S 1934 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT,PEN ONLY
CITY OF CUPERTINO BUILHNG-ELECTRICAL - PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL , 1934
`V
BUILDING PROJECT 11)F.NTIFICATION
❑UI�NG ADDRESS. � � I r�OQD {$ryV�pyl/1J��' SANITARY ND. APPLICATION SUHMITTAL DATE
WNER'S(iINNA3F.'�('�l`���/•/�• PII)Nli: .•� .DNTIj(.C'('D� • IC NO�
•ARCHITECT/ENGINEER: LIC NO: 1UDR 5: ❑
CONTACT: - PHONE. f BUILDING PERMIT INFO
.IuS (73041363 ❑ Consultant Fee.s Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Ague w,sw 69r
LICENSED CDN IRACI ORS DECLARATION QTY, I ELECTRIC PERMIT FEE
1 n m by fT that I licensed d I f chapter 9(a if..facing - JOB DESCRIPTION
PIQO whbS i ]Blxl) fD"' 3 fth Run a and P f Cwfe mJ myliee.cis PERIOD ISSUANCE RESIDENTIAL: -,
Fa� fullf canlellec 40,80V&i ❑SFDWL ITCHP.N REMODEL
6 W U Lopt Qe� —Lick APPLIANCES kgSIDP.NTIN. ❑ADDITION PL BING R8-PIPE
�a 0. Co,tray
p,7m
ARCHITECTS DECLARATION PANELS. - El MULTI-UNIT ❑STRUM URAL
Z p y z 1 understand thy plans shall be used as public records MODIFICATION
Oz`0 UPTO 200AMPS [_1 INTERIOR E3 CHIMNEY REPAIR
F4tW Licensed Professional 201-I(X)CAMPS IMPROVEMENT - E]SWIMMING POOLS
q•y'9; OWNERBUILDERDECLARATION
❑R-+Ca d 1 hardly affirm that 1 vin stomp,richt the Conmmrnr's License Low be the OVER 1000 AMPS El BATH REMODEL/RBPAIR DEMOLITION
iy(O kO fallowing reason.(Seaton 9(131 5,[Increase and Professions Cade:Any If',or weary SIGNS ELECT RICAU [I OTHER
IL a W y which requires it permit to construct,alter,improve,demolish,or repair any smmmre
F.u'.OG prior to its issuance,:dsa require,the applicant for sato parrot,mfileasigned namment SPI3CI Cl1ITIMISC.
ppp ythat he to licensed pnsumnt to the provisions of thin Coordinator's Lieernc l.aw(Chapmr9
(comunhemg with Sodium 7003)of Division 3ofthe Bmincsc and Professions CoAe)nr TEM i l'ER OR POLE INST COMMERCIAL,
11 iaG C that he is exempt therefhatl and the basis for the alleged corruption.Any viclmiom of El NEW BLDG/ADDITION ❑DEMOLITION
Wim Sce0un 9113L5 by any applienm fnrapermu suhjee,e the vpplicanno ueivil penalty of POW.R 'ES ❑TENANT ❑FOOD SERVICE
y not more,than five hundred dollars($500). IMPROVEMENT
�+ dDl,vsowncrofthcpropengor my entpinyceswi,h wages nstheirsolccampensntiun, SWIMMING 14 RIC
{�P.,� will Ao thework,unA thegmewreis not imm�dnl or olTered far vele(Sce9f114,9usiness ❑OTHP,R
0.'a° and Professions Cube The Commdors License Law does not apply Io an owner ofU I OUTLETS-SWI'TCHE. CURES
property whe food Id'or frapervasthereon, d who does such k In n'If dtrongh
his own employees,provided tl a t such nopeovername Ear not intended or offered for NEW RESIDENTIAL ELEC'11i, SQ PT.
sale ll the h dd' g p ¢neer Id within ) f pl tier,the SQ.FJIII�QIj,ARP.A 5/SQ.FF.
co-bailder will have the burden of proving that he(lid riot built]or improve for pen- Y'' ddAA LJ
tsw Ealc),
ors owner of the properi exclusively contracting with licensed contractors to 4 TOtFAL:' JUL
construct0 project(S 7044 BusinessdProfessionsCore,))1'heContractor sLi - -. -, `RN�1D
Law does not apply loan ownerofp open who builds or-improves tncre m,and QTY PLUMBING PERMIT,', FEE
w no contracts for such p jells with a contractors)licensed pum,an0o the Contractor s_ - (1
License Law. PERMIT ISSUANCE:. I�Ur �Up'thl(INV
❑ I am¢scents,model Sec ,B&P C for this rensnn
ALTER-DRAIN&VENT-WATER(EA) is ygLUATION _
• Owner Uam
WORKER'$COMPENSATION DECLARATION BACK FLOW PkOI'ECI'.DEVICE
I hereby told an under penalty arts jury one of the follow lag Workernnns /
E] I have and will maintain a Certificate of Converttoself-rheum for Worker-r Comport- pRA1NS-pLOOk,ROON.ARBA,COND. STORIES 'TYPE CONSTRUCTION
ration,m provided for by Section 390c1 oi'the Labor Core,If,,the performance of is
work far which this peanJt is issued. FIX CURES-PER TRAP
❑I have and will nmintein Worker's Congrensation Insurance,br required by Section
3700or,he Labor Carla fort he minaret too work far which this permit is ie,and. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC. ,OUP APN
My Worker's 1 e d Policy nut CIp�/ q
/
Carrier: (`.�,ennsuranc cvrrm Policy No. 99V" , �• CAS-EA.SYSTEM-0OVER
Policy
Olt EXEMPTION FROM WORKERS'
COMPENSA'I ION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR gl11LD DI SIGN FRES
('1'dissection need am he completed irme permit is fermi¢hundreddellan($100) ❑R9ASP.TRAP
or len.) PI. CHECKF , `
Iccdify that in the pertarocif or the weak for which this permit is issued,Dart SEWER-SANI'PARY-S'LORM EA.200 FT.
not employ any person In anymencersoocroher a cancer or(he Workers'Compen- P.NERGYP
entice Law-.of Gllifnvia Did WATER HEATER W/VEN HELECI'R -
z O Applicant s - GRAD] FEE
F-t raj, NO'T'ICE TO APPLICANT:IL after making 0Js Cre irate of Exemption,yon should WATER SYS9'8M/CREATING
haeme nuhjeal aide Walker',Cmnpensmitm pho,mianc of the Lalwr Code,you must SOlks
Wforthwith comply wilt such provisions or this permit shall be oriented oriented. WATER SERVICE
Q
UCONS'T'RUCTION LENDING AGENCY NEW RESIUI3N'fIAI:PLM 9. SQ.EL PAID _2 I haechy uffine 0m flare is acot....coon lending agency Ter thepedto ccof _ ate - Rewlpt#
V the work for which this Palmer is issued(Sec.S097,Civ.C)
Linda's Name i 'COTAL:
-� CUSI Lender(,Address TOTAL:
I eerO[ @at IInve read,hic'application and state that database infatuation is BIIILDIN THE
..raid carrem.l agree amply win au dry and county admances ind state laws relwing m 'QTY. MECHANICAL;PERMIT FRF.
'V 7. hnilding umary it .andlerelyour, ralzc represenia,ivecnRhis dry mcmw upon the SP,ISMI PF.P.
aheve-memioe ropumy for inspectorepurpnccs.
(Wife 'c e,inJmnnify,ind keep homeless the City of Cupertino ugamct PERMIT ISSUANCE BLECr IC PEE
save,
heIivM1iEdes,iudg c costs and oxpamxcs whicM1 may in any way ncenm again,Haid City AL'TE'R OR ADD TO MF.CH. PLUM NO FEP.
m
in consequence I!I remit gof this permit.
APPLICANT U.D S , D9 AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0,10 CPM)
SOURCE REGUL\q JS n MCCH,NICAL PEE'
op ON AIR I IANDLINGUNIT(OVER IB,B00 CI'MI CDNST UCTION TAX
Signature of Applican indirchalin, . � -Dow EXHAUST'HOOD(W/DUC'p
HAZARDOUS MATERIALS DISCLE HOUSIN Il'ICATIOMFEF.
O I1R
Will the n,heant or future hnilding occupant smrcnr hanJle ha ouleus material IIEAHNG UNIT(TO 100,000 BTU)
m defined by the Corrasion Municipal Code,Chirpier 9.12,and the Health are]Safety
Cods,Section 25532m)Y ABATING UNIT(OVBR,I 00,000 B I U)
❑Yes No VENTI LA'1'ION PA N(SINGLE RESID) PAID "-
. are Date keceipt p
Will .,Protein ,a—cluing occupant Management
BOILER COME ORPOR I(Bi 111 U)
civil 11-: cam n k' ee Aehned by the Be,Aron Air Quality Managemun 'COTAI:
District' I' HOII.BR-COMP(OVER'I(X),B(1011'I'G)
7Yes E]No
I leave mailfe e materials q tinder Chirpier fists 1 the Core
AIR CONDITIONER •
ISSUANCEE�D
forms,Health&SftySections25505,25.133
and 25534.1understand
uA .t hatiftNEW RESIDECIA.MCf. SQ.FT
buidgdoeintentional,l oatchiral:
that)ismy responsibilityt the occupant
ofrequirements which est M met pit '.. aneof o Certificate oifOcupancy
'
Owner or nmlmrimd agent - Dale 1 rAH ISSUED BY:
OFFICE