99110107 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
ITY OF CUPERTINO IIUILUING-ELECTRICAI• 3RA11'I"
APPLICATIONIPERMIT rLUMnING-:+fecnnmcAl.
BUILDING DIVISION ItUli.U1NG 1'R(1JECI'ID4:NT14'IG+TI(yN SOOOI
SANITARY NII. APYLICAI'IIIN SUHMI'TU\I,UAE'
Ii UILDIN(l AU13111155:
; o)5Zl NO/fiNwi�/kl �r1u�G
OWNER'S NAME: PHONE: CONTRACTORS NAME: LIC N¢ NIC CONTROL#
e,(Al )/ LGYuo ate%- 9.02— '50 LEl
.IC NO: ADDRESS: Sla)'O�i /a03T �V)
ss'✓ 9s9 y
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLUG ELECT PLUMB MECH
❑ ❑ DQ ❑
LICENSED CONTRACTOR'S DECLARATION QJ•Y ELECTRIC PERM IT FEE ,IOU DESCRIPTION
1 bcrehy offnn that I mo liccn%al under pnwision,of Cbupmr 9(cmmnencing
ZOZ wise Section 7000)ol Division Sol let Baanw,,md Profeadonx Code.end toy license is RESIDENTIAL
CSF- In �-3� I'ERMI'1'ISSIIANCi:
F- O full force and cRca ❑SFDWL ❑KIT CHEN REMODEL
WF-EU Lmcnse Cl:yu —Lic.p AYYLIANCLS-HFSIDEYTIAL ❑ADDITION ❑PLUMPING Rr-PII'li
to 6 L Date 9 Q/—Centtaelnr. --yy
ARCHITECTS DECLARATION lAt- PANELS ❑h1ULT1-0NI'f ❑MODIFIATIO
zonz I understand my plan.%shall he used as public records MODIFICATION
1_111'0200AMPS El INTERIOR ❑CIIIMN17Y REPAIR
N��aAa Licensed Pndessional 201-IWOAMPS IMPROVEMENT' SWIMMING POOLS
,1f� OWNER-BUILDER DECLARATION OVER 1000 AMPS C3 BATH REMODEUREPAIR ❑DHMOLIDON
C 6 I herehy nfEnn tbar 1 am caempt food the Contractor's License Law for theQ OTNER Tom{^ �pA�-=
Ea. a U following reason.(Section 703 1.5,nminvss and Professions Cade:Any city or county SIGNS ELECTRICAL
1+131L rn which 4 ".I,Ic tract.alte,repooe,denolkh..1 opeollay:wcmn
F
ii:
{�{nn� prion t I. 4 thef hpermit t flsigned st(anent SPECIAL Cl RC(HUMISC.
�2y Ind lot . Ip , Il ,lftpContractor'I (Chapter9 COMMERCIAL:
.1ad1� (comnenung with Seero,](NN))of Dbis'm 3 of the 9uslness andl f sCode)nr O:MP.ME)HRGRPOLFINS,L
tca e that he ix exempt themfrnm and ahc basis for the alleged exemption,Any violation of ❑NEW BLDG/AUUI'IION El DEMOLITION
W^,N Secriun]031.3 by anY applicamforvpenitit wnjects the vpplicannnacivil penalty of POWER DIiVICES ANT ❑FOODSERVICE
re than Bvu hundred dollars($500). hIPIR EMENT'
F.=Q E] I.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC ER
L.0 will do the work, the structure is not intended or alpwd far sale(Set.]OIJ,Business
^� ;aid 14nluxlanx Codc'.'The C, rector,hlcmma law Joe%not apply ,,m,owner of OU'1'LBTS-SWI"TCIIES-fl%'fUHIiS
property who build,or improve,tnernm,and who doe,such work himself nr ihfuagh NEW RESIDENTIAL ELECI'R SQ ITT
his own cmplayws,provided that such impmvemcnts arc not intended or offered for SQ.19'.FLOOR AREA 5/SQ.En
sale.If,however.the building or improvetnenl is sold within ane year of compleowntion,the
erbuilder will have the harden of proving that he did not build to intpmvc fur pur-
pow of,aky TOTAL:
❑h ns owtmr of do,property, on eschnrvcly eontn,cting with licensed contractor,to
construct the project(See.7I44,]business and Professions Ctdeo)The Cu donch"s Li-
mLaw does not apply to air owner of property whis builds or improves therem,and QTY. PLUMBING PER M IT FEE
who contracts for such projects with a contractuds)licensed pursuant u,the Contractor's
License Law. PERMIT ISSUANCE
Iameneinplunder See. ,BkPCfa this rwson
ALTER-DRAIN&VENT-WAfER(EA) VALUATION
Owner Daae �rSdorJV
WORKHNS CUMI'IiNSA'1'I(IN DI!CI,ARATION BACK ROW PRI YPECI'.DEVICE
I hereby affirm under penalty of perjury,one of the following declarations:
I have and will maintain a Carifcate of Consent to sdpinsum for Workers Comped- DRAINS-FLOOR.HOOF.AREA.CON0. STORIES '1'VI'E CONSTRl1Cl'IC
moonon-
as pmvidcJ for by Section 3](X1 of the Labe Code,for the performance of the
k fm which this perrnil is nsvcd. Il}(TURP_S-PER'IRAP �G-
1 have,md will mainitial Workers Compcnsativa Insurance,as required by Section
. glut the Labor Code,for the wrtunnance of the work for which this Tomtit is issued. GAS-EA.SYSTIM-I INC.a OU'D.ETS OCC IiKt M'
MCaYrtWienr:r '
l lr?60- 1 MIN
kcrs Cghu �MIIrand Policy num4 /�
GAS-IA.SYSTEM-0VLR4(IA)
Policy Na, C]
CERTIFICATE OP I.%EMM'[ON FROM WORKERSGREASOINDUS'TRL WASTE INT F.RCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FE-ES
(This waion need not he ttm,plc¢dif the permit is Turnor.hundrW dollen(SIM) GREAS17TRAP PLANCHECK PEI.
or le )i not Es'
work for tubi hihispsumiti%IsmJ,IshnlE SEWfiR-SANITARY-STORM I.A.2tN)FT. ENERGY IPI:
nal employ any pc.nm in any manner v, o here xuhicFt In hr.Wmkcis Campw- //
,Z xatian Lawaof Caliburan Dw (/'l WATER HI!AfF:R W/VENT/LLECI'R USV/ GRADING Mibi
00 Applicant i 1
Z y NOTICE TO APPLICANT:If,rifer mating this Cer ificate of Exempunn.you should WATER SYSTIiM/TREATING SOILS FEE
f- become subject m the Workers Coml'cah000 pmvixiom of the Lake Code,you must
humvilh cam ply with such provisions nr this pe.,it shall be Deemer revoked. WATER SERVICIi
Q PAID
0.
CONSTHUCI'ION LENDINGAGENCY NF.W RESIDIiNI'IAI,PLMn, SQ.PI'' Uwe HecciptK
VIherahy aff nn ahauharc ixe tt,mwmction lcnding agency for the perfurmanee of
the work far which this permit is issued(Sec.3097.Civ.C.) .�^ 'I OPAL:
0 f Lenders Name TOTAL: 5,
UU Lender's Address BUILDING 1'I711:
Lkt I certify(hat 1 have mod this applicatio i trod sunt ihw the above information i%
rn
hart I agree mamply wise all city and const y....lianas.,,it law Laws relwlng a, QTY. MECHANICAL PERMIT FEE SEISMIC IPI.
U z hdmgea.mmefan.and hereby nmhmice reprmcnl:nlvha oldo,rdym wmrapon the
ahsn'e"mentioned Timothy for inspection purpnu,. PERMIT ISSUANCE ELECTRIC 1-1711
We)agree to save,indemnify and keep huntress the City of Cupertino against
Imbilitics.jud,doomm costs and expenses which may in any way revive against said City ALTERORADDTOMECH. PLUMBING FEE yJ',167
in consequence of the granting of this phnnil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH At.[.NON-POINT AI R HANDLE NG UNIT 10900 CFM) MECHANICAL PET!
SOURCE REGULA'I'[ONS.
AIR HANDLING UNIT(OVEItIool CFM) CONSTRUC'HON'TAX
Signature of ApplicanVCunlmctor 4y/ Det9e / PXHAUS I'HOOD(W/DUCL) HOUSING MI"rIGAT10N FEE
HAZARDOUS MATERIALS DISCLOSURE
Will applicant or future building occupant.same or handle harardnus material HEATING UNIT TIO I00,0003]'U)
ax defnW by the Cupenlno Munlcipol Code.Chapter 212,end the Ilwhh and Safety HEATING UNIT'(OVER Int00013'IU)
Code.Sccdnn 25532(%)'! ('AID
0Yes ANo VENTILATION PAN(SINGLE RUSH)) [—)are Rtccipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP QHP OR 100.000 BTU)
et ha.hom,air codmminana as defned by the Bay Asea Air Quality Managhmenl TOTN.:
uicr! ,_,/'' BOILER-COMP(OVER 100.0X)HTU)
Lf
Ya, RINI,
AIR CON A I'IONEIt ISSUANC1i DAPH
as%e read me na..amasn,aaedmx ttgnin•,ne„ts ander cnaaer nv5 nr me caRSafety Code.Seelions 5505,25533 and 55N.1 umlentw,d that it the NEW RESIDENT IAL MUCH, SQ,14,oes nm currently have a ahead.that it is my responsibility to notify the occupantld ens which mu m nvuunce ofo Cent em f(kcu r�L'�(/j �� TOTAL: ISSUED BP.r uG laonvsoagent -c
OFFICE