S 2169 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO HIT UAING.El.ECIISHCAI. 1-17811 NO
BUILDING DIVISION APPLICATION/PF,RMITrLunuilNc-Mi:cuArvlcnl" 21 6 9
BUILDING PR11JEC'1'IDI:N'1'IFICA"ITON
BUIIDINGADDRESS! SANITARY NO. AI'1'I.IC,AI'ION SUBMI1TALDATE
oZICNO:
v e S9
OWNER'S NAMII: CONfkACH)R- AMT!: LIC N¢
TNIC CONTROLN
ARCIIITECITENGINEER: AD NESS: ❑
kiss
CONTACT: PHONE: BUILDING PERMIT INFO t,
❑ Consultant Fees Paid by Applicant(Initial) HI.DG FLLE-CIT PLUM MECH
LICI!NspH CONTRACTOR'S DLCLARAI SON QTY ELECI'R IC PERMIT FEE
1 hereby'fain ani l alt.rcen.ed ooMr,WWi.ion,of Chaim,9 Rommentlng JOf3 DESCRII'"I'ION
OeeZ with Section 7(Nlfll of Uivisinn3of,hc liwinnx unit Pmfessiem Code.and my fiennse is BESIDENTIAI;
W O I'1!RMI F ISSUANCI!
1-nl= in full forceand s. ❑SFUWL ❑KITCHEN REMODEL
QVU Lice,ne CLva
Lie APPLIANCES-RI ❑ADDITION [__1 PLUMBING RE-PIPE
F Z W Umc Cnnuuctor
vs6a ❑MULTI-UNI T ❑S'I'kUCTURAI.
ARCIII'IIiCPS DHChAHATION
F 7 w PANELS a HmN CATION
zo-Z IunJcrxumA niY plans shell MuscJ us public rcmtJv lll'T021NIAM1',S
d\ ❑IMPiRIOR ❑SWINIMiN,POOL
[[=�F',� LicmueJ l'rofcxsional 201-❑NMIAMPS IMI'R(lVliMliNl' SWIM M1fIN(i POOLS
L'O C Scdiuli]u)1�911iuxinc amt lr,lkal ON OVER I0n0AMPS ❑BATSIRE )ELIREI' IR DoI?M(1LI'PION
J
C Q I hereby al'fitm,M1u,I int exit front ie Cn draclor'x License haw fur,he,
y W I]OIf11:R pita -
x 11 inh owing pawn,( ulu'Code:Any city^r rimn,Y SIGNS I!LI!C'Tltl(:Ah
li 31n y winch,nllJrc.a Mnnn m cnnnmm,.'hint intpmw,dnn,nExn.m rcpmr am stmcwre \k -Q' �.a'�C� 1
�-�.�� pnoneiasiumnco,alno,eqnim%the applim,m for such permitto file a signed statement IREIDENTI
III'17MI:'E� than he is licer,edpurwun,tu(he prnmrions of,hc Commdore License],a,(Chupmr9Wo,... cingwith Seaton 7(XN)lof Division 3of,hc Bmine,,tod ProfcxvioncCod0or 'I' UIt POI COMMERCIAL;bm he is uumtthc,ufnnn mutthe htuis for,rte alleged exemp,inn.Any violationof ❑NEN'PLDNADDITION ❑DIiM01.1'1lON
iC W Section 911315 by any appllcom Ga n pnmi, .bjen,the applieum a,a civil penally of PCES12nnnarnhan EvchunJrcU Dollars(ES(x1). ❑'TI?NANT1.001)SERVICE'
= I,as owner of the n em to vex with sea es LLC their role atm lion, tiool.liLliCfklC IMPROVEMIiMI'pr, y,orn, P > g pens' ❑OTHER
will Jo the wrk,and theammum kBol ialendederoffend forwle(Sec.7614,Business
W3m and Pmfe..ions Ceti ITC Contractors License law dears not apply to an owner of GI'1'CHIS-19%'I URISprogeny who buildso,improvesThereo ,and wan does such work himself e,throughhis own employees,provided Thal mcll improvements arc nt imeaded or offered for NTI AL HLEC!'R SQ FT.
sale lf.h,mevcr.lhc huilJing orimpmvemem issnlJ within ane year of a,mplction.the '� SQ. � '.( AR1i ESQ.FI'.
nertmilder will have the burden of proving that he did not build or improve for put-
n 1. MAY 10 1999
❑h us owner of IrnpcnY.ora cxdmivdy contracting with licensed common,.nt TOTAL:
construct project(Sec.7044,liuciness and Professions Conic)The Contrition'.Li-
nselawdoesnotapplymanownerofpmpcnywho bonds or improves Merron.and QTY, PLUMBING PERMIT FEE
wbo comma,for such predict,with a a,mraclods)licensed pursuanum the Commnors
License L.W. RAIJ
FRMH ISSUANCI! O By
❑1 am exempt under See. .R d P C for this mason
'I?k-GRAIN kVENT-WA'I'T:R[EA) VALUATION
QWmr U.IO WOHmirr, CO,yot:pSATION OI?Ce olle,ON ACK I'LUW 1'It(YTIiCI.UI!VICPM1uruy adinn unerInnullynl'perjury oneof drfallowing Jedvm,inm❑ I have and will maintain a CertilicaleofConentmnelf-in sure ler WnrkerxCompen- RAINS-ITLOOR,ROOP.A iA.CONO NICHES 'I'YI'll C(INSTkUCfION
w,iun,as provided fn,by Sectio^7700 of the labor Code,Er the perfor nrred ufthe
w k I...1,tis permh its i saved. IXTURES-PER'I'RAI'
�'flntw and will molIT6u Workers Cuntpntxmion Imurunec,as required by Section
3700of lb,Lubnr GXlg fa,lheperko, enceal,heworkSorhh Jild is ixwufAS-I!A.SYS'I SIM-I INC.4 OU'I'I.I], OCC.GROUP APN
MY W„ moot It s n cu rand Policy number
Cnrricc t rztc Polity N,x�nh^Z� ti� GAl-I!A,SVS'rEMOVI?R4fi?A]
ICI!NIIIICRIT OF UUMPI ION PROM WORKERS GREASI%INDl1sI RI,WAST I!IN I I!RCEPI OR NIIILUING DIVISION IMS
COMPINSAI'ION INSURANCE,
fillissueliannecJnot be conlpined fIne,mnnitlx iia one hundred Jolliev(SI(X1) GRI!ASII'I'RAP
or Esv) PLANCHECK IPI?
Irenifythat imild p,noarr ,,oi0mwo,k,nrwhich Im,,wmnis issued.[,hall SEWER-SANITARY-S'PORM HA.HIS IT.
not employ any person in any nlannerno as to Mcome subject m the Workers Compen- ENERGY hili
Z ration laws of California.[)am WATER HEATER WIVENT?LECI'R
z Q GRADING I
Applicant '1!li
NOFICETO APPLICANE If.alter making this Cer ilicme of Exemption,you.should WATER SYSTEM'l R17AT ING
h OILS ITE
? Mcome subject,o the Workers Conlpcnxxlion provisions of the tabor Code,you must
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE,
a0
CONSTRUCTION LENDING ageV NEW RESIDENTIAL I'LM1IH. SQ.FT PAID
V O Ihcmby uflirm,hm there i.aamamnion lendingng agency for mlee pedormancc of UuHwcpt4
,Z
U he work far whieladd,permit is ixmed(Sec.3097.Civ,C.)
U LeoJers Name '1'OIAh:
U Urchins Address TOTAL:
BUILDING
0. 1 certify that I have,mail this application and state that Me above infomm,ion is PGi
F" (A correct.I agnea ,,comply with all city and county entrances and stale laws relating to QTY MECHANICAL PERMIT FEE
building criminaland hereby authorienepmsenmlWmpo
ofthis chyus cram,unlhe SEISMIC FF:E r) Z —
uhnve-mentioned property for impretin0 purposes. PERMIT ISSUANCE ELECTRIC ELECTRIC Iq?ITT.1 We)agree m xava,indemnify.,,it kccp harmless the City of Cupertino ugainsl
Iiahilitien,judgmmnx.awu nnJ expenses whkh nmy in any Way oceans agmen saiJCity N,TF,RORAUDTOMLCH. PLUM1ININC PE:
''panne of the gaining of this permit.
APPI.ICANI'❑NHI!NS'IANUS AND WILL COMPLY WITH ALL NON-POINT Alk HANDLING UNI"I'(TO IIIJXXI CPM) MI!CIIANICAI.ITJl
5( 1 RECIII.A'1'IONS. r,
{� li AI It i IANDL I NO U ISI(OVER I POISON)CIIMI COUSNGMIHGSAX
A-li/1 t LL - •� CONST I<UC'TION'1
Slgnamo.a Applin .nnu'nctot �i Dulc II%IIAfJS9'1I0001 W1UUC1} 'HONFI9i
HAZARDOUS MATI;RIAI,S DISCLOSURE
Will beepplicun (it fulmebuilding occupant store or handle hazardous material l IIEA'TING IINI'1'fT0IfN1,01X111'1'U)
it,defined by,he Cupertino Municipal Cndu,Chapter 9.12,and the health and Safety
Calc,Sectlan 2553200 HFAI INC,UNIT(OVI!R IOd,(XN)BTUI
[:1Ycs �Vn PAID
VHN'IILAHONI'AN(SINGLERILSIDI Dam Reccip,N
Will the uppl'teanl or furore building xcupad,are cgammenl or device.Which Boll FR-COMP(3HPOR 100.000 NTH)
emit M1azurdaas air containment,as Ill by the tiny Arca Air Quality Management 'IOI'AI;
Diane'? / NOILER-COMPOVEH I00.k)OBTU)
El Yes /f llrl 1
I Lase maJthe hatudousnmmrialxmr,iremems under Chapter 6.95 of,he Cali ` AIR CONDITIONER ISSUANCE DATE
lemma Ilwllh k Safety Cone.secants 25505,IS533 and 25511.1 uoJcrsmnd Ihan if the NEW RESIDENTIAL MECH. SQ.IT � � a q
huilJing J,nsnrn curmndy harcamnnn,.,hm it i.my mslxm.ibilitymnaify the acupam (J P
Qf II myuim ,.whicM1 set hi met prim m icsuancc of a CeniGcam of(kc pm,cY.
(to L.0 �F-'lI.,IC
EC4
Ownx,u7mthuarW T,,rd Dam TOTAL: ISSUED ITY:
OFFICE