S 1851 "APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY-OF CUPERTINO HUII.DING.ELECTRICAL PE IT NO. �k r. ,I
BUILDING DIVISION APPLICATION/PERMIT 1'INCLUNR PROJECT
IDENTIFICATION
18 5 1
nuu.nwc PROJhC,T u)r:NTu+IcnTloy ..LL VV as JJ 1
BUILDING ADDRESS: .SANITARY NO. APPIACNI'[ON SIIBMITI'AL IIATIi
0 BAST TES VC- I 7-1r-(j
NLR'S- AMIE
THUS CONI' ACTOR'S NAME: .IC NO
f� /LCT'= NIC CONTROL#
AROII I'I!C'I'/ G ;ER: LIC AD NESS: ❑
CONTAL PHONE: BUILDING PERMIT INFO
3 / O / ❑ Consultant Fees Paid by Applicant(Initial) BLIND U PLUMB NIECE
0._ X010 W ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Q'rY. ELECTRIC PERMIT PEE
I hereby auim,mal I am Ea+mrd lade,pnoo,a o of chapter 9 manufacturing JOB DESCRIPTION
WIZ sous Section 9lXXB<,fllivishin3o[lou Buainus%anti Pndcssions Cents.nnA myliccnsc i. RESIDENTIAL:
W 00 PERMIT ISSUANCIi
F�W F in full force and effect. ❑SIDWL ❑KITCHEN REh10DF.1.
Q,UU I"a"Clan, Lic#
y�W Date Canmrecmr AE•I'LIANCES-RESIDENTIAL []ADDITION [I PLUMBING RIiPII'V,
6 ARCHIT[CT"S DECLARA'T'ION ❑MULTI-UNIT [I STRUCTURAL
PANELS.
z O y Z 1 lindcr.wnd my plat,.hall be.,ed uv public oaands MODIFICATION
Oz-0 UPTO NOAMPS El INTERIOR ❑CHIMNEY REPAIR
G—FJoe
Licensed Professional 201-100AMPS IMPROVEMENT SWIMMING POOLS
CY�-V
OWNER-BUILDER DECLARATION OVER HIMAMPS ❑BATA REMODEL/REPAIR [IDEMOLITION
C W Q 1 hereby affirm mat I am m th
exempt froe Comracmrs License Law far the
3 U fallowing mawm.(Section 9031.5.Business and Professions Code:Any city or county SIGNS 1!hBCTItICAh ❑OTHEk
W O,. which ro,circ,,Pmri.. t lm,imitative,oJ,nofi,h,.,,m,a, y.uucmr.
Q pi....... GV
. I . �
Rat he is licensedpursuant me prooisions ofthContractor's License La (Chapter9 l
alC 0 (commencing with Section 7Rr(if I 'ei 3,01he R IP f.siam Code)or TEMP.METER OR POLE ST.\ COMMERCIAL:
%%
E.X e C thus be is cwmpt mherefrnm unJ the hasis for the alleged csemption,any violation of ❑NISW BLDG/ADDITION ❑I31iM01.TION
XmW Semion7031.5bYany a,pllcanr Ter a,ennit suhjen,rhe applicant to a civil penalty of POWER DIiVICIS
Way / ❑TI!NANT ❑FOOD SERVICE
=Q nm marc Than live hundred dollars(SSIXry.
(] I,as owner nl thcpmpcny,ur my anployccs with wages as their sale o(s .R vine, SWIM,NING P(IOL r:LE OHHHR IMPROVEMENT
ciffir.. will Aomt"nal Cook: he Contractor's
Lllded Law ad Raor applySesIn an.owner
of ❑0'1'HIiR
13add� pro rty so
ohob Cook:The Conwcreo License a sl I.nwdoes notapply s unowner of QUIT f!TS-SWITCHES-FIXTURES
propmn who builds or videdsproves mvamh 11 and as lit;Jens such ware hamded or or through
his awn employees,the building trim such menti is sol w arc not i corer ftl m plete ,for NEW RESIDEN'IlAL ELIiCIR If SQ IT.
rale.IL htnveveL the building arimpnmemem is sold within ane year of mmplmion,the SQ IT FLOORAREA S/SG.14.
a-heilder will has,the burden al'proving That he did ort build ao improve for poo-
,,sg of sale).
as r of the propcny,am exclusively contracting with licensed commiclom to
4TOT c
act mbc l,j,,,(Sec.AW4,Bevins.and Prolcssinn,COJc:)'no,Cunnacmdx Lo-
mw Law does and aa
pplymansnn,nfpmpeny who build.,,improves thrown,and QTY. PLU M B 116,111FR FEE
w.contracts for via projau soon it consumer licensed pursuant m the Cnntracmr'.
hiccn.e Low. PERMITISSUANCE
']1 amcrAac, .R&Y C h�ni.�
ALTER-DRAIN&VENT-WATER CA
a� ( ) VALUATION
WORKERS COMI'ENSATK N DECLARATIC IS BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty ufpnrjury one of It,following dsiaMi'mr.
haveand will maintain acenihca,of Consentao self-inwre for Worker's Compen- DRAINS-11.008.ROOVAREACOND_ STORIES "TYVECONSTRUCrION
,amino,us provided lot by Section 3700 of the Labor Code,for the performance of the
work for which thlu Icrmif is issued. FIXTURES-PER 9'RAP
0 1 have and will maintain Workers Compemadion Insurance,as required by Section
3900oflhe labor Code,births,performanreol'the work for which this permit;.issued. GAS-EA.SYSTGI-I INC.40U9'LF,TS
OCC.GROUP APN
My Wnrkcr s Cnmpensaminn In.wmnce carrier and Pnllcy nonuser arc:
Came,: Policy No.: GAS-EA.SYSTEM-OVI!R i(FA)
CEIRI'IPICATE OF EXEMPTION FROM WORKERS'
Jet
COMPENSATION INSURANCE GREASEDINDUSI RL WASIli INTERCEPTOR P
(Thi,section need non he committed if the permit is ffrone hundred dollars(SIM) BUILDING DI\9SIONFIi13S_
nr less GRIiASH TRAP
ECK PF.Ii
Toy anythat inure any mannce rofonc work
comewhkect1.permit W'k".Cois nsst.- SEWER-SANITARY-
notemlo to breomemKwtmtbn Wadcri Com SIbRM EA.20)FT.
employ person in any matter u,u.. ) pen- ENERGY F.
O ,� ,atin.Laws of California.Dame WATER HEATER WNENT/ELECI'R )Y�f
Z O Applicant J IIA dNG PF.I!
% NOI'ICf;'TO APPLICANT.If.after making Ni,Certificate of Exemption,you.should WATER SYSTEM/IRIdATING `1
a ? born..¢subjetn In the Workers Compcosmion provisions of the Labor Gxly,you ran, SOILS PEE
W forthwith comply with such pmvis+ons or this permit shall be dimmed revoked. WATER SERVICE
a Q
Uz CONSreisa RUCTION LENDINGAGENCYagency
NEW RESIDENT IAL I'LM13. SQ.PC PAID
U Ifor by whihlinthuuhe iisuad(Sao.i30 lending agencyfonhe pennrnanec of I re Reccipm#
� P he work far wmnn nil,pemdt 1,1„aa1(Sao.3097.em.ca
O U I,enderx Name "TOTAL:
r Lender'.,Andres, TOTAL
y I senify mhm I have read hi,app0nwon.o.I bac that the above fit f nuueon i, BUILDIN E'
UrV) wast.l agree to comply with all city and county ordinances and%rate laws relating to QTY. M17CHANICAL PERMIT FEE
2 builJingcon.wctin I,and herchytmthoriz,repressmativea of this city u+enter upon the SEISMIC
atnrvenmrnmead p,i,,ny for inspection pnrpv.e,.
(We)agree at save,indemnify and keep hannlms one City of Cupenino against PERMIT ISSUANCE O
Iiubditic,jaJrncn,m,_,and canvases which EhIiCI'RI +EE
6 he m 1 1 1 1 yin any way accrve against said City ALTER OR AILD TOMECH.
mryucnce of the gaming of this pennim. PLIIMNING 'F.Ii
APPLICANT UND17RSl'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON['T(TO 11
10. 01)CFM)
SOURCE REGULATIONS. .MECHANICA.IEE
AIR II ANDLING UNI'I'(OVER 100A)CFM) CONSTRUCTION TAX
Signature ofA,licnnVContraetnf Date EXHAUST HOOD DODUCt HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will meat Ii,em nr future huilJingtne...al use to,bundle anommoe,mmenal HEAPING ON IT OO 101.000 BTU)
defined by he Cupcnlno Municipal Cal,Chapter 9.)2,and the IIcehh sad Safety
Cala.Satinet 2553'_(0)". HEATING UNIT(OVER 100,000 B'TO)
),. U Von ❑No
VENTILATION PAN(SINGLE R17 JD) PAID
Will the applicant comm of taste building by he Be,se en Air Qu of Juices which Doc Rtteipm#
ion'tznNnes air cnmaminanmmAClincJ by Om l{ Arca Air Vnnliry Munogiment ROIhI!N-COMP OHP OR 1(X),(XXI If"fU)
Uiarid'! 'fUl /
❑Yon 0 N BOILER-COMP(OVER I(k,IXO B"f U)
I have mai one havardous material%da,limments under Chapter 6.95 of the Cali- AIRCONDITIONEN ISSUANCE DATE
ford.Helm&Safety Cale,Section,25505.25533 and 255311 unintentional Nat tithe NEW RESIDENTIAL MECH. SQ.F1'.
huilding Jocn nomurmnrly h:rvenmount,what it is my mc.,ponsibilify Ire ramify the occupant •� 9
of the calcifications which must be met chains i...unee of a Ceniicate of Occupancy. ,
Owncrormmareed.,car Ilam TOTAL J�r /
ISSUED BY 1 DI
OFFICE