S0041 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUFERTINO RUILDING-RLECTRICA], PERM['No.
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BUILDING DIVISION APPLICATION/PERMIT i'LIIMBINU-MIiCIIANICAI. JiLL:.ii��
k....DING 1PROJECT IDENTIFICATION
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DING ADDRESS: 7SAN[TARYNO. APPLICATION SUBM1'fl'AL DAT Iipv� _ rrtf-f r'N,{1�JS NAME: PHONE: C ry/y'R/1sC�y`ySpaVyA�ME: LIC NO
^ IS of rt� 1� IT I�J,"vrf uM" tk 73;Z61( CONTROLARCHITEMIl NGINEER: LIC NO'. UR[SS
CONTACT: PHONE: �(JJ�X-- lJ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLO h I{ NJ
LICENSED CONTRACTOR'S DECLARATIOQTY ELECTRIC PERMPF FEE JOB DESCRIPTION
I henby aRmn Ilial 1 unt licemed under Pmvieions.f Chapter 9(commencing
Z with Section 700knof Division J of he Business and Pmfessiom CWc,and my license is RESIDENTIAL'
WQ� `°' PERMIT ISSUANCE
CSFn full force am,�r,.36 6/ ❑Sh'DWL CHEN RIiMOUHI.
<UIf
U Liansc Class Lic.N pPPLIANCP_S-RESIDLNTIp1. []ADDITION LjMBING RE.PIPH
FZu) Date Contras.,
w 6a. ❑MULTI-UNIT C STRUCTURAL.
F=y ARCHITECT: E.LARATION PANELS
m 1u mmVm plat(r hal11M ux a, ubl!ic r��cc9yNs MODIFICATION
—44nINS k UPTO 2IXIAMPS C1 INTERIOR ❑CHIhINIiY REPAIR
1-'4,F-i.4ll Licn.ed tensional 201-1000AMPS IMPROVEMENT I]SWIMMING PULLS
C C C Q 1 hereby afro ha OWNER-BUILDER exmpt i)rmr he Cord..mr,License Law for the OVER 1000AMPS ❑BATHO`FHR REMODEVREPAIk ❑DEMOLITION
O Y O fallowing rwv n.(Section 711415,Rusiwes and Profusions Qdc:Any city or county SIGNS ELECTRICAL �OTHEk
a 3 W y which requires a permit la consovch Allan Impow,demolish,or repair any structure
Q prix f t c I: y napplicantl suchP )I I 6 ed.I Icment SPECIALCIRCUI UMISC.
ad,y, y"'I Em he I dpursuant I II p of the C L 1 (Chapter9 COMMERCIAL'
W3rO� (sun n,,ol,Sal 70000ID vt 1 IIM1 B . e,, dl f.. .Code)., TEMP.METER OR POLE INS I'.
Q.d e C thin he is cxcnnIn thercfrmn odd the hails for the alleged exempt ion.Any v olatton of ❑Nli BLDG/ADDITION ❑DBMOhI'I'ION
mW Semon 70JL5 by any appheanl bon,conlit labioav the applicum n,ucivil penalty of POWER DEVICES ;NANT ❑FOODSERVICI:
.. not more than live hundred dolla'v($5(X)),
�S¢ I,ns owner of the n to Ili wa their sole cam lion. SWIMMING POOL ELIiCI'KIC I ROVF.MENT
G prolve y.or my crop yecs wi ges as Icnsa ❑OTHER
E. will done work,andthe structure is not infaolcd ormTcnd!liarxale(Site 701,1.Rosiness
3 m
and Professions Code: the Contractor's license Law does not apply no an owner of OUTLETS-SWI'1'CIIIiS-I'IX'1'URIiS
propcny who builds or improves action,and who docs such work himself or through
his awn employerbuilds1 I intended or offered for NEW RESIDENTIAL ELECTR SQ 11'.
cd nonsuch such irePdwemcnIs am o
sale If.hnwcver,thee badging or improvement in anlJ aloin one year of c.mpleu.n.he SQ.FT.FLOOR pato $/gQ.PI'.
owner-builder will have the burden of proving hat he did not build or improve for per, p� A
pave of sunt.). '101AL Ir
F1 h as owner of the property.am exclusively contracting with licensed contractors to M
construct the project(Sec.7194,Business add Professions Ctde:)The Commemes Li- 2� MtB�
ens Law does not apply it)anno,net of propcny who builds or improves thereon.and QTY. PLUMBING PERMIT FEE p�ttY v
who contracts for such Embeds with a contmmnr(s)ltermad pursuant m nc Contractors MAY
License Law. PERMIT ISSUANCE
❑1 am emmpl under Sec. .B&P C for xis maw)) Wt'eM UN
ALTER-DRAIN&VENT-WATER(I?A VALUATION
Owner Date
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirn under penally of perjury,one of the fallowing dedatation,
I have and will maintain a Cerificae of Consetn loself-iroute for Workers Compen- DRAINS-FLOOR,RWP.AREA.COND. STORIES TYPE CONS'THl1CIlON
sminn,as provided for by Scdinn J70f1 of he Labor Code,for the performance of the
and,for which this larnit is issued FIXTURES-PER FRAP
❑ I have and will maintain Workers Compensation Insurance.as require)by Section
471X1 of the Labur Cude.for the performance of the work for which this permit is issued. GAS-BA.SYSTEM-I INC.40U1'1.IT1'S OCC.GROUP AYN
/ Ca r�k- L V ace comer Andy N.
lent toy N.
GAS-EA.SYSTEM-OVER 4(EA)
CIiK'FI FICAI'E OI'17XEIM(TION FROM OH1SEE'R ,y R
DUSTRL WASTE INI'IiRCFP1OR
COMPENSA[ON INSURANCE tk't(p5/7]�['Y^R BUILDING UIVIS]ON PEGS
1'ILismnlnn aced n.fMwinplmed it the permit is tin nnc hundred dnllurc f811)B) APPLANCHECK FEE
IcsX)lanifyhm in the petlnnnnmnflhewnrk Gdwhichthia pixmit is issued,lshall NITARY-STOKM IiA 11X11'1'.and ctnploy Eby erwnn in anyamourw as to become subject to the Workers'Camper- ENERGY PEE
zgonion lanwaafCulif.rnin Data 'TBRW/VEN'DEI.IiCTKz ApplicantGKADING[LiN(ITICH TO APPIACAN'1:Il,ulnar leakingthis Canitiallanf Fixcnmtinn,you should I'I:Mn RBATINGhecmne nubjmt m the Wmkcr's Cnl^Iwnsadon PmOson,of the Wb.r Code,you meet SOILS IrEE
forthith cnlnply with web pro,,u i,nnhis wroul shop he deemed revoked. VICEC0N5'1NIJCT'ION LENDING A(iIiNCY IiNTIALI'LMH, SQ.Pll PAID
'7 z Iherch ffmn bufficre k—on,tra n lending agency for the Embarmance of Dae Kaxiptp
UO
F the work for which this permit is i.swed(Scc..107,Civ.CJ
Lender's Name T(YFAI:
Le
W Looders Address BUILDING FEE
1 reNfy fh d I have road this applicmion and stale than dle above information sus
contest.l agree to comply with all city and county ordinances and state laws,doing to QTY. MECHANICAL PERMITFTE SEISMIC FEE
V z building construction.and hereby salicin representatives ofthis city m enter upon the
aMve.mentioned pmpeny for inspection papaws. PERMIT ISSUANCE IiLECTj HE
(We)agree n,.save,indemnity and keep harmless the City of Curatorial against
Iiabilitics,judgmcnfs,cons and expenses which may in any way accrue against said City ALTER OR ADD TO MECIL PLUMBING FEE
in consequence of the gmming of this permit.
APPLI A "1'UNDERSTANDS ANI. N'ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.000 CFM) MECHANICAL FEE
SOUHC C n 1'10,`
J� 1� A — AIR HANDLING UNIT(OVIiR 10.1X0 CFM) CONSTRUCTION TAX
Sig arca Applicam/C.nttuctor mak• Date EXHAUSTHOOD(WNUCT) HOUSING MITIGATION FEE
HAZARIX)US SIS ERIAI S DISCLOSURE
Will he applicant of fararc huildogmwcupantmmi handle hamnlom material HEATING UNIT(TO IBM")RTU)
as defined by ne Cupertino Municipal Code,Chapter 9.12, it he Hendo and Safety
Code.Scdinn 25532m)P HEATING UNIT(OVER 100,000 B'I'Of
[D Yes 0 N VENTILATION PAN(SINGLii RESID) PAID
Dame Beer#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP IJHI'ON IIXI,IXp I{'TU)
emit hmaNnm our ammntinume.,,turned by he Bay Area Air Quality Manugemem 'D FFAI.:
District? BOILER-COMP(OVER 100,XXI H'TU)
C]Yes [:1 No
I Intoe wool the bwmdons materials rat juirenicuts under(buffer 695 of the Coh- AIRCONDI'HONER ISSUANCE DATE
Gamin Ilenllh&S:deny Coda Sedinns 25511.5,25544 and 25514I undcisnnJ'hat if The NEW RI,SIDI!N'IIAI.MIiCH. SQ PP.
huildmg dms nm vurrcntly have n n'.anl,In,iris ony,c......ibuity, to notify tha cei,son
of the rapincmans whichmud he run pd..Ini nion,cof it Coonan.of O11.1rc,1
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE