00010007 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
y CITYOFCUPERTINO BUILDING-ELECTRICAL. rr;RMrrNa
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
I BUILDING PROJECT merenFICA11ON S0001
IiNLIIING ADURFSS, SANITARY NO. APT'LICAI'ION SUBMITTAL DATI
2/l�i'D Cryo &0,4 y l�r%�/ZT/ND 1 .
OWNER'S NAME: i�� v / yO� CON gL�pR,�NA E:� LIC O 1
N L` NIC -CONTROL
RCHITECI'/F.NGINEER: LIC NO ADD$F S /!/� �,� ❑
CON'T'ACT': PHONE: /(/^ /r G BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB NIECE
❑ d ❑ ❑
LICI NSf D CONTRACTOR S DECLARATION AkATION QTY. "' 1 LIiCT RIC PERMIT Y FEE
1 hereby affim,that I licensed a p of Chapter 9 armme 'tg _ JOB DESCRIPTION
WOO with Sccin openodfllokitn 3.1 the B,x Professons Cale.nal my PERMIT ISSUANCE RESIDENTIAL;
aUO License Cle and effect /,l // 0 ❑SFDWL ❑KIT CHEN REMODEL
!!// Lic.M V
tFQW Da¢ Contractor API'LIANf,1iS'-RLSIDEN'IIAI. ❑ADDITION El PLUMBING RF,-PIPE
ARCHITF,C'I'S DECLARATION PANELS It' ❑STRUCTURAL.
O Z y 2 1 understand by plans shall he used as public scan 1, MODIFICATION
pp IIP TO NXtAMI'S ID INTERIOR ❑CHIMNEY REPAIR
H<�.~.ti1 LmonseJ l'rofesstnnnl
OWNER-BUILDER DECLARATION 201-1000AMPS BATH
[I SWIMMING POOLS
aL CCC 1 hereby affirm that 1 am exempt from me felsouvror's License v Low bucolic OVI'R IOINIAMI`5 ❑HATH Rf3MODCL/k1iPAIR 0 DF.M01.1'I'ION
tyxj3�F fnlLswing mamm(Scnion l(D1.5,IWsincss trod Podcssi"ns Calc:Any city or county SIGNS ELECTRICAL EJ OTHER
F u'O N which requires a permlT .coo..mtl,alcor,Intpmve,demo)eh,nr repair any nWcutre /�
h poor to its issuance,also requires the applicant for such penuit to Tile a signedstatemem SPECIAL CIRCUIT/MISC. —���g.
ahe,heisherawd'iummor to the provisionstf the Cnlnrarinr's License Law(Chrpte,9 G /7
ne
WSJ 170 (commencing with Section 11.)at Division 3t111e Business and Professions Code)01 THAI MITER OR POLE INST1
0,W y, that he is ascmpl Therefrom and the basis fill oho alleged excmpdn't.Any violation of EW B..2t;DITION ❑DEMOLITION
ad�H Section 70315 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES
not TnmeThun five hundred colors($500). E-1 TENANT ❑FOOD SERVICE
1 01,vs nwnerofthe pmpeny,or my empdyces with wages uc aheir sole ctmpenmlinn, SWIMMING POOL HLECTRIC IMPROVEMENT
FO toll do the wnrk,tmd thoxmtemrvix oat imm�JeJ"rnRereJ for
late(Set.]Obl,B"siness ❑OTHER
L3 and 1'rofes.ions Coda:The Comments,License law does not apply to an owner of OUTLETS-SWITCHES-FIX'I ORES
property who huilds or improves Norman.and who does such work himself
his own employees,provide)that such improvements arc not imcnded o n 1 I? If
\11 C
sale.ILhowever.the building nrinTprOvcmemissold withinnne y.,"room � mn, hr SQ.FT IT.00N AREA LSQ.FT.
nor-madder will have the Farren of proving that he did nm build m imps" -
pase ofsalcJ.
❑ I,as toner"I the pmpeng atm exclusively commedng with licensed svaleach, ,ay:
comuum the project(See 8111,Business cad livfessinns Code:)The Contactor.
vault,Law does urn pplyIt,an owner illpmpeny who builds or imonvici "nom,
who contme¢for.such projects with a contractu s)licensed pursuant n the Connrac ` T.
License Use.
❑ Item ascmpl under Sec. ,R A,PC foI)ls.T' n PF IS N
Owner Data TER AN (I i VALUATION
W(1RKER'S COMPENSATION DECLAkA910N to III B ), ICI: -
I hereby athrm under pendty 0f perjury one of the fallowing declarati"an: '
I have and so muimvin a C,iifcrool Consent no salt-Insure fOr Worker',Cnmpen- DRAINS-FLOOR,ItOOP ARRA.COND,
73700ofth,
in,as provided for by Section 37W of the Labor Cade,for the performance of the STORIES 1'Y I'll CONSTRIIC'I'ION
rk Its which this permit is tamed, PIXTUR HS-PER Tit AP
1 have and will maintain Worker's Compensation Insurance,as required by Seen.
Lahr Cole,fon hcpalooll.acenl'the work fur which this pemtit is...tied. GAS-EA.SYSTEM.I INC.4 OUTLETSOCC GROUP y workCs ti Ins �, dPolicy nu hr me rier, Cu ncen.a ALJU a Policy Na.. GAS-EA,SYSTEM-OVER 4 TEA)
CERTIFICATE OF EXEMPT ION FROM WORKER y -
COMPENSATION INSURANCE GREASIVINDUSTRi.WASTE INTERCEPTOR
(Ibis action neN nm he enmpleN ifihe permit is fomnehundmd("tins.131 W) BUILDING DIVISION FRES
or lass.) GREASE TRAP Iramify that inthc rformunce of the work for which 1'LANCHECK FEE
pa the
is SEWER-SANITARY-STORM EA.200FT.
not mnpiny any person in any mannas so as m become subject m the Workers'Cnmpen- ENERGY FEE
mono Low..f California.Dale
� I WATER DEATHS N'/vGNI'/F.LIiCTR GRADING IEEE
O NOTICE
OTI nm
H Nance subject
APPLICANT:If,afar perking this Cenono,of of Exemption,you should WATER SYSTISM/I'REATING
5 became mommas the Worker's h Tua Cmntto Ibis p.,it hot"f the Labor Code,you mush SOILS ITE
W I� forthwith comply with such pmvisanns nr this peatit shall he(canted revoked WATER SERVICE
Z A
� z CONSTRUC'T'ION LENDING AGENCY NEW RIiSIUHN'I'IN.PLMB. SQ.11 PAID
U Thereby vffmnbauhcre i.nronswction tenting agency fnrthe performance of Date Receiptp
LI.TF the and,lilt which this poring is ismed(Sec.3097,Cie.C.1
Lender's Name
O W Lender's AddrossTOTAL
TOTAL: _
1 ecnif,that I have mad this Snd....... +Ptl sate that the aNice information is .. T BUILDING PEE
Fr to enrol.1"µme T"wntply with all city 4"J coo y ominaneu and auTTe Inwx iulating to QTY. ' ( .,MPCHANICAL PERMIT FEE V ,`� building construction,and hereby authorize eotmNes of this citya eater upon the SEISM IC FEE
sh—c-mentional pmpeny for Inspection p ,.
Wo)a PERMIT ISSUANCIi
( gate m cove,indemnify and p armlet t try"f Cupertino nguinst Ii1.EC'1'RI 34CI""'�"•�_I
liebililies,judgmmnrs,costa and expait'es -i h ay In tiny a TmemmTgaittst soil City Ai;l'13R OR ADD TO MF.CII. T,
on .a uence"f the ani gofthi is, I PLUMBING FUR
APPIA T IIND-1ST NDS ANTI V ..COMPL W TH ALI.NON-POINT Alit IIANDLINO UNIT(10 I(f0s)CFM) IL/'
SOUR ULA ON ME ANICAIATEi
AIR HANDLING UNIT(OVER 10,000 CFM) C t C O
Signor ,f Applicant/ o Tacmr Date FXIIAUSTHOOD(W/DUCO
H ZA DOUS PRIAM DISCLOSURE n HOUSING MITIGA'T'ION FEE
Wi The vppliam ornma bulb ingoanpvm,dm nr handle haarron,matcrinl HEATING UNIT(70 100.0ad)B'OU G)t.
es Ac0 eV by the CupcNino Municipal Code.Chapter 9.12,and the Health and Safety
Cale Section 255320Up BEATING Del r(OVER 03,000 BTU)
E]It's ❑Nn VENTILATION FAN(SINGLE RESID) PAID
40 Will the applicant or entre(wilding(occupant use equipmentor devices which
Date Receipt a
tit haadnus lr commitments ns defined by the Ray Area Air Quality
Management BOILER-COMP(7HP OR 1011.1X70 R'TU) ,Q
Uislrict' TOfAI.:
❑Yee � a aOILP.R-COMP(OVP.k IW,IXI(1 BTU]
Ilvtve read the haarras teriulc V rt cons under Chapter b.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fonds Health at Su Ty Calc. ms 255(15. 5 13 and 25534.I unJerstanJ that il'the NEW kiiSIDENT1Al.SUCH. Sp,PI'. r
ing d,ez sac only ha nom,thnt' TnY ad s,
to notify the acupam
"fill "at, wloahn x1 met prior run"^Ce�i�tes-otpanc.
rout n Uwe IOTA h: ISSUED 9Y: I P
OFFICE