S 0579 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELECTRICAL PERMIT NO,
CITY 016 CUPR SION PLUMBING.-MNCUANICAL S 0579
,ILDIN"lyB IHI 5v N APPLICATION/PERMIT BUILDING PROJECT 11)ENrIF'1CATION'
.UILUINC A DUR&SS SANI'T'ARY NO, APPLIES]ION SUBMIT1'AI.DATE
2-000O Milal [
OWNERS NAME: �PHONE: CONIRACD)R:S NAME LIC NO.
\' SI 1 blVS NIC C IROLp
ARC1 YENGINEER: LIC NO: )DR'E'SS: ❑
7 jCi L/ r- 0. S z
CONTACT':
PHONE: UILDING PER TINFO
❑ Consultant Fees Paid by Applicant(Initial) Irl Ii IiC I'LT sat MfiC I
2 r�L Z (a —el it, ET ❑
ICIiISSED CONTRACTOR'S DECLARATION QTY ELIiCTRIC PERMIT FEE
I hereby Maranhao I um llcenxJ under pmvlsmus of Chapter 9lcommencing OB D RIPTION
M=ZWOO with Section 7000)of Di vision 3 of the Business and Professions Code.and my license is R IU
WOO PF.RMI"1'ISSUANCE F W in full force and cdc t. ❑SF DW ❑KITCfiIiN REMODEL
QUU License Cort 5m, APPLIANCES-RESIDENl'IAL ❑7,,T1,_.11
;ON ❑I'hUMItING RF.PII'1?
FZW Uate Cnntruc core_-a.e�a.l�1-'�/�].�
tnQa ❑ IUNIT E]STRUCTURAL
ARCHITECTS DECLARATION
F y Z I undcchand my plans.hall M:u.anl un PUMic mcordx PANELS MODIFICATION
O Z=� Oil 102S)AMPS IOR [I CHIMNEY REPAIR
f'W LiccrecJ Profe.aional o_MI-IIXXInMPS IMPROVEMENT' ❑SWIMMING POOLS
G F,j OWNER-BUILDER DECLARATION O1-INX)VER )MAMPS ❑BATH RY.MODEIIREPAIR C1 DEMOLITION
�ci Cv C I hereby nitron tout I ant uxnntpt linin the Conon ew,',License Law rot the
eiiyyS5 O W rnllowit matron.(See.lam 70131 S.Rhein.,.and Prufcesiom Cndn:Any city nt wmaY SIGNS ELECTRICAL ❑Of I IER
13+3 W U,i which requires a I'erntii ser construct,uhcr.Improve,deninihh,or repair any amebae
nor I I :momer.al...rt,m,dor.,licantI 11 tr filc u,,red,memorm SPECIAL CIRCUI'IIMISC
ilear he is licensedP ;u lt the pri-siotiv mile c t' I License Law(Chapier9 COMMERCIAL
(commencing with Section7oad f ) r.' 1 fro B and f Calc)nr 'CMP METER OR 1'01,1:INS'f
)Oa G that h nPl there) mJ the M1asis fm the alleged exe pt A y '1 n nn of X ❑NEW BLDGIADUITION ❑DE'MOLI'TION
X Sccbon](UlSby anY uppliaam foralwnnn suM1jauthe applicant to anvil Woodyof POWER DEVICES ❑T13NANT ❑FIX)U SERVICE
W nolmon,than five hundred dollars(S500).
F=6 I,mownerofmc n.ornn Ince,with war as lheirsole cum tion. SWIMMING I'(N)I.ELECTRIC OTHERV1:MIiN1'
p Q PmK Y Yot employee, 6 .Buss El OTHER
f- anti do the imir,and the structure is not intended TM,doeeamed s
alepply1. n Business �
aim andstry who bt Ce e:The Comraereo License Lawsansnmapply 1.an
rther of OUTLCI:S-SWITCHCS-IrIX'I"URGS
progeny who builds or improves thereon,and who asses sono work himself ofthrough
his own m,evercea provided tom such mens is sold
art not intended of or offend for NEW R6510CNTIAI.ELIiCI'R 5
ale.If.hmvever.the Wilding or improvement is sold within one year of completion,the SQ,17.FI.q)R AREA ASQ FE
o ner-W der will have the burden of proving tom he did not build or improve for purr
poseofale.). TOTAL: LI
❑1,a,owner of the progeny,am exclusively contracting with licemml contmemn to '
noncom the project ISec.Inca.Hosiers and Professions Coder The Contramrs Li
cense Law Jens not apply to an owner of progeny whit builds or improves thencon.and QTY. PLUMPING PERMIT 'EE
who contracts for such projects with a commenr(s)licensed puvuannnt
o the Coractus.
License Law. PERMIT ISSUANCE CX/y
❑1 am eacmpt under Sen. .B&P C for do,masse.
Late ALTER-GRAIN&VE - AI'ER(E (yhC VAALL/I ON
Owner WORKER'S COMPH SA ION DECLA it ON ACK PLOW I'R(l !C'.D. I Exk
h'
I hk-Aereby affirm under penalty oI'perjury m¢of the finllI, ngdulamtioas;
/I have and will maintain u Certificate of Consent self-inxurelrWnrknds Cotnpen- 1 AIN5-PLOD UO AREA STORIES 'E CONSTRUCTION
'Ainn,as provide lir by Section$71X1 of the Lahr Cade,for the'dotmunae of the
ark for which this perair i,,,mcd. Iq TURKS-1'I' I'
1 hove and will maintain Wurkr's Compensulon Insurance,as require by Section
370X1 of the luhor Cndn fur lhe,donnance oldie work for which this permit k o,ticd. -EA.SY. 1'EN INC.40ITI,I. OCC GROUPAPN
My Wnrk�S/�' Coa,nsmion In,uranan canicnmd Policy numlr,� ��r�
Carrier;STArG fZ4!� Palmy No.: I/15J'cya_7; G '- IiA.SY*1RMd)Vli Ili
CERIR4CA I OF EXEMPTION FROM WORKERSG I A. ANI S'IRL W ST C 'TOR
COMPCNSADON INSURANCE IHJII.DING DIVISION IBES
TI'his section need not be mnopleted tithe permit is for one hundred dollars($10) ORI SL 'R I'
nr PLANCI{ECK PIAT
less)
Ivenify Ilial in)heperformuncreflnc work lir which this permit i-lord,Inbell SF :R-SANIT Y-, OR :A.200FP
not employ any pennn in any manna so as it,become subject m the Workers'Co-pen- ENERGY Flip
7, sation Irws of Califirmia.Date W ER HHAU R WIVE 1'.ECI R
ZQ Applicant GR )INC FEE
NOTICE TO APPLICANT,If,after making this Certificate of Exemption,you.should WATER SYSTEMI TREAT G
�'; hecnme ahjcq w tnc Workers Cutnpcnatinn provisions of the Iubnr CWe you must 14S Ai
� forthwith romply with such pmvisinns onhis permit shall he Jecmcd revoked.
WATER SBRVICIi
6 P D
7z CONh.isCf10Nse;ion LENDING NEWRESIDE S Dam Rttciprx
i U� Ihercby affirm that them isattsnammion lending agency furthe performance of
the Work for which this permit is issued(Sec.3097.Civ.C.) TOTAL:
:
O U Lendce,Name
U LenJd,Adrl TO AL:
1 certify that 1 have mad this application and state that the above information is BUILDING Igili
Fr y correct.I agmen comply with all city and county ordinances and store law,relating to QTY. MECHANICAL.PERMIT 'E SEISMIC FEE
U Z building constmcdnn.and hereby authorize repn,moutives ofthih City to enter upon be
Movenmmioned o,o,for inspeninn PUPwaen. PERMIT ISSUANCE ELECTRIC FEIi
(We)agree ser ave,indemnify and keep hermlca the City of Cupertino against
habilne,judgntents,costs and expenses which may in any way accuse against said City ALTER OR ADD'1'0 MUCH. PLUMPING FEE
nseyuenee ofilm granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL.NONPOINT AIR HANDLING INTI('TO Koff) MECHANICAL Ig3E
S( REGULATIONS,
fT
AIR fIANDLING UNIT R)VHR IIMaM CPM) CONST RUC'I ION'I'AK
:igname of Appocion/CnIloretor Dote EXHAUST I IOOUOWIDUCT) OUSING MI'I'IGAHON PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the upplieum nr fuutm huilAing neeugum xmm or orotic hnzordoux material Ilh'ATING 11N1'1'1'fO IN tNNt H'1Ip
'
us defined by the Cupertino Municipal Cod,Chapter 9.12,and the Health and Safely g
Code,Section 255321104 HEATING DISH T(OVER INMfoo it
❑Yes �o VENTILATION 'AN(SIN 117 ' IDI 'All Dam RcaiptX
Aft Will rhe applicant or future building occupant use equipment or devices which BOILER-COM 0HP I, N) TU)
emit hvardous air nmmminart,as defined by the Bay Area Air Quality Management '1'OTA I-:
hmaone'? BOILER-COMP ) 1. 1H PT'
❑Yes ;on
I have d the hmMulem,,materials"Mumcros anter ChaPmr 691 of Nc Cali- AIR CONDI' E ISSUANCE DATE
forma Health&Safety Code.Sections 25505,25533 aml 25534.1 undersand that if the NEN'RESIUIi 1'IA M1 ICI{.
10.Ff
huildingdoes act currently have a meant ded it is my mapnnsibility a notify the ocap int
ohne��yu���Is�;'hien r rat lc met p- en issuance of a Certificate of Occupancy.
/ ' 71t. 14a_i.af g/.6-571
OO(Gammoatnnr..doge t Dae TO L: ISSUED BY:
OFFICE