenl in.add within one yevrM pempletion,the(if the p �+�S�Q�PT'�,�FQL.00�R AREA $/SQ.IT
wn II will have burden fp- gtl'Ih Id not p ripe r- Pz; T"'
I a,owner
poc 1 )- 'I'GI'AL �/ -97,
mtIy exclusively ly IIg 'with err contractors � 9 (�
ons,reed,fa.......e(Scw 7044,frolics,and P'eRseionsCcdc:)Tlie ConmeoseLi-
Centro Law does not apply to in owner or pmpeny who hujld—,impmvae Taronen and QPY. PLU rRIC0RmjT FEE
who counters fill such profess with a dmtrachu(s)licenced puCannot ersnano the Canns
License Lnw. PERMIT ISSUANCE
(( ( (
❑ I din exempt under Sec. ,R&P C lot this revere
Pro AT IDR-DRAIN&V13NT-WATER(EAT VALUATION
1 A (lN Df CLARATION BACKFLOW PRM CI.DEVICE
Ili O
e hY' d p hY fP l Y Cd f ll g l r f _ V�{�1 0
❑ I have and w'll maintain a Certificate of ConocinI If' lot Worker,C pea. DRAINS-I'FOOD,ROOF,AREA CONDI. STOltli!S '1'YPG CONS'rRUC'rION
salon,vc provided for by Section 3700 of the Labor Calc,for the perfnr ce me of flat
wort[ h hbu,can l . L FIXTURES-PER I'RA -) ••�,�_
❑ Ih 1 `T alr W k NC pt:al' I . a y ' IhyS lion 11 1
3900 10 Leh Code,Finite pH e fth kfor'whc This p nts'csued. GAS-EA SYSTEM 1Nj-400'1 LT51� OCC,CROUP APN
My W k C ransic I at c l[ I'y mumbo ere. SA
Carrier: n tPolicyNo.: GAS-_ASYSTF - MER BA)
CERTIFICAHL OF EXEMPTION FROM WORKERS' r
COMPENSATION INSURANCE GREASPANDI IST wAs IFPTVRC?pTgR
BUILDING DIVISION FIBHN, A('I his section need nal heumnplelcd if llnnpnmil is Biome hinhoddnllvls(S 100) GRF.ASH'TRAP
Or leu.) PfANCI 'C PGG
curl jfy tuna In Ihn performancennM work for wubjethis pursues eased, elmll
nm cmNaY any 9GWGR-SAN R �S'I'O�<M IiA.2110IT.
y pervon m any senna so as to heacmcsuhjen In Ihn Workers Camps- ENBItGY P
zr ppnernl WATER 11FA1ERW'NENT/GLEC` OR IN 'Eli
7 2
Z sdnu Lvws nl California Unity
Dale
O n
ql NOT ICG'f0 APPLUATED If,after making III,Co rdino en of Exemption,von should
WAIT SYSTCM/IRF.dTINO
become novel m I[,aW son,Counpheation pmvisjnos of the Labor Cale,you nmsl
forthwith dnnply with such provision,or In,permit hall be deenned mvaknd. WATER SERVICE
d
CONSTRUCTION I.IiNITNG AGENCY NEW RESIDENTIAL PLM& SQ.ET PAID
U O l herebyafron that Wcrc is aamstruction lendingegence,for lbs Tdahnmanw of Date Itwei tp
tbu work Inrwhkh this fiction is marred(Sea 3099,Civ.Cd
ULenders Name
Leaders Address 'I OTAL:
aI ernlfy that 1 M1nvc rent)Ihie applicntinn and seam Ihel IhC abnve'mfnmmtion is BUILD C PEG
m entered.I agree lecomply wjm an city and coueiy nnaneneese id state Taws refuting In Q'PY. MECHANICAL,PERMIT PEEIN If
U huilding consenmion,and hereby authorize representatives of this city scoter upon the SF.I. IC PE'
above.nm
real ad ppeny for inspersion pugnmev.
(We)ugrce I,ase.lodemnify tmd keep Its loss flee Cr,of Cupertino against PERMITISSUANCE F. .FH13
Iwbilities,judgtnertg.... .rd,vidn'tl which nmy in any wey:acntn no said City ACTRIt OIL ADD TO MECH.
on mccyuencenr lhe6ranuh,of an,fennif P MRING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNrr(1'0 Ig000 CFM)
SOURCE REGULATIO O A1LCI IANICAI.FEB.
AIR HANDLING UNIT (OVER Ig000 CFM) . NSTRUC'f10N TAX
Sigtu
narehA m
eaunCnracho T��Date-'i/f EXHAUST H000(WIIJUGq ILO NG MITIOA'fION PEP,
HAZARDOUS NIA'I'ITTIA1S DISCLOSURE
Will(he appliemI...loran buildingoccupantporeor handle hasold tmmen'al I WA'I ING UNI T(IO 100,000 BTI!)
as donned by The Cupertine Mun'sipel Code,Chapter 1),12,and the Ilealth and Safety
Code,Sector,25532(n)? HEATING UNIT'(OVER 100,000 BTU)
❑Yes E]No PAID
VENTILATION FAN(SINGLY,RI351D) Dnt Rcneipt k
will the applicant(or balance building occupum use equipment or devices which pOILER-COMI'l3HI'OR IIIgfN)O ITT nil hazallooc air conlaminams as defined by the Buy Area Air Qualify Mvnegenmm
Distad^.
L'
❑Yes ❑Nn 1301LER-COM1IP(GVHR 1011,000 BTU)
I have read the hazartlnns mn¢ria6 reyuiremenis undo'Cha,lor 6,95 of the Cah- AIR CONDITIONER ISSUANCE DRIB
I'omjn Ileahln&Sudy Cade,Sections 25505,25533 and 25934,1 malnmmnd that it the NEW RESIDENTIAL MFCIL SQ.PP.
buildingdcal not cunenfly huveal hat it is my ot,oesihil ley to notify the nauptml
Iftheregni,thentcwhichmus a nrmiesntoccenCnrtiGcntear4c Incy.
7i
Evocrecaudwnvu age IsDec TO'T'AL:
fffISSUED BY:
OFFICE