S 3064 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF
CUPIdR7 i BUILDING-ELECTRICAL. PERy7IT NO, 0
BUILDING DIVISION APPLICATION/PERh11'F DING PRNG-0IECHANIFic k`.7
BUILDING vxun:cr u)ENTIPIcnnuN
64
BUILDING ADDRESS: SANITARY NO. APPLICATION. DATE
10360 l - z 7A
WNER'S AME:S. PIIONB' „ CONTRAC'U7 E: LIC NO'.
"q/ a 19„1 NAM
NIC CONTROLp�f
ARCHITECT/ENGINEER; LIC NO: 1!o ADDRESS: ❑ 'J
A T:
CDN PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG it_17 PLUMB MECH
A_;zq4-1060 1� y c�
LICEN. -D CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby.ffnm tem 1.m licensed about pr vivion of Chapter 9(commencing JOB DESCRIPTION
MZZ with Section 7000)of Division 3..fthc Business and Professions Code,and my license in RFSIDENTIAI:
WOO PERMIT ISSUANCE
CLLF+ in full force andclTec(. ❑SFDWL ❑KITCHE REMODEL.
QUU License Class I.ic'M APPLIANCES-RF_SIDENI'[Al. [I ADDITION ❑PLUMBING RE-PIPE
to 7�of Date Contractor
Fah ARCHIT'ECPS DECLARATION PANIiIS ❑MULTI-UNIT ❑STRUCTURAL
Z O of Z 1 unJemm�J my plans shall he used as public retards MODIFICATION
OZ1p UP TO 200 AMPS [3 INTERIOR C1 CHIMNEY REPAIR
F 4-F,W Licensed Profnsinnal 201-10(s)AMPS IMPROVEMENT ElSWIMMING POOLS
Sa�C; OWNER-IR111. rom n
UIiH DECLARATION OVER I(xXt MPS ❑BATH REMODEL/REPAIR ❑DEh1OLIT1ON
as 1 hereby aliina that I am uxcntpt fthe Cmnaahs,license Law lin the
pe 3 LLon
U following re....a(Section]031 S.Business and Professi .Code:Any city or count, SIGNS ELEC' 1. ElT
OHER
which requires a permit m construct.a1hn,imp...e,demolish,or repair any umemre
R.LLp I prior to its issuance..]...requires tacti'diant fo orch permit...flea signedstamment SPECIAL. MISC.
'A
N
that he is licensed pursuant to e provisions..fthe Commemr.License Laos(Chi ter9
W 4^' it C) (commencing with Section 9000)o(Division 3 of the Business and Profession]CoJe)rn TEM('.M17ER0 :(NST. COMMERCIAL:
4 4 m C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLD ION
U^VN.
Section 7031.5 by aryaPpllcant for a Emmis subjects(heamficam ma civil aroby or POW ER DEVICES ❑'I'fiNANT El FOOD SERVICE
y
or more than live h...and dollars S5011), IMPROVEMENT'
C�Q I.as towner rilhe property,or illy rntployee.s with wages as thcirsectura,mation, SW IMMI NG PO OL
will do Ne arork.emdthesuucmre is not intended or..tiered Batch(Sec0M
.T1,Business DOTTER
as, and Pm&ssiom Castle:The Contractors License Law does not apply man owner of OUTLETS-SWITCHF_S-Irl R
4 3^ property who build.,or improves therton.and who dual,such work himself or through
his own employee,,provided matriarch improvements me not intended m offered(or NEW RESIDENTIAL ELECTS SQ Irl'.
sale If,howeveq the buddingorimpmvemunt is sold within line marracomplebon,the SQ.FT.II.(%>R AREA 95Q.FT.
7 owner-huilder will have the brmlen ol'prnvin,(hat he did not build or Improve liar par- 1 r
pose of sale
?P,, w^).
er of 0m property ru
am exclusively comcling with licensed contractors m
'fO'1'
met the prnj,,,(Si 7844,Emir,and Pmmv iota CAA:)The Co.,.,........
cense Law does not applyan abet ofp apenywhto buildsorimprovestherverrand QTY PLUMBING PERMIT FEE
wh..r..ntm mchp j is..than,,. a 0licensed pur.uanl to the Contractors
License 1: PIBMI'I ISSUANCE
� 1am ex m oder. ,13&P C(nnbis rent..
ALTER-GRAIN&VEND-WA'ILT (EA) VALUATION
Ow Doc
WOR 'S COMPENS ION .ARATION RACK FLOW PR(OTECf.DEVICE
I hereby affirm under penalty of perjury one of the following declarations: v. 0
❑I have and will maintain a Cenifcam of Consent an self-insure for Wei Compen- DRAINS-FLUOR,ROOEARI3A,COND. STORIES TYPECONSTRUCTION
cation,as provided for by Section Thin of the Labor Cole,fair the performance of the —
nrk for which this permit is issued FIXTURES-PER TRAP
❑I huvo ural will maintain Wnrlet,Compemvorn Insurance•m required by Section
391 LaborOxh,battle perfnnorna ofthe work livwhieh this perm!,it issued. OAS-17A.SYSTEM-1 INC.4OU'FLETS OCC.GROUP / .p]PN
My Workers Cn aberration Insurance scom .md Policy number um: 3.N / Zq
Caricc Policy No.: GAS-BA.SYSTEMOVER4 Hi 2 J
CERTIFICATE OP Ii%IiMI'1TON FROM WORKERS' GRP.ASHANDUSTRL WAS TE:INTERCEPTOR ✓
COMPENSATION INSURANCE GILDING DIVISION FEES
(TM1issection need not be completed Tribe Permit is battle hundred dollvrs($IN)1 GREASETRAP
nr less.) 11 LA NCXIQj IF.i Q
Iconliy,M1m in thr perfonnuncv nflhcwurk far whlch,hi,permit i,issued,l shall _SANITARY-S'I'ORM EA.200 IT.
torn employ any poi in any manna xo an to become mhNitto the Workrrs C....list, 13NE GV 20
..tion Laws of California.Dam TIiR HEATER WIVEisiVELECTR
Z O Applicant GR 1 .E
NOTICE TO APPLICANT.IL a bo urriking this Certificate of Exemption,you should TFR. ildff IiAT1 NO
a ; become subject m the Worker's Compression provi mem of the L.tor Code,you must Si .E
BJ forthwith comply with such provid sarthispermitxhalllse deemed revt,ked. CE
ti
Q
CONSTRUCTION LENDING AGENCY 'Illi. 'NTIAI.I'LMII. SQL FT
PAID
z Ihcrcb IErm(hvnhcre ix.am,mnlnn lenJln 4m the fnmwncu of Dn,e ReaiptN
U O ya . .) per
F" the Lenders
for which this Permit is issued(Sec.3097,Civ.C.7 O
Gr Lender's Name OTA(
U Lender.Adoral, TOTAL. • w
Lk1 1 certify that 1 have read this application and state that the above information is HUILDI f�f
CL.
toren.Lgree to comply with all city and county refinances and state law,relating at QTY. ETA CAI,PERMIT FEE
V� building condrusinn,and hcrehy mutilation mpresenmtivex nl shit city,.enter upon the firS P i k�
ohnvamemloned property for inspection purposes PERMIT ISSUANCE BLL RI PER(We)agree m m
save,Indemnify and keep harmless the City of Cupertino against
bitbilitics.judgmeni...(s and expenses which may in any way acerae against said City MACRORADDIOMECII,
in nuquence oche Rollick or is permPLUM GFEE
APPIt ANT UNDERS 4 D nNDWILLit ( MPLY WED1 ALL NON-POINT AIR HANDLING UNIT(FO 10,00)CFM)
S U iREGU1.AT1O MLC LAICAL PEG
X AIRHANDLINGUNI'T HOVER IO.(XXICFM) CONSTR . ION'TAX
Slperame of Applicmn/ ontmchar r D E.XHAUS'THOOD(W/DUCT) HOUSING IGA'IION EEE
HAZARDOUS MATERIALS DISCLO. kE
Willmeapp]ic rad.,far..holding..ecupan,si andle hazardous material HEATING UNIT(TO 100.000 BTUO
as defined by the Cu amino Municipal Core.Chapter 9.12,and the Health and Safety
Coda Section 255326x0] H17ATING UNIT(OVER 100,000 BTU)
❑Yes 'k3 No VENT'I LATION FAN(S I NOLL RESID) PAHO Dam RureiptH
�f
Will d 1us aPPliantarfum,eb llding..mupem anon Air Qali,y Mecswhich BOILER-COMP(311POR 100,00OBTUI
7 emit hazardous air conmminanls m efned by Ne Bey Ara Air Quality Management q
District?
C3 Yes ROILIiR-COMP(OVI3R IlxLgp PTU)
AIR CONDITIONER
1 have mad the hao"'cul mmeriula requireme is boder Chapter 6.95 of the Cali ISSUANCE DATE
font!.! Rh&safety=,S 25505,2553 nd255.14.1undecsmndthe,ithe NEW RESIDENTIAL MITCH.
hul daanotuumm(ly have oam,thm door .p imil' m notify the txamant
p, nfthe qb crecnowhichan t rnr( ; nf• f crf Occupancy.
~ ^ /
Owner or am Hud egcm Due T(OT ISSUED BY:
OFFICE