S 1269 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL PESapIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL V 1269
BUILDING PROJEcr ITSF,NTIFICATION
BUILDING ADDRESS: 1AaR7ARY NO. APPIACATIONSURMITTAL DATE
q uH S�SG� 'L lg g8
OWI:I+R'S YI{ONE � CIINTR )HY NA NI
t 1. :. EC CONTROL#
ARCIIRECf/ENGINEER'. IC NO: At)])RESj ❑
CONTACT. PIIONE BUILDING PERhIIT INFO
❑ Consul(ant Fees Paid by ApPlicaall In ) 4G HLDGELECT PLUMB MECH
LICE1,1SI.0 CONTRACI OR'S DCCLARACION QTY ELECTRIC PERMIT FCC ❑
I hunch,afr,n m.l I not I:<nom mall pn,.ninl..of Cwq«9 Baha teneing' JOB DFSCRI PITON
[[i.05 rl,Smion 700). 3PIthe Bu'mor nm Code,add my license is RESIDENTIAL:
F�'� in full taxa aM of n I l4iRMI I ISSUANCE
ea.WF 6c ❑SIUWL ❑KETCH EN RI1.10D1.1,
<uu Liacnu Claw 6 APPLIANCES-RESIDENIAL ❑ADDRION ❑PLUAIRING RE PIPIT
W Dale Cmoracm,
Fly AHCHIT1iCTS DECLARATION PANELS ❑MULTI-UNIT ❑SfRUCfURAI.
z0`nz Iuml mid on,platashall be asses pWlc mcords MODIIICATION
OZ-a UVT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
P LLW Uccmed Nor—iowd 2111-I000AMPS IAIPROVEMFNf SWIMMING POOLS
OWNER BUILDER DECLARATION
CC d hcrchy vllimm that mn uomp tram the Conwmnr's L cone Law for the OVER HXX)ANIPS ANT REMODEUREPAlk El UEMOLITION
K a V rdlma�ing moan.(Section WJI.S.Hurhtea.wad 1'mPoaioms Code:Any my«sw
rnty SIGNS ELECTRICAL
OTHER
3 W which mcmreo s noil ,,cotnlmct,ager,impm c,dervol kh,or rcrymC any,some,are
psi«Ioit,muuae,also".it ,me uppllcmI f«ech permif Blentigoadaitmam SPECIALCIRCUIUMTSC.
Thal k is licemcd'oasm to lbe pmvismmmir IN,C«uracloalr Liecn.lc Lia-(Chaprr9
W X00 (0O1avYetline with Scwtioo 700)of Division 3oOte Bmomic.sod Profsoo,GdC)or TEM P.Mf:THR OR POLI INS'I'. COMMERCIAL:
d 1 Nat he is cmntps therefrom and Ile hesk Gr the alleged exemption.Any v'vAmlon of ❑NEW BLDG/ADDfHON O DEMOIdTION
x'ga� Section 7031.5 by any.,If.,bar.pmtnit n.NeOv the vlrplic-.ttt leach ml c-lly M POWER DEVICES
u1^y ❑TENANT Ll FOOD SERVICE
na m«oterm Fee humtrs dalton ycm,i
U11'ROV ILMENT
d Ill do thenerof the popeny.m lnyetltpin)xs wiNwaeesur Noir wk mmEmctiom. SWIMMING PIXIE,ELECERIC
W an motdnthexot1 Code:e hl Cofeisnot,inleMs«oBeml11111f ally to
B icor ❑QTHFR
�3 w and lddcvri,timid, :o into Cnmmntnr's toil w low dovx ttm ci mrm f owiwroC OVI'LET'S-SWI'rCHLS-FlRfURES
noted,man
wen!milds o-i,ed n dm va,h oeM,eni ,u .wch soak himself«IMwgh
hie rose employees paiklo, Nil pooh impnrvemetns lh on intents«oB'els Ina NEW RESIDENTIAL ELIiCTR SQ IT.
sole.If,boweveillthaocc ngmitnWftvemunl is mdwiid noncyvur mol tplaior tare SQ.IT.(,71lM�t Aftl'� YSQ.ET.
Poser-buiRkr will hevc the huNcn of pmvin{Nal he did not baiH or iatynoox f« M I
L war-
Pose Pf.ole.l.
❑ I,as twos vo Ihn pm,70,1 .B renes ivey Pommeling with liccn i conuoetnrs j- 1O'TA L: Cam
cen,c La1dte-not (Sec.oan owner
rof andry w ho builds
Code)ori,M cs11 vcmh ,,d lj- `YY 9
c olnwd«wnmmmppymtun umi.TofpnmenY wcen ilA.miolm me Cmidswmmd QTY PLl1MBIN R IT FEF; /you
pont comtaacta f«such pmjaos sots a caurums(s)licensed pursuant m IM Cunuacnls ,1
License law. PERMIT ISSUANCE
❑ E am cxcnp nntk scc. .B n PC fm This—on
Owner Date
WORKER
R-DTRAIN&VEN -WATERT ) VALUATION
WORKERS COMPENSATION UECLARATION BACK ITOWPROTECf. I" pe�
I hereby affimttd
rurr penally of pajuy one of the f(Alotwing declamations:
E]IhaviceM will muinluina Cerom....of Comtism It,elf-im,me for W«kcd Cool, DRAINS-FLOOR.RIN)F,A H N). STORIES 'TYPECONSTRULTION
onio,m psoidN tis by Section 370()el(he L abort Coda,r«Ise percommwnce of marc
weak I«w hich Nis pemut is ices. FIXTURES-PER TRAP
❑ I have and will ominlain Worker's Compencuien Inwrmse.as rrymrs by Section
3701 ofthe lnborCde,for Tv,pettantwmc of the work for which this pemtitk ises. GAS_EA.SYS15W-I INC,4 COME OCC.GROUT APN
Fh fa Ensu vM Policyn
1MVII ION
GAS_IIA.SYSfI1M-0weRaa3A)
CERTIFlCAI'E OF SATTO 1'10S FROM WORKERS
COMPFIJSATION INSURANCE GREASI%INDUSfRL WASTE INIERCEPNR
BUILDING DIVISION ITIS
(This,coon,es«R txe ummpletedif the, urnPI is fortate homy dollar,($nM GREASE TRAP -- -
«kr.l I'LANCI{F.CK PEE
I cenily diel in the pa4wmanceoflhe pooh l iowhich Nispermil kisucd.I Jball SEWER-SANITARY-STORM ITA.21X1 ET.
no toploy any pcoo nosy mttfox.r m so to hccamosubjc:I fo me Workers'Cero,n- ENERGY FIiE
z cation Law,of Califs-m Date WATER I TEATI:R W/VPNI'/EI.F;CTR
O Applinot GRADING FEE
f~q NOE ICE'I'Is APPLICAN'P 11,afar nwkmg Ihis Cenifieme of Exemption,you slamld WATER SYSTENU T'REA'TING
F" becmne subject to Inc,Worker's C«npen,gian paovisions PI Ne Tab«Cede.You muse SOILS ITE
WfonhwImeoinply with pooh Moivonv mlh,spcmut shall bnhromcd mvoks. WATER SERVICE
aQ
7z CONSTRUCI'ION LENDING AGENCY NEW R'LSIDFNDALPIJd B. SQ.FC PAID
EL IhorwhicRnu ,nernottlyove,E]Wieve.. lcMing Pgutrty tort the pcdonmwmof D.ec t mp
Ile w«t far which Nis pcamil is isatas l.Scc.3(197.Civ.CJ
17'u Lemle,Nemc )TAI.
yO Lnmukr'I cemiry TOTAL:
y I cenily Ibaa 1 have Icad sic vppHC0Iw11 and sole that the above infnamatioe u BUILDING FEE
h comecf,Iagreo m comply with en oily and cnumyowdi.,ant .Is laws relating to QTY. MECHANICAL PERMIT FEE,
C..1 z huihling ectisvunltun.and hereby aminnne acpresenmlivaol thlscly menlurupan the SHISMICFEE
above menliomH Me seny few irspmlion pniwecn. PERMIT ISSUAN07
(We)ug—nova,iock,.mly and keep hanmdew Ne C.fyof Cupcnima a,moo ELECTRIC :IS
I iahih,ics.jmJ,mrnls.c'osts and expenses which may in any way aceme s,asim,l said Clay AI T[R ON ADU TO METH.
in consi lu oflbe gmn'ine of Nma pcmdl. PLUMPING ITE
APPI.IC T INDHIdIANDS ANOWILL COMPLY WITH ALI.NON-POINT AIH 1{ANDLING IINI'C(10IU.(XMICFMI
SOURCE 'G)LATIONS. MECHANICAL I_cE
AIH HANDLING UNIT(OVER 10,000ChA1) LONSI'NUCCIIIN A%
Sigatm o f ppliOmt/Conlaaclm Date EHAUST HOOD(WfDUCT) HOUSING MITI!ATION FEE
IEAZNRDOUS MATERIALS DISCLOSURE
Will Thu epplicft«Immo,huildinp ormupanl sore«hmd1P berankms material IIEAFING UNIT(11)1101X0 It I U)
as def nN by be Cupenion Maoiciful Code.Chepler 9.13,ant Ina,HeaIN and Safny
Cork.Scetion 255130x1^. HEATING UNIT(OVER IW.00X)RTU)
❑Ven L]No PAID
VENTILATION FAN(SINGLE RE-SID) Ilene Rev - N
S Will tM applimml ser furore oidm,twcupum u.¢ttlm,mcntser deviacs which
emit h:uvms doau mmants
nmmas defined by did Bay Ana AU Quality Managenxnl BOILER-COME'OHP OR I00J00 BTU)
TOTAL'
Dituim^.
❑Yeo 0NP ❑OILER-COM P(OVER IIXLIXXI IiTUI
I have read the hararGws materials re,morncmn umkr Cha,am 6,95 of the Cali. AIR CONDITIONER ISSUANCE DATE
undo I{eultb N Safety Cook.Se7imi,SAH,25533 ant 255}1.1 utuknmaxl Nm if the NEW RF_SIDENNIAL MECO SQ.Ff
bur
serdtu ei ryruir n
Jten cculmulYhaveaIcaW1.Nv 11 tato,rcp«mxihililY WIavifl'Ile occupant
enta which mos M my(tri«IP iuuw¢c M u Cenifievm of(kcvpnn y.
Owxr«euNmiu .,nl Doe TOTAL: ISSUED BY:
OFFICE